Failure to Investigate and Replace Missing Resident Belongings
Penalty
Summary
The facility failed to ensure that a resident's right to retain and use personal possessions was honored when a resident reported a missing pair of shoes and a hinged knee brace. The resident, who had diagnoses including type 2 diabetes mellitus, unsteadiness on feet, hypertension, and difficulty walking, was cognitively intact as indicated by a BIMS score of 15. Upon discharge, the resident reported the missing items to the Social Services Director (SSD), but staff did not follow the facility's policy to investigate, document, or offer replacement or reimbursement for the lost belongings. Interviews with facility staff revealed that the standard procedure for missing items included searching for the item, checking the resident's Inventory of Personal Effects (IPE), and completing a Theft and Loss Monitoring (TLM) form. In this case, the SSD acknowledged that no TLM form was completed at the time the items were reported missing, and the process for resolving the missing belongings was not initiated within the required timeframe. The IPE did note the missing items, but there was no evidence of a timely investigation or follow-up as required by facility policy. Further review of facility policy confirmed that all reported losses, especially those valued at $25 or more, must be documented and reported, with a written inventory established upon admission. Despite these requirements, the missing items were not properly investigated or replaced, and the resident was not reimbursed for the value of the lost possessions. This resulted in the resident losing personal items without appropriate action from the facility.