Failure to Document Resident Belongings on Admission
Penalty
Summary
The facility failed to implement and document inventory sheets for resident belongings upon admission for three newly admitted residents. For one resident with diagnoses including type 2 diabetes mellitus and congestive heart failure, the family reported that a back brace was missing upon arrival, and there was no inventory sheet in the electronic health record. Interviews with staff confirmed that the inventory sheet was not completed at admission, despite the facility's usual practice to do so. The Director of Nursing acknowledged that staff were responsible for ensuring inventory sheets were completed. Another resident, admitted with multiple diagnoses such as lung cancer, emphysema, and heart failure, reported that no inventory sheet was completed for her belongings, and she was unsure if anything was missing. Staff confirmed that all records were kept electronically and that no inventory sheet was present in the resident's record. A third resident, with conditions including hypertension, diabetes, and malnutrition, also indicated that no inventory sheet was completed at admission. Review of his clinical record confirmed the absence of an inventory sheet. All three cases demonstrated a lack of documentation and safeguarding of resident belongings at the time of admission.