Failure to Safeguard Resident's Personal Property and Inadequate Tracking of Missing Items
Penalty
Summary
The facility failed to safeguard a resident's personal property, specifically a blanket of significant personal and religious importance, as well as some clothing items. The resident reported that his blanket, described as yellow and tan and referred to as a "Jesus blanket," had been missing for several weeks after being sent to laundry and not returned. The resident expressed distress over the loss, noting the blanket's personal meaning and his background as a Catholic priest. Interviews with staff and family confirmed the blanket's importance and the resident's repeated notifications to staff about the missing item. Family members also reported asking staff about the missing blanket on multiple occasions, with staff responses indicating uncertainty about its whereabouts and suggesting it might be in laundry. Facility staff interviews revealed inconsistencies and gaps in the process for inventorying and tracking residents' personal belongings. Not all personal items were inventoried at admission, and there was no maintained list of missing items. Staff members were unclear about the procedures for reporting and resolving missing items, with some indicating that missing items should be reported to laundry or a nurse, but no evidence was provided that the facility followed its own policy for documenting and resolving such incidents. The facility's policy required a running log of missing items and a signed resolution report, but no such documentation was available for the missing blanket.