Failure to Investigate and Follow Up on Missing Resident Items
Penalty
Summary
The facility failed to properly investigate and follow up on missing personal items for a resident with severe cognitive impairment and total dependence for mobility and transfers. The resident's family reported missing blankets, clothing, and stuffed animals to staff, but could not recall specific staff names. The social worker designee stated she had not received any concerns or grievances regarding missing items from this resident or their family, and no concern logs were found at the front desk as required by facility policy. Laundry and housekeeping staff reported that missing clothing is a frequent issue, with reports received verbally or in writing, but these notes are discarded after a search is conducted, and there is no documentation or follow-up. Clothing items without names accumulate in the laundry room, and staff are often informed of missing items by residents or families but do not maintain records or communicate outcomes. Certified nursing assistants confirmed that families had reported missing items, but after searching the laundry, no further action was taken or documented. During a resident council meeting, multiple residents confirmed that missing clothing was a widespread and ongoing problem, with little to no follow-up from staff after reports were made. Review of resident council meeting minutes showed repeated complaints about missing items and a lack of documented follow-up or resolution. The facility's grievance policy requires all grievances to be recorded, investigated, and maintained, but this process was not followed for missing items, resulting in unresolved concerns for residents.