Failure to Complete Resident Personal Inventory on Admission
Penalty
Summary
The facility failed to maintain complete and accurate records for a resident upon admission, specifically by not completing a personal inventory sheet as required by facility policy. The resident, an elderly female with severe cognitive impairment as indicated by a BIMS score of 02, was admitted with age-related cognitive decline. Review of her admission documents showed that the inventory form, which should have listed her personal belongings, was left blank and was not updated at any point after admission. The admission packet required the resident or responsible party to complete this inventory, and the facility's policy stated that it was responsible for accounting for all resident belongings. Interviews with the DON and Administrator confirmed that the inventory process was not followed for this resident. The DON acknowledged that the inventory sheet was missing and that nurses were responsible for its completion, while the Administrator stated that the process was shared among nursing and other staff. Both confirmed that there was no documentation of the resident's belongings, and the DON had not previously noticed the omission. The facility's policy and documentation guidelines required a personal inventory list to be completed on admission and included in the medical record, but this was not done for the resident in question.