Incomplete Inventory Documentation for Resident Personal Effects
Penalty
Summary
The facility failed to ensure that the inventory list for a resident's personal effects and valuables was complete, as required by regulation. Upon review, the inventory list for one resident was found to be missing signatures from both the responsible party and the facility staff who completed it. The Director of Nursing confirmed that the responsible party had not signed the inventory list at either admission or discharge, and the staff member's signature on the discharge section was illegible and could not be identified. Additionally, the responsible party stated that the inventory list was never reviewed or provided at either admission or discharge. Further review of the resident's records revealed that the resident was not their own responsible party and had been admitted with a left artificial hip joint and dependence on supplemental oxygen. The responsible party was present during the discharge process, as documented in the general notes, yet the required signatures were still missing from the inventory list. The facility's policy indicated that Certified Nurse Assistants were responsible for completing the form, but the specific staff member involved could not be identified. This deficiency was identified through interviews and record reviews, which demonstrated that the facility did not follow its own policy or regulatory requirements for documenting and verifying residents' personal property inventories. The lack of proper documentation and signatures had the potential for personal belongings not to be accurately accounted for, as directly stated in the report.
Plan Of Correction
1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has been discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. A 100% audit of all current residents' most recent MDS assessments was initiated to ensure accuracy of sensory and communication sections (hearing and vision). Any discrepancies identified were corrected, and care plans were updated accordingly. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. All MDS staff and licensed nurses involved in assessment and data collection were re-educated on: - Accurate completion of the MDS per RAI (Resident Assessment Instrument) guidelines. - Verifying resident sensory status through observation, resident/family interview, and review of medical records prior to submission. The MDS Coordinator and DON will ensure that each admission and significant change MDS is reviewed for accuracy before final submission. 4. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. The MDS Coordinator or designee will conduct weekly audits for four (4) weeks, then monthly for two (2) months, of at least three (3) randomly selected MDS assessments to verify accuracy in the sensory section. Audit results will be presented during QAPI (Quality Assurance and Performance Improvement) meetings. Any errors identified will be corrected immediately, and staff involved will receive retraining as needed. --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has been discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. A facility-wide audit was conducted of all residents identified with hearing deficits to ensure that appropriate, individualized care plan interventions are in place. Any missing or incomplete care plan items were immediately corrected by the IDT. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. Licensed nurses and members of the IDT were re-educated on the requirement to develop and update individualized care plans that address all assessed resident needs, including sensory impairments such as hearing or vision loss. The MDS Coordinator and DON will ensure that any sensory deficits identified on the MDS trigger an appropriate care plan intervention. Newly admitted residents with hearing or vision concerns will have their care plans initiated within 48 hours of admission. 4. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. The DON or designee will conduct weekly audits for four (4) weeks, then monthly for two (2) months, to verify that residents with hearing deficits have active, individualized care plan interventions addressing communication and social engagement needs. Audit findings will be reported and reviewed during QAPI (Quality Assurance and Performance Improvement) meetings. Any identified deficiencies will be corrected immediately, and additional education provided as necessary. --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has been discharged from the facility. Prior to discharge, the resident's condition was stable, and no adverse effects were noted related to the oxygen administration. The attending physician was notified of the incident and made aware of the resident's discharge status. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All current residents receiving supplemental oxygen were reviewed to ensure oxygen is being administered per the current physician's order. Any discrepancies were immediately corrected, and physicians were notified as needed. No other residents were identified as affected. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. A facility-wide in-service training was provided to all licensed nurses regarding proper administration and titration of supplemental oxygen according to physician orders, documentation of oxygen saturation readings, and the notification protocol for oxygen levels outside the ordered range. The Nursing Supervisor or designee will verify that all oxygen therapy orders clearly specify flow rate and target oxygen saturation range. All new and readmitted residents with oxygen orders will have those orders reviewed by the Director of Nursing (DON) or designee to ensure clarity and completeness. 4. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. The DON or designee will perform weekly audits for four (4) weeks, then monthly for two (2) months, to ensure residents receiving oxygen are administered therapy per physician orders. Audit results will be reviewed during the Quality Assurance and Performance Improvement. --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #3 was immediately assessed by the licensed nurse for physical and emotional well-being following the incident. The resident denied injury or distress related to the event. Emotional support was offered if needed, and the attending physician was notified. The alleged perpetrator (CNA A) was immediately suspended pending investigation, and the allegation was reported to the California Department of Public Health (CDPH) and the Long-Term Care Ombudsman as required. The facility completed an internal investigation, and appropriate disciplinary action was taken based on the findings. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All residents were interviewed and observed for signs of distress, fear, or mistreatment. No additional residents reported or displayed evidence of abuse or neglect. Staff were reminded to immediately report any allegations, suspicions, or observations of abuse to the charge nurse and administration per facility policy. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. All facility staff will receive re-education on the Abuse Prevention Policy, including definitions, examples of verbal abuse, resident rights, and mandatory reporting procedures. Education emphasized that any form of disrespectful, degrading, or threatening language toward residents is strictly prohibited. The facility reinforced a zero-tolerance policy for abuse. New hires will receive abuse reporting training during orientation and annually thereafter. The DON and Administrator will ensure that all allegations are promptly investigated, and corrective actions are implemented as required by regulation. The DON or designee will conduct random staff and resident interviews weekly for four (4) weeks, then monthly for two (2) months, to ensure that residents feel safe and that staff adhere to the facility's Abuse Prevention Policy. All findings will be reported and reviewed during QAPI (Quality Assurance and Performance Improvement) meetings. Any identified issues will result in immediate corrective action and retraining. --- 5. Element #5: Completion Date. Date of full compliance: November 21, 2025 --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has been discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. A review of the previous seven (7) days of temperature logs was conducted to identify any inconsistencies. No additional adverse findings were noted. The kitchen staff were instructed to verify and document meal temperatures before every tray line service to ensure food is served within the safe and acceptable temperature range. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. A comprehensive re-education was provided to all dietary staff regarding proper food holding, monitoring, and serving temperatures in accordance with state and federal food safety standards. Staff were re-trained on the requirement to record and document hot and cold food temperatures before each meal service. The Food Service Director or designee will conduct temperature audits before each meal service daily for two (2) weeks, then three times per week for the following four (4) weeks, and weekly for two (2) months thereafter. Audit results will be reviewed with the Director of Nursing (DON) and Administrator. Test trays will go out at least twice a week to varied staff with test tray slip to document temperature, presentation, and taste. CDM will make corrections based off test tray notes. Findings will be presented during QAPI (Quality Assurance and Performance Improvement) meetings. Any deviations will result in immediate staff retraining or disciplinary action, as appropriate. --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has since been discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. A comprehensive audit of all current medication orders was completed by the Director of Nursing (DON) and Consultant Pharmacist to identify any potential irregularities or incomplete medication indications. Any identified discrepancies were clarified with the attending physician, and orders were corrected as needed. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - The Consultant Pharmacist was re-educated on their regulatory responsibility to review all monthly medication orders for accuracy, appropriate indications, and potential irregularities. - The Consultant Pharmacist has changed the protocol at the Pharmacy for any muscle relaxant medication to only be approved for a diagnosis of muscle spasms. - Licensed nurses were re-educated on the requirement to ensure all PRN (as-needed) medication orders specify the indication for use (e.g., pain, spasm, anxiety) and to clarify any vague or incomplete orders with the prescribing provider. - All new orders will be reviewed daily (Monday-Friday) using an order listing report at our IDT meeting. Any discrepancies will be corrected and/or clarified at that time. - The DON will ensure new medication orders are reviewed upon admission and during monthly medication regimen reviews for accuracy and completeness. - A process was implemented for the Consultant Pharmacist to document any identified irregularities and corresponding physician responses in the monthly review reports. 4. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. The DON or designee will conduct monthly medication order audits for three (3) months to ensure orders are complete, accurate, and free from irregularities. Audit results will be reviewed during Pharmacy & Therapeutics and QAPI (Quality Assurance and Performance Improvement) meetings. Any deviations will result in immediate correction and re-education. Continued compliance will be monitored through ongoing monthly pharmacist reviews. 5. Element #5: Completion Date. Date of full compliance: November 21, 2025 --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has since discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All current residents have the potential to be affected by this deficient practice. A review of all abuse allegation reports from the past 60 days was conducted to ensure proper and timely notification to CDPH, the Ombudsman, and law enforcement. No additional discrepancies were identified. The facility confirmed that all other incidents were appropriately reported in accordance with regulatory requirements. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - All licensed nurses, department heads, and supervisors were re-educated on the facility's Abuse Prevention, Reporting, and Investigation Policy, emphasizing immediate reporting requirements to CDPH, the Ombudsman, and law enforcement within mandated timeframes. - The Abuse Reporting Checklist was updated to include verification boxes for required notifications. --- 4. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1's medical record was located and properly filed in the designated medical records storage area on the same day the issue was identified. The record was reviewed for completeness and accuracy, and no missing documentation was found. The resident experienced no negative outcomes related to this deficiency. 5. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this deficient practice. A facility-wide audit of all residents' medical records was completed to ensure that all records were filed accurately and were easily accessible. No additional misplaced or inaccessible records were found. 6. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - The Health Information Manager (HIM) and Medical Records Clerk were re-educated on the facility's policy and procedure for medical record management, including filing, accessibility, and secure storage. - A Medical Record Location Log has been implemented for tracking temporary removal of charts (e.g., for audits, MD review, or IDT meetings). - A sign-out system will be maintained to ensure all records are returned promptly to their designated storage area. - The Administrator and DON will ensure that any new or updated records are filed daily. Education was provided to department heads on how to properly request and return resident charts through the HIM department. 7. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. --- Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1's medical record was promptly retrieved and returned to the facility upon discovery. The record was reviewed for completeness and accuracy, and no missing documentation was identified. Resident #1 experienced no adverse outcomes because of this deficient practice. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this deficient practice. A complete audit of all current resident medical records was conducted to ensure that all records were on site and properly secured. No additional records were found to be missing or removed from the facility. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - The facility's policy and procedure for medical record management was reviewed and revised to clearly state that resident medical records must always remain on facility grounds. - The Medical Director and attending physicians were re-educated on this policy, with emphasis that no original records are to leave the facility under any circumstances. - If a physician requires information for off-site review, photocopies or secure electronic copies will be provided by the Health Information Manager (HIM). - The Health Information Manager and Administrator will monitor compliance by verifying that all records remain on-site. --- Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has since discharged from the facility. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All current residents have the potential to be affected by this deficient practice. The facility conducted an audit of all current residents' "Daily Skilled Charting" to ensure that assessments accurately reflected residents' actual functional and sensory statuses. Any discrepancies identified were immediately corrected, and nurses responsible were re-educated on accurate documentation practices. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - All licensed nurses were re-educated by the Director of Nursing (DON) on the importance of completing accurate and meaningful daily skilled charting that reflects each resident's current condition, including hearing, vision, and communication abilities. - The facility Daily Skilled Nursing Documentation Policy was reviewed and updated to include specific guidance on validating sensory documentation against current care plans and assessments. - The MDS Coordinator will ensure consistency between MDS assessments, care plans, and daily skilled documentation. - Any identified inaccuracies during documentation reviews will result in immediate correction and staff retraining. --- Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has since discharged from the facility. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All current residents have the potential to be affected by this deficient practice. The facility conducted an audit of all current residents' personal inventory forms to ensure each form was complete, current, and signed by both facility staff and the responsible party. Any missing signatures or incomplete forms were corrected immediately. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - The Charge Nurses were re-educated on the facility's Resident Personal Property and Inventory Policy, emphasizing that both the staff member completing the inventory and the responsible party (or resident, if applicable) must sign and date the inventory form upon admission and discharge. - The facility updated the Admission Checklist to include a verification step ensuring the inventory form is signed by both parties before completion of the admission process. - The Social Services Director and Admissions Coordinator will ensure that any changes to resident belongings during the stay are documented and signed accordingly. - The Director of Nursing (DON) will review the process quarterly to ensure compliance. Element #5: Completion Date. November 21, 2025