Incomplete Documentation of Resident Inventory Lists at Discharge
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for two residents when the discharge portion of their Inventory Lists was left blank. For one resident with severe cognitive impairment and another with intact cognitive skills, the Inventory Lists at discharge were not completed, and in one case, belongings were picked up without being listed or signed for. Interviews with staff revealed that Certified Nursing Assistants were responsible for filling out the Inventory List at discharge, while Social Services was tasked with verifying its completion the following day. However, audits by Medical Records indicated that Social Services was not consistently completing or verifying the Inventory Lists, and there was a lack of communication regarding incomplete documentation. The facility's policy required that residents' personal belongings be inventoried and documented upon admission and updated as necessary, but this was not followed at discharge for the two residents. Staff interviews confirmed that belongings were packed and held by Social Services until picked up by family, but without a completed and signed Inventory List, there was potential for items to be lost. The Administrator acknowledged that the Social Service Department failed to check and complete the inventory lists after discharge, and failed to obtain the necessary signatures when belongings were picked up.