Failure to Perform Admission Inventory Allows Resident to Possess Weapon
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision by not performing a required inventory check for a resident upon admission. As a result, the resident was able to possess a BB gun within the facility, which was not detected until a staff member searched the resident's belongings after noticing suspicious behavior and the smell of smoke. The facility's own policy requires an inventory of personal effects upon admission and updates when items are brought in or removed, but there was no documentation of an inventory list for this resident, nor evidence that belongings were checked after the resident returned from hospital visits or potential passes out of the facility. The resident involved had a history of criminal behavior and was assessed as moderately cognitively impaired. The care plan indicated the need for appropriate supervision and observation, but the facility did not routinely check residents' belongings unless there was suspicion. Staff interviews revealed that the BB gun was not listed on the resident's inventory at admission, and there was uncertainty about whether the resident had left the facility and returned with new items. The facility did not have a process in place to check for contraband when residents left and returned, and staff were unable to produce documentation of the resident's inventory or records of out-of-facility passes. The facility's contraband policy prohibits weapons and requires staff to act if there is suspicion of contraband, but does not mandate routine checks. The BB gun was only discovered after a staff member searched the resident's belongings due to suspicious circumstances, not as part of a standard procedure. The lack of an initial and ongoing inventory check allowed the resident to keep a weapon in their possession, which was only addressed after it was found by chance.