Failure to Complete and Verify Resident Personal Effects Inventory at Admission and Discharge
Penalty
Summary
The facility failed to properly complete and maintain an accurate inventory of personal effects for one resident, resulting in a deficient practice related to residents' rights to retain and use personal possessions. The resident was originally admitted with diagnoses including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. The resident’s History and Physical indicated capacity to understand and make decisions, and the MDS documented moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. The facility’s policy required that, on admission, a staff member complete an Inventory of Personal Effects form, record all personal items brought in, and obtain signatures from the resident or responsible party and a staff member, with the original kept in the health record and a copy provided to the resident or representative. During an interview and concurrent record review, the DON acknowledged that the resident’s Inventory of Personal Effects form was not complete. On admission, the form was not signed by a facility representative as required by policy. On discharge, the form was again not properly completed, as it lacked the resident or responsible party’s signature to certify that the personal effects were received, and the facility representative’s signature was dated after the resident’s discharge date. The DON stated that, on discharge, residents or responsible parties are supposed to receive a copy of the discharge summary, medication list, follow-up orders, and the inventory, and that the inventory is important to show if any items are missing and to ensure important items go home with the resident and family. Despite this, the required signatures and completion of the inventory form were not obtained at admission or discharge for this resident, contrary to the facility’s written policy and procedure on personal effects.
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