F0557

B

Failure to Document Resident Belongings at Discharge

La Habra, California Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The facility failed to follow its discharge process for resident personal belongings for one of five sampled residents. Facility policy on Resident Personal Belongings required the protection of residents' rights to possess personal items and to ensure those belongings were rightfully returned to the resident or representative upon death or discharge. A separate policy on Documentation in Medical Record required that licensed staff and the interdisciplinary team document all assessments, observations, and services in the medical record to provide a clear picture of the resident’s experiences and progress. For Resident 1, who was cognitively intact per the MDS assessment, the Resident's Clothing and Possessions form dated 12/12/25 contained two sections: "On Admission" and "On Discharge." The "On Admission" section listed items brought in at admission, while the "On Discharge" section had only a slash across it with the notation "discharge AMA," and no itemized listing of belongings.

During interviews and concurrent closed medical record reviews, staff confirmed that the discharge section of the belongings form for this resident was incomplete. CNA 5 verified that the "On Discharge" section was not filled out and stated that the resident’s belongings should have been counted and sorted by a licensed nurse or CNA, placed in a bag labeled with the resident’s name, and then given to social services. RN 2 also confirmed the form was incomplete and stated that the licensed nurse or CNA team lead should have completed the form to ensure no items were missing. The DON acknowledged these findings and stated that the form should have been completed when staff packed the resident’s belongings, with the person packing the items specifying them on the form so the facility would have an accurate account of the resident’s belongings.