F0584

D

Failure to Inventory and Track Resident Personal Property Resulting in Missing Clothing

Lynchburg, Virginia Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

Facility staff failed to honor a resident's right to a safe, clean, comfortable, and homelike environment by not tracking the resident's personal property as required by facility policy. The facility's "Personal Property" policy dated 10/01/2021 stated that residents' personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. For Resident #4, the Director of Nursing and Administrator were unable to locate any record of a personal property inventory in either the electronic medical record (Point Click Care) or in paper form, and no admission inventory or subsequent updates could be found.

Resident #4 was admitted with multiple diagnoses including muscle weakness, quadriplegia, urinary incontinence, Type 2 diabetes mellitus without complication, pressure ulcer of the sacral region, deep tissue damage, irritant contact dermatitis, bacteriuria, GERD without esophagitis, constipation, insomnia, lactose intolerance, moderate protein-calorie malnutrition, unsteady gait, abnormal posture, and limitation of activities due to disability. The MDS showed a BIMS score of 15, indicating the resident was cognitively intact, but functionally dependent for ADLs and required staff assistance. During the resident’s stay, there was no documented inventory of personal belongings despite the resident’s dependence on staff for daily care and management of personal items.

On review of the resident’s discharge instructions, there was a documented note that the resident reported missing clothing items, including a grey hoodie, a pair of Levi’s, two pairs of grey sweatpants, and a grey shirt. There was no further documentation of follow-up regarding these missing items and no record of a personal inventory at admission or any time during the stay. Interviews with staff, including the Social Services Director, Environmental Director, housekeeping, and a CNA, described general processes for searching for and addressing missing items and acknowledged past issues with clothing being placed in incorrect laundry bags, but did not identify any existing inventory record for this resident. The DON confirmed that no personal property records for this resident could be located, and the Administrator acknowledged the absence of a system that ensured the resident’s personal belongings were inventoried and tracked as required by policy.