Failure to Maintain Accurate Inventory Documentation of Resident Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records, specifically related to documentation of a resident’s personal belongings at admission and discharge. An 83-year-old female resident with Alzheimer’s disease, major depressive disorder, and anxiety was admitted and later discharged against medical advice (AMA) at the request of her responsible party (RP). The resident’s quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment. Record review showed no documentation that the resident’s personal items were inventoried at admission or at the time of discharge, despite the resident’s discharge summary and nurse notes documenting the AMA discharge. Multiple staff interviews confirmed uncertainty or lack of action regarding the inventory of the resident’s personal items. The Administrator stated she was not certain whether an inventory sheet had been completed at admission or discharge, although she reported that the family took all of the resident’s personal items home. LVN A and LVN C both stated they could not recall whether an inventory of personal items was done at discharge. CNA B specifically stated that the family left with all of the resident’s possessions and that an inventory sheet was not completed. The DON confirmed he could not locate any initial, updated, or discharge inventory sheet for the resident. The RP confirmed by telephone that the family took all of the resident’s personal items and did not recall signing any inventory sheet at admission, during the stay, or at discharge. The Administrator and DON both described a standard practice that resident personal items should be inventoried at admission, during the stay when new items arrive, and at discharge, but they acknowledged this was not done for this resident. The facility was unable to provide a policy on inventory of resident personal items at the time of the survey, although its Transfer or Discharge, Facility-Initiated policy required documentation of the disposition of personal effects in the medical record. This lack of documentation and missing inventory records for the resident’s personal items at admission and discharge constituted the cited deficiency.
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