Failure to Assess and Document After Unauthorized Room Entry and Property Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an unauthorized individual entered a resident’s room and allegedly misappropriated the resident’s property. The resident involved had diagnoses including diabetes mellitus, malignant neoplasm of the endocrine pancreas, muscle weakness, and difficulty walking, and required moderate to total assistance with ADLs. An MDS assessment indicated the resident’s cognitive skills for daily decision-making were intact and that the resident had moderate to severe depressive symptoms, including little interest or pleasure in activities, feeling down or hopeless, and sleep disturbances. On the morning in question, an unhoused individual gained access to the facility through a front door that did not fully close and lock, entered the resident’s room, and slept in an unassigned bed in that room. The resident’s family member reported that the resident discovered the individual in the room, pressed the call light multiple times, and no staff responded for a while. The family member stated that the resident’s mobile phone was later found missing and that the resident felt terrified and unsafe following the incident. The family member reported the missing phone to facility staff. A LVN stated she observed the unauthorized individual in the resident’s room early that morning, noted that no resident was assigned to that bed, and escorted the individual out after determining he did not belong in the facility. The LVN reported that the individual appeared homeless, carried a plastic grocery-type bag, and showed a mobile phone while claiming he had checked in. The LVN did not assess the resident after the incident, did not document the event, and did not report it to management or other staff, and she did not know how long the individual had been in the room or what he had done there. The DON later confirmed there was no documentation in the resident’s medical record of the incident or any post-incident assessment, despite facility policies requiring complete, objective, and accurate documentation of changes in a resident’s condition and requiring identification, investigation, and protection of residents in situations involving possible abuse, neglect, exploitation, or misappropriation of property.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.