Failure to Document and Protect Resident’s CPAP as Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property by not documenting the resident's CPAP machine on any inventory forms during admission or discharge. The facility's Personal Property policy required that residents' personal belongings and clothing be inventoried and documented upon admission and updated as necessary. The resident, who lacked capacity to understand and make decisions per a history and physical dated 12/19/25, was admitted with personal belongings documented only as jackets and shoes on the Resident's Clothing and Possessions form. A physician's order dated 2/6/26 directed the use of a CPAP device for obstructive sleep apnea, and the responsible party later complained that when the resident was transported home, a different CPAP machine was received than the one originally provided to the facility. During interviews and record review, LVN 1 confirmed that the resident used their own CPAP machine in the facility and that she was responsible for both the admission and discharge processes, including completing the Resident's Clothing and Possessions form at discharge. LVN 1 stated that staff were expected to record belongings on admission and use a Personal Inventory Update form, which includes fields for add/delete, description, serial number, and quantity, whenever new items or equipment were brought in or removed, and to itemize belongings returned at discharge. However, there was no documentation of the CPAP machine on the admission inventory, no Personal Inventory Update form completed, and no record of the CPAP or other belongings sent with the resident at discharge. LVN 1 acknowledged that the CPAP machine was sent with the resident but could not recall the type of CPAP or other items sent, and the DON confirmed that staff were expected to record each personal item at admission, update, and discharge.
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