Failure to Replace Lost Eyeglasses and Notify Resident Representative
Penalty
Summary
The facility failed to protect a resident’s personal belongings when the resident’s eyeglasses were lost and not replaced in a timely manner. The resident was admitted in late 2025 with a diagnosis that included a brain disease impairing memory, and an Order Summary Report dated 9/17/25 documented that the resident did not have capacity to make medical decisions. The resident’s responsible party (RP) reported that the facility had lost the resident’s glasses and had neither replaced them nor reimbursed the cost of replacement. The Social Service Assistant (SSA) stated that the usual process for a lost item was to complete a theft and loss form, communicate with family, and have the facility pay for the lost item if it was not located, with a copy of the form kept in the social services office. During interviews and record review, the SSA recalled that the RP had reported the glasses missing and that the facility had met with the RP to discuss the loss, and she stated that a theft and loss form had been completed. However, the SSA and DON were unable to locate any theft and loss form for the lost glasses, and the SSA could not identify the exact date the glasses were lost, only that it occurred sometime between September and December 2025. An eye exam form dated 1/22/26 showed the resident declined new eyeglasses after the exam, but the SSA confirmed the resident lacked capacity to make medical decisions and that the RP should have been notified, which did not occur. The SSA confirmed that nothing further had been done to replace the glasses and acknowledged that glasses were important to help residents see. The facility’s policy on investigating incidents of theft and loss required prompt and thorough investigation of theft or misappropriation, prompt response to complaints, and notification of the resident and/or representative of investigation results and corrective action, which was not demonstrated in this case.
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.