Failure to Thoroughly Investigate and Resolve Grievances About Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve resident grievances related to missing personal items and laundry, and to consistently follow its grievance and personal property policies. Multiple residents reported that laundry items such as clothing and socks frequently went missing. One resident, who was also the Resident Council president, stated that missing laundry was a recurring issue discussed at Resident Council meetings and wanted staff to resume bringing unclaimed personal items from laundry for residents to sort through. Another resident reported missing pajama pants and a sweater, stating the Nursing Home Administrator was aware and had said the items would be replaced, but this had not occurred. A further resident reported a missing nightgown with cardinals, and both that resident and the roommate indicated staff were aware but had not located the item or provided an update. Review of Resident Council minutes showed that missing clothing and lost-and-found items had been discussed in prior meetings, and staff had acknowledged working on an improved process to decrease missing items. Despite this, the grievance log contained no entries for the residents’ missing items. In the laundry area, the surveyor observed a bin of unlabeled clothing and a bulletin board listing residents’ names and missing items, which laundry staff used informally to track lost belongings. Laundry staff reported that residents’ belongings were supposed to be inventoried on admission and sent to laundry for labeling, but this process was inconsistent, and items were often laundered before being labeled. Laundry staff also stated that they were not always informed when items were missing, and that missing items occurred almost daily. Another component of the deficiency involved a resident whose borrowed brown wheelchair went missing shortly after admission. The resident, who had intact cognition and used a wheelchair, reported telling multiple staff about the missing wheelchair and expressed a desire to have the friend’s wheelchair returned. A grievance documented that the care team reported the missing wheelchair, that staff searched the facility and interviewed the receptionist, and that a new wheelchair was provided, with the grievance noting the resident was reportedly satisfied and had no further complaints. However, the grievance did not include interviews with other staff or residents to determine if anyone else had seen the wheelchair or knew its whereabouts. Additionally, the resident’s medical record lacked an admission inventory of belongings, and the Assistant DON confirmed that while belongings should be inventoried and documented, no such inventory was found for this resident.
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