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Based on medical record review, observations made during tour of the facility, facility document review and staff interview, the facility failed to ensure patients were afforded respect for personal property (A129). The facility failed to ensure patients right to care in a safe setting (A144).

Based on medical record review, staff interview, and facility document review, the facility failed to ensure patients were afforded respect for personal property for three of 10 patients reviewed (Patient #6, #5, and #15). The facility's census was 47.

Findings include:

Review of an undated facility document titled, Securing and Storing of Patient Belongings- Process and Documentation Map, revealed "1. Upon patient arrival to hospital personal belongins are secured in the Intake Area for safety and security purposes." "4. If patient is admitted Inpatient Intake will complete the steps below: a. Initiate the Patient Belongings form." "5. Patients with $50 of more on their persons...Have two staff members count the money in front of the patient, document the amount,". "Unit staff will complete the steps below at DISCHARGE:...8. g. Review the list of items on the patient belongings form; verify each item and document "Yes" beside each item to indicate patient received items at discharge." "Have patient sign under the disposition/release of property at discharge to include date and time." "Unit staff will sign under the disposition/release of property at discharge to include date and time." "Verify form is complete and items returned to patient at discharge is clearly documented."

1. Review of Patient #6's medical record revealed an admission date of 09/16/23 at 9:35 P.M. and a discharge date of 09/21/23 at 12:58 P.M. The patient was admitted with a diagnosis of bipolar disorder with current episode of depression, severe without psychiatric features, and suicidal ideation without a plan. Review of a Progress Note dated 09/21/23 at 1:00 P.M. revealed "Patient #6 discharged from facility with all belongings and instructions."

No personal property form was located in Patient #6's records.

Interview on 11/02/23 at 10:51 A.M. with Staff A revealed that property paperwork was not being returned to the patient charts upon discharge and verified there was no property form in Patient #6's chart.

2. Review of Patient Belongings Log for Patient #15, who was no longer in the facility, revealed the log listed "money", without an amount written on the log. On page 2, it was noted a "jar medical marijuana" was in Patient #15's backpack, but this item was not listed on the medication list on page 3. The list was not signed by Patient #15 as being accurate. The list was not verified upon discharge by a staff member, which the policy stated staff will "verify each item and document 'Yes' beside each item to indicate patient received items at discharge."

Interview on 11/01/23 at 3:47 P.M. with Staff GG revealed that Patient #15's items were locked in a secure room due to the high value of money he brought in with him. Staff GG stated Patient #15 had more than $50. She stated that she was not educated on how to complete the personal item log, she was told if the patient signed it, that was all that needed to be done.

3. Review of Patient #5's medical record revealed an admission date of 10/31/23 and a small baggie containing two black and silver colored garment buttons secured in her physical chart with the personal item log. The items were not recorded on the log.

Interview on 11/02/23 at 10:51 A.M. with Staff verified that the garment buttons were present in Patient #5's physical chart but were not documented on the property form.

This deficiency represents non-compliance investigated under Substantial Allegation OH00146846.

Based on medical record review, observations made during facility tour, staff interview and facility policy review, the facility failed to ensure the patients' right to care in a safe setting for one of 10 patients reviewed (Patient #9). This had the potential to affect patients in the Adult and Adolescent Behavioral unit. The facility's census was 47.

Findings include:

1. The low acuity Adult Behavioral unit was toured on 11/01/23 at 3:00 PM. Six patients were observed to be sitting in a locked room watching a large flat screen television. A small sign on the glass surrounding the room revealed the room was the Noisy Activity Room. There was no staff member visible in the room. This surveyor attempted to open the door and found it to be locked. As Staff A, present during the tour, looked around the unit, a staff member was observed walking up to the Noisy Activity Room. The staff member used her badge to enter the room. It was confirmed with Staff A that the staff member should have been in the activity room to monitor the patients.

The Adolescent 100 Unit was toured on 11/02/23 at 3:30 PM. Seven patients were observed in the Noisy Activity room. No staff member was observed in the locked room in order to monitor the patients. The staff member assigned to monitor the patients in the activity room was observed walking in the activity room moments later. Staff A, present during the tour, confirmed that patients should not be left alone in the locked Noisy Activity room.

2. Review of the medical record of Patient #9 revealed the patient was admitted to the facility on 08/18/23. The patient was admitted from an Emergency Department after cutting herself. The patient reported being sad about a previous suicide attempt. The patient was ordered to have an every 15 minute level of observation.

A nurse's note dated 08/22/23 at 6:30 PM stated staff observed the patient in the Quiet Room. Upon entering the room to check on the patient, the nurse observed the patient trying to cut her left forearm with a comb. The patient became combative when a staff member attempted to take the comb away from her and was placed in seclusion. The patient was discharged on 08/26/23.

The facility policy titled, Contraband, was reviewed on 11/03/23 at 4:20 PM. According to the policy, upon admission a thorough search will be made of the patient, purses, pockets, luggage, and belongings. Staff will attempt to send any contraband back with family or place contraband items in the designated locations. Staff will consider the following to be contraband:
a. Any item deemed unsafe by any staff member.
b. Grooming equipment including combs.

The Adolescent 100 Unit was toured on 11/02/23 at 3:30 PM. Observation of the patient rooms revealed one large black wide-tooth comb in a bucket placed in a cubby shelf next to bed 1 in room 101. The teeth of the comb were noted to be bent in numerous directions and also very sharp to the touch. Two additional combs were observed in the bathroom of this room. It was confirmed with Staff A, present during the tour, that the combs could be used for cutting, were considered contraband, and should not be left in a patient's room without supervision.

Staff A was interviewed on 11/03/23 at 4:25 PM. It was confirmed that the combs should be considered contraband and placed in a designated location.

The deficiency represents non-compliance investigated under Substantial Allegation OH00146755.