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Based on observation, record review and interview, the facility failed to ensure patients personal property rights were upheld, as the facility failed to document receipt of and return of personal property that had been retained from the patient by the hospital for 4 of 4 patients reviewed (Patient #1, #2, #3, and #4).

Specifically, the facility failed to maintain documentation of personal property withheld from patients to ensure protection and security; and failed to return personal property to patients who had been discharged from the facility for Patient's #1, #2, #3, and #4.

This deficient practice was not in compliance with facility's policies or patients' rights, and resulted in an allegation of loss for Patient #1's personal property.

Findings included:

Review of Complaint Intake TX00305395 revealed Patient #1 alleged the following allegations, in part:
Upon arrival to the facility, all of Patient #1's personal belongings were "confiscated with no documentation" as to what those belongings were. Patient #1 was not provided with any papers to sign which showed that she was the owner of the belongings taken away when she arrived. Patient stated her purse and personal items in the purse were taken away; as well as the ring she was wearing. Upon discharge the evening of August 6th, 2018; Patient #1 stated she only received back her ring, wallet, keys, and cell phone (valuable items) which were in the purse that was taken away. Patient #1 stated all the other contents, including the named brand purse itself could not be found after the nurse who attended to her discharge looked for her purse and its other contents. Patient #1 indicated the attending nurse told her to make a list of the missing items and the hospital would have to reimburse her since they could not be found. On August 12, 2018, Patient #1 indicated she sent a letter to the hospital containing a list of those items to the attention of the Patient Advocate; requesting reimbursement. Patient #1 stated she had not received any correspondence or acknowledgement from the hospital staff regarding her personal belongings she never received back after they were taken from her. Patient #1 submitted an itemized list for the total cost of her personal belongings to have been at $435.84 for replacement. Items listed included a blood pressure cuff, support hose stockings, wristbands for carpel tunnel, eye drops, sunglasses, make up, the named brand purse itself, etc.

Facility Policies Reviewed (Provision of Care, Treatment and Services):

The Personal Belonging and Valuables Policy #PC.5.14, last revised 1/25/17 indicated the following, in part:
1. Prior to arrival of potential patient to the Intake Department, the staff assigned to greet the potential patient shall secure a "personal belonging bin" and have it ready for the arrival of patient.
2. Upon arrival of potential patient to the Intake Department, he/she will be asked to "place all belongings in the bin." At that time, Intake staff shall ask the patient if he/she are in possession of any weapons or other disallowed items (to include purses, cell phones and valuable) and ask that these items also be placed on the bin. Any medications will be placed in a sealed plastic bag and also placed in the bin.
4. "The bin shall then be secured with a zip tie, labeled with two identifiers (name and birthdate) and taken to the designated area in the Intake Department."
8. Disposition:
d. Admit the patient- Once the decision is made to admit the patient the intake staff initiate the personal search and transfer belongings as follows:

Intake Process
1. Intake Registered Nurse and another Intake staff take the patient and the bin to the exam room for the skin and contraband check.
e. Any contraband found [during search] is gathered, to be placed in bin when the bin is opened.
2. Intake staff and RN take the patient and bin to an interview room with cameras and clip the zip tie in view of camera. The contents are handled as follows, in part:
b.) Valuables
i. Intake staff, removes all valuables (wallets, credit cards, jewelry, cash, cell phones, small electronics, etc) from the bin. If family is available, patient is encouraged to send valuables home. If family is not available or patient refuses to turn items over to family, staff places the valuables in the envelope. [This envelope is placed in the safe].
c.) Personal Belongings
i. The Intake staff will ask the patient, what items he/she would like from the bin to keep on the unit.
iv. If family is available at the time of admission, the patient is then encouraged to allow family to take home contents of the bin and medications brought by patient.
v. If family is not available or patient refused to allow family to take home items in the bin, the bin is then secured with a black zip tie indicating that the bin is ready for storage.
vi. The items in the bin "are not inventoried" as they are secured in the presence of the patient (or if patient is not able, the staff witness).
Vii. Personal belongings that the patient will be allowed on the unit are placed in a paper sack and given to the patient. Personal belongings will not be inventoried.
vii. the Personal Belongings form, which includes acknowledgment of the handling of belongings and securing of bin, is signed by the Intake staff and by the patient (parent/LAR). If the patient is unable to sign, a second staff signs the form witnessing the securing of the bin with the black zip tie.
4. The Intake staff escorts the patient, along with the bin, any sealed luggage and sealed medication bag, with the medication inventory, to the unit.

Unit Processing of Belongings:
1. Unit RN greets the patient, and assumes responsibility of the patient and the belongings bin by taking a report from the Intake staff and signing the following documents:
c) Receipt of Personal Belongings form, acknowledging bin was delivered and is secured with black zip tie.
3. The bin is placed in the designated area on the unit.

The policy included the two forms to be utilized:
1.) Patient Valuable Contraband, and
2.) Personal Belongings Inventory

Review of the Discharge Planning policy, last revised 1/25/17 indicated the following, in part:
B. At the time of discharge
5. The patient's belongings shall be given to the patient or family member, who will be asked to sign the patient's valuables list.

Review of the Basic Rights for All Patients pamphlet (undated) indicated; 10. You have the right to keep and use your personal possessions.

Observations conducted on 4/3/19 at 12:30 PM of the Unit Patient Property Room (C2105) with the Director of Admissions and Nurse Manager present revealed multiple plastic bins with lids that were zip tied closed on the ends. There was were multiple plastic bins with the lids off exposing the personal belongings. There were multiple brown paper bags with patient personal belongings, and white plastic bags with patient personal belongings that were not secured. Multiple brown paper bags had been torn open with the personal belongings exposed. There also was an open red basket with clothing. A random patient sample of 3 plastic bins were obtained during the observations; Patient #2, #3, and #4.

Review of Patient #1 records revealed she had been transferred from another facility on 7/29/18 and discharged on 8/6/18. The facility did not have evidence of the property disposition for her personal belongings that were not deemed "valuables contraband."

Review of Patient #2's records on 4/3/19 revealed she had been discharged from the facility on 3/12/19. The facility failed to document receipt of; and return of Patient #2's personal property observed in the facility's patient property store room.

Review of Patient #3's records on 4/3/19 revealed he had been discharged from the facility on 3/28/19. The facility failed to document receipt of; and return of Patient #2' personal property observed in the facility's patient property store room.

Review of Patient #4's records on 4/3/19 revealed she had been discharged from the facility on 3/20/19. The facility failed to document receipt of; and return of Patient #2's personal property observed in the facility's patient property store room.

During an interview on 4/3/19 at 3:00 PM with the Director of Admissions (DOA) confirmed Patient's #2, #3, and #4 had already been discharged from the facility and their personal belongings remained in the facility's storage room in bins. The DOA was asked about the facility's process on handling patients personal belongings and she stated the brown paper bags were used when patient belongings were dropped off with the receptionist after admission, and the white plastic bags with patient belongings were used when the facility ran out of the plastic bins. The DOA stated when a patient is admitted, the staff go through their belongings to determine if there is contraband that they are not able to keep with them. A paper bag is given to the patients with their personal belongings they can keep with them on the unit. Their valuables (i.e. money, cell phones, keys, wallets, credit cards, etc.) are placed in a sealed bag and placed in the facility's safe. The other miscellaneous personal belongings are placed in a plastic bin and zipped tied on the ends for security. The plastic bin is then placed in the storage room and "logged in on the sheet" that the patient has personal belongings in the room. The DOA stated an itemized list of patient personal belongings is not completed any longer for the items that are kept from the patient and kept in the storage room on the unit. She further stated the facility "used to do that, but not anymore." The DOA further confirmed there was not any documentation in the patients records to document the receipt of and return of personal property unless it was valuables or medications. The DOA confirmed there was not a current documented system in the patient's record for verification the patient's belongings that had been maintained and placed in the storage room were returned back to them upon discharge. The DOA stated the facility searched their storage rooms and were not able to locate the personal belongings of Patient #1 as stated in her written complaint (TX00305395).

Review of the facility's Process Improvement Team Meeting Minutes dated 11/26/18 documented the facility had identified areas for improvements to reduce lost belonging complaints by 50% based on patient complaints; "On a daily basis the hospital receives numerous complaints regarding lost belongings." The facility's plan was to utilize belonging bins with labels on the side of the bin. Bins were to be zip tied. Valuables will be taken to the safe by admissions staff.