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Based on observation, interview and record review, the facility failed to follow their policy and procedure (P&P) when patient belongings were not properly inventoried, stored, and returned on discharge for 11 of 31 sampled patients (Patients 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31).

These failures resulted in patients not having their personal items returned to them prior to discharge and could have resulted in a breach in confidentiality and impact the overall quality of patient care.

Findings:

On September 16, 2024, at 10:55 a.m., a tour of Unit A was conducted with the Director of Medical/Surgical Unit (DMS 1), and the Nurse Educator (NE). During the tour of Unit A, in the soiled utility room, two bins labeled "PATIENT BELONGINGS was observed. Inside the bins, multiple bags labeled with patient's names and some without labels were found in the bins including loose items such as clothing, dentures, wallets (identification, credit cards, insurance cards, bank cards, social security card, and miscellaneous cards), medications (from home and from the facility), an original advance directive, jewelry, cell phone, car key fob, discharge instructions, life alert lanyard, prescription glasses, and sun glasses.

On September 16, 2024, at 11:05 a.m., an interview was conducted with DMS 1. DMS 1 stated she did not know how or why the bins labeled "PATIENT BELONGINGS" were placed in the soiled utility room. DMS 1 stated these bins should not be in this room and was not sure how long they have been there. DMS 1 stated patient belongings and medications should never be stored in the soiled utility room.

On September 16, 2024, at 11:25 a.m., an interview was conducted with Environment Services (EVS). EVS stated he was not the one who placed the bins in the soiled utility room, but they were present on September 15, 2024.

On September 16, 2024, at 11:32 a.m., an interview was conducted with the Director of EVS (DEVS). DEVS stated the bins do not belong in the soiled utility room and did not know how or why the bins were placed in this room.

a. A review of Patient 21's medical record was conducted on September 16, 2024, at 1:45 p.m., with the Orthopedic Program Manager (OPM) and the Clinical Effectiveness Coordinator (CEC).

During the tour of the soiled utility room, a belonging bag was observed to have the following medications in it with Patient 21's name on them; Pantopazolone sodium 40 mg (a medication used to treat gastroesophageal reflux disease) 6 tablets, Pantopazolone sodium 40 mg 13 tablets, Atorvastatin 10 mg (a medication used to decrease cholesterol) 15 tablets, Glimepiride 4 mg (a medication used to treat diabetes) 3 tablets, Aspirin 81 mg one tablet, Metformin 500 mg (a medication used to treat diabetes) 23 tablets, Lisinopril 20 mg (a medication used to treat high blood pressure) 15 tablets.

A review of the facility's document titled, "History and Physical (H&P)", indicated Patient 21 was admitted to the facility on March 21, 2023, for aspiration pneumonia (an infection of the lungs), swelling of the lower legs, and acute kidney injury.

A review of the facility's document titled, "Valuables/Belongings," dated March 21, 2023, indicated Patient 21 did not have any medications.

A review of the facility's document titled, "Progress note-Nurse," dated April 3, 2023, authored by the House Supervisor (HS). was conducted. This documented indicated, "...Personal Belongings...Called emergency contact number [family phone number] to let the family know this patient left some of his personal belongings in the room...This HS left a message with a return contact phone number to reach me at. Will hold belongings at the charge desk..."

On September 18, 2024, at 10:45 a.m., an interview with the Director of Pharmacy (DOP) was conducted. The DOP stated patients home medications are never stored at the bedside and should not be in the soiled utility room. The DOP stated home medications are inventoried (tablets counted) and sent to the pharmacy. The DOP further stated there was no record that Patient 21's home medications were stored in the pharmacy.

b. During the tour of Unit A, a patient's belonging bag was observed in the soiled utility room which contained an original "Advance Health Care Directive [legal document that expresses medical wishes]" form and other articles of clothing with Patient 22's label on the bag.

A review of facility's document titled, "H&P," dated May 4, 2024, indicated Patient 22 was admitted to the facility on May 5, 2024, with a syncopal (fainting) episode.

A review of the facility's document titled, "Valuables/Belongings," dated May 5, 2023, indicated Patient 22 did not have the original "Advance Health Care Directive" on the inventory list.

On September 16, 2024, at 12:02 p.m., an interview with DMS 1 was conducted. DMS 1 stated the original "Advance Health Care Directive" should have been given back to the family member after a copy was made for the Electronic Medical Record (EMR). DMS 1 further stated, the articles of clothing should have been returned to Patient 22 on discharge.

c. During the tour of Unit A, a biohazard bag (a bag used to collect wastes products containing tissue and blood) in the soiled utility room was observed with a silver-colored watch and with Patient 23's label on the bag.

A review of facility's document titled, "H&P," dated May 25, 2023, indicated, Patient 23 was admitted to the facility on May 25, 2023, with encephalopathy (disease of the brain that can cause altered level of consciousness), and hyponatremia (low sodium levels).

A review of facility's document titled, "Valuables/Belongings," dated May 28, 2023, indicated, "...watch At bedside...Returned upon Discharge..."

A review of the facility's document titled, "Progress note-Nurse," dated May 28, 2023, indicated, "...Going over D/C [discharge] with Night Shift RN [nurses name], went over belongings list and no watch found at bedside. RN went through belongings bag and no watch found..."

On September 16, 2024, at 12:02 p.m., an interview with DMS 1 was conducted. DMS 1 stated the watch should have been placed in the safe when found and the patient/family should have been called to pick it up and this was not done.

d. During the tour of Unit A, a biohazard bag was observed in the soiled utility room which contained a cell phone and a brown wallet and with Patient 24's label on the bag.

A review of facility's document titled, "H&P," dated September 16, 2023, indicated, Patient 24 was admitted to the facility on September 16, 2023, with a subdural hematoma (blood to the brain), Chronic Obstructive Pulmonary Disorder (COPD, a lung disease that makes it difficult to breath), and Hypertension (elevated blood pressure).

A review of facility's document titled, "Valuables/Belongings," dated October 6, 2023, indicated, Patient 24 did not have a cell phone or a wallet on the inventory list.

On September 18, 2024, at 11:15 a.m., an interview with DMS 1 was conducted. DMS 1 stated the cell phone belonged to Patient 24, and his wife was notified of this on September 17, 2024, and she would be in to pick it up. DMS 1 stated the wallet belonged to another patient the patient's family was notified on September 17, 2024, and would be in to pick it up. DMS 1 stated both items should have been placed in the safe and patient's notified when items were found, and this was not done.

e. During the tour of Unit A, a biohazard bag was observed in the soiled utility room with a pair of prescription glasses and with Patient 25's label on the bag.

A review of facility document titled, "H&P," dated April 20, 2022, indicated, Patient 25 was admitted to the facility on April 22, 2022, with hypertension, impaired ambulation (walking), and lower extremity edema (swelling).

A review of facility's document titled, "Valuables/Belongings," dated April 24, 2022, indicated the patient did not have eyeglasses on the inventory list.

On September 18, 2024, at 11:15 a.m., an interview with DMS 1 was conducted. DMS 1 stated the patient should have been called to retrieve the glasses and this was not done.

f. During the tour of Unit A, a biohazard bag was observed in the soiled utility room with a brown wallet and with Patient 26's label on the bag.

A review of facility document titled, "H&P," dated November 14, 2023, indicated, Patient 26 was admitted to the facility on November 15, 2023, with Congestive Heart Failure and lower extremity edema (swelling).

On September 18, 2024, at 9:30 a.m., a concurrent interview and record review were conducted with the Clinical Effectiveness Coordinator (CEC). The CEC stated an admission belongings inventory was not completed. The CEC further stated document titled, "Valuables/Belonging," dated November 16, 2023, indicated, "...No Data Available..."

On September 18, 2024, at 11:15 a.m., an interview with DMS 1 was conducted. DMS 1 stated a patient belongings inventory list should have been completed on admission and the wallet should have been sent to the safe. DMS 1 stated the P&P was not followed.

g. During the tour of Unit A, a biohazard bag was observed in the soiled utility room with a container containing lower dentures in water and with Patient 27's label on the bag.

A review of facility document titled, "H&P," dated August 7, 2023, indicated Patient 27 was admitted to the facility on August 7, 2023, with COPD, weakness, and coronary artery disease (blocked arteries due to build up).

A review of facility's document titled, "Valuables/Belongings," dated August 10, 2023, indicated, Patient 27 "...with upper dentures, lower dentures..." was listed on the inventory list.

On September 18, 2024, at 11:15 a.m., an interview with DMS 1 was conducted. DMS 1 stated the patient should have been called to retrieve the dentures when they were found. DMS 1 further stated Patient 27's care giver will be in to pick the dentures up this week.

h. During the tour of Unit A, a biohazard bag was observed in the soiled utility room with a pair of prescription glasses and with Patient 28's label on the bag.

A review of facility document titled, "H&P," dated July 30, 2023, indicated, Patient 28 was admitted to the facility on July 31, 2023, with hypertension, coronary artery disease and syncopal episode.

A review of facility document titled, "Valuables/Belongings," dated July 31, 2023, indicated the patient did not have eyeglasses on the inventory list.

On September 18, 2024, at 11:15 a.m., an interview with DMS 1 was conducted. DMS 1 stated the patient should have been called to retrieve the glasses when they were found, and this was not done.

i. During the tour of Unit A, a biohazard bag was observed in the soiled utility room which contained three boxes of eye drops, Timolol, Maleate, Prednisolone Acetate, Ketorolac (eye drops used to treat glaucoma, a chronic eye disease caused by damage to the optic nerve) and with Patient 29's label on each of the medication boxes.

A review of the facility document titled, "H&P," dated May 22, 2023, indicated, Patient 29 was admitted to the facility on May 22, 2023, with a syncopal episode and abdominal pain and has a history of glaucoma.

On September 16, 2024, at 12:02 p.m., an interview with DMS 1 was conducted. DMS 1 stated the eye drops came from the facility and should not be stored at the bedside or in the soiled utility room.

On September 16, 2024, at 1:30 p.m., an interview with the Quality Supervisor (QS) was conducted. The QS stated the facility does not have an outpatient pharmacy. The QS stated the eye drops for Patient 29 should not have be given to her since these were medications provided by the hospital pharmacy to be administered while admitted.

On September 18, 2024, at 10:45 a.m., an interview with DOP was conducted. The DOP stated the eye drops were dispensed by the hospital pharmacy and should not have been placed in the patient belongings bin. They should have been returned to the pharmacy. The DOP further stated medications should not have been stored in the soiled utility room.

j. During the tour of Unit A, a biohazard bag was observed in the soiled utility room which contained a life alert lanyard and with Patient 30's label and a note "...[Room number], discharged 10/24/23 [October 24, 2023]..."

A review of the facility's document titled, "H&P," dated October 19, 2023, indicated, Patient 30 was admitted to the facility on October 19, 2023, with altered mental status and anemia (condition that occurs with blood loss).

A review of facility's document titled, "Valuables/Belongings," dated October 19, 2023, indicated Patient 30 did not have a life alert lanyard on the inventory list.

On September 18, 2024, at 11:15 a.m., an interview with DMS 1 was conducted. DMS 1 stated the patient should have been called to retrieve the life alert lanyard when it was found, and this was not done.

k. During the tour of Unit A, a belonging bag was observed in the soiled utility room which contained a urinary catheter drainage kit and a key fob with Patient 31's label on it.

A review of the facility's document titled, "H&P," dated March 19, 2023, indicated Patient 31 was admitted to the facility on March 19, 2023, with possible pneumonia (infection of lung) versus pulmonary edema (fluid in lung).

A review of the facility's document titled, "Valuables/Belongings," dated March 20, 2024, indicated, "...Other...At bedside, Returned upon Discharge, key..."

On September 17, 2024, at 12:50 p.m., an interview with DMS 1 was conducted. DMS 1 stated the patient should have been called to retrieve the key fob and her items when they were found. DMS 1 stated Patient 31 was contacted and came in on September 17, 2024, to pick up the key fob.

On September 16, 2024, at 1:30 p.m., an interview was conducted with the QS. The QS stated the P&P for placing valuables in the safe and medications brought from home and dispensed from pharmacy were not followed.

On September 17, 2024, at 12:50 p.m., an interview was conducted with DMS 1. DMS 1 stated the P&P for patient belongings, placing items in the safe, and storage of medications were not followed.

On September 18, 2024, at 10:45 a.m., an interview was conducted with the QS. The QS stated letters were not sent by security per policy to patients when valuables/property ownership was discovered. The QS stated the P&P for patient valuables was not followed.

A review of the facility's P&P titled, "Discharge Medication Counseling," dated August 8, 2022, indicated, "...For medications ordered by the physician for the patient upon discharge, the remainder of a multiple dose container of medication previously dispensed to the patient for inpatient use will NOT be provided to the patient to take home..."

A review of the facility's P&P titled, "Patient Valuables and Belongings: Admission Process," dated October 18, 2018, indicated, "...At the time of admission, inform each patient to have a family member or friend take all the patient's property or valuables home, However, if this action cannot be accomplished, valuables are placed in a valuables envelop and stored in the safe...Inventory all valuables with patient or patient representative...Found Patient Belongings (Non-valuables)...Patient belongings that are labeled with the patient's identification and are found or left behind after discharge will be sent to the nursing clinical supervisor's office. The clinical supervisors will call the patient/family to return to the hospital to pick up the belongings, and document the date contact was made on/inside the bag. Belongings that are not picked up within a week of notification will be discarded or donated. Belongings found without patient identification will be kept for a one week after which time they will be discarded or donated...Found Patient Valuables...Patient valuables found that are unlabeled will be turned in to the Security Office. The Security office will secure the valuable and contact the Patient Advocate to determine if any reports of lost valuable have been made matching the description. If a possible match is made, the Patient Advocate will contact the patient/family. Valuables not claimed will be appropriately discarded or donated after 90 days..."

A review of the facility's P&P titled, "Valuables and Property: Security Process," dated February 8, 2021, indicated, "...Unclaimed valuables/property found in rooms, parking lots, hospital grounds...found within the hospital facility...if an item has been found within the facility, obtain a patient belongings bag and place the item(s) inside the bag. On the outside of the bag write the patient's name if known, location/room number, date and time...Contact Security/House supervisor to log items into lost and found cabinet or safe...Security will maintain a Lost Item Log for any items turned into security. Security will access this log for appropriate personnel who call regarding an item which may have been lost. The Security Officer will be responsible for placing the phone calls...A letter will be sent by the hospital if valuables/property ownership can be identified. The letters will be prepared, sent, followed-up on, and retained by the Security Officer/Plant Operations at each facility..."

A review of the facility's P&P titled, "Medications/Devices Brought from Home by Patients," dated of June 10, 2024, indicated, "...If medications or device cannot be sent home with the family, it shall be sent to the pharmacy for safekeeping. It will not be kept on the nursing floor...Nursing will document on the chart that medications were brought in and sent to the pharmacy and the storage bag tag will be placed in the patient's chart..."

Based on interview and record review, the facility failed to ensure the facility's condition of admission (COA - a document that includes provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risks and benefits] for treatment and may also require the patient's confirmation of understanding on various arrangements related to the treatment the patient will receive in the facility) was provided for three of 31 sampled patients (Patients 4, 12, and 23).

This failure had the potential for patients to not be informed of their rights, which may also result in their inability to effectively make decisions regarding care or treatment.

Findings:

1. A review of Patient 4's medical record was conducted on September 17, 2024, at 1:30 p.m., with the Sepsis and Quality Coordinator (SQC).

A review of the facility's document titled, "History and Physical (H&P)," dated August 31, 2024, indicated Patient 4 was admitted on August 31, 2024, for ethyl alcohol (ETOH) cirrhosis (liver damage due to alcohol), acute renal failure (kidneys not working), and gastrointestinal hemorrhage (bleeding in the colon).

A review of the facility's document titled, "Condition of Admission/Registration Treatment Authorization and Financial Responsibility," dated September 14, 2024, indicated, there was no documented evidence the COA was provided and Patient 4's emergency contact person was not contacted to complete it.

On September 17, 2024, at 2:36 p.m., an interview was conducted with the SQC. The SQC stated Patient 4 did not have a signed COA and the policy was not followed.

2. A review of Patient 12's medical record was conducted on September 17, 2024, at 1:40 p.m., with the Stroke Program Manager (SPM).

A review of the facility's document titled, "H&P," dated August 23, 2024, indicated, Patient 12 was admitted on August 22, 2024, at 12:14 p.m., for chronic gerd (a backflow of stomach acid), skin ulcer (open sore on the skin) of lower leg, and schizophrenia (mental disorder).

A review of the facility's document titled, "Conditions of Admission/Registration Treatment Authorization and Financial Responsibility," dated August 29, 2024, at 2:51 p.m., indicated, "...Unable to sign...Verbal Consent...August 29, 2024..." There was no documented evidence the facility attempted to follow up after the initial attempt with patient or emergency contact.

On September 17, 2024, at 2 p.m., an interview was conducted with the SPM. The SPM stated the COA was not signed, and no follow-up was conducted.

3. A review of Patient 23's medical record was conducted on September 17, 2024, at 1:45 p.m., with the Orthopedic Program Manager (OPM).

A review of the facility's document titled, "H&P," dated May 5, 2023, indicated, Patient 23 was admitted to the facility on May 25, 2023, for acute encephalopathy (infection or lack of oxygen in the brain), coronary artery disease (arteries blocked due to buildup), status post coronary angioplasty (procedure to open blocked arteries), and chronic kidney disease (damaged kidneys not functioning properly).

A review of the facility's document titled, "Condition of Admission/Registration Treatment Authorization and Financial Responsibility," dated May 25, 2023, indicated, "...Unable to sign..."

On September 18, 2024, at 10:55 a.m., an interview was conducted with the Director of Admissions and Patient Access Services (DAPA). The DAPA stated Patient 23's COA signature was not obtained, and the family was not notified and should have been.

On September 18, 2024, at 3:15 p.m., an interview was conducted with the the DAPA. The DAPA stated if the patient was unable to sign at admission, a follow up should first be made with the patient, and if necessary, with their representative, power of attorney, or emergency contact. The DAPA further stated once the patient is admitted, the facility aims to obtain patient's signature promptly.

A review of the facility's policy and procedure (P&P) titled, "Consents," dated May 13, 2024, indicated, "...To set guidelines which define when consent is necessary...Routine hospitals services/activities require the patient or legally authorized representative consent via the signed...Condition of Admission..."