HospitalInspections.org

Based on document review and staff interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to inventorying patient belongings on admission and sending home medications with patient upon discharge and/or transfer for 1 of 1 (#1) patient medical records reviewed.

Findings:

1. Policy III-B.28, Personal Belongings Inventory, revised/reapproved 2/16, indicated upon admission a staff member will inventory all patients' belongings, and sign the Personal Belongings Inventory Form.

2. Policy II-F.72, Handling of Medications Brought to the Hospital by the Patient, revised/reapproved 10/15, indicated upon discharge any home medications will be sent with the patient upon transfer. Any medications left in house will be a) destroyed after 45 days or b) family will be contacted to retrieve medications.

3. Review of patient 1's medical record on 6/23/16 at approximately 1310 hours indicated the Patient Belongings Inventory Form section titled "Personal Valuables List - Items Placed in Safe" lacked documentation of patient's Advair Disc brought from home. Upon discharge patient was transferred to F2 in stable condition without their home medication.

4. Staff 3 (Director of Compliance) was interviewed on 6/23/16 at approximately 1347 hours and confirmed patient 1 came in with Advair Disc aerosol inhaler as a home medication. There is a section on the Patient Belongings Inventory Form titled "Personal Valuables List - Items Placed in Safe" that has a space to document other belongings and describe them. The home medication was not documented on this list or sent with the patient on transfer to another facility as required per facility policy and procedure.

5. Staff 4 (Outreach Manager [Community Liaison]) was interviewed on 6/23/16 at approximately 1333 hours and confirmed they brought the patient's Advair Disc inhaler to F4 because it did not get sent with the patient upon discharge from F1 as required per facility policy and procedure.