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Based on review of policy and procedures, facility documents and staff interviews, it was determined that the facility failed to ensure that the medical record included documentation of the chain of custody of patient belongings when documentation supporting personal belongings and valuables removed from a patient upon admission, during hospitalization, and returned to patient upon discharge from facility for one patient (P) (P#1) of four records reviewed.


Findings Include:


A review of facility's policy titled "Patients Belongings and Valuables Protocol,", Policy No.: RL041, last revised 09/24, revealed that is the policy of the facility to provide safe storage of valuable patient possessions during in-patient treatment. All patients admitted to the facility will undergo a safety search. A patient's belongings that have been brought into the hospital and that do not accompany the patient onto the assigned unit will be stored in the Patient Belongings Closet (PBC). For security purposes, belongings that are considered valuables will be stored in a safe within the Patient Belongings Closet. Storage of patient belongings and valuables and access to the Patient Belongings Closet will be done according to the following guidelines:

Process for Belongings at Admission:
1. For patients who are brought into the facility via Emergency Services, they will undergo a safety search and have belongings and valuables removed, bagged belongings labeled and placed in a cubicle within the ARS Department. The safety searches will be conducted by two employees, one as the primary search conductor and the second to review and double check the process.
2. During this safety search time, the patient will be allowed to get phone numbers from their phone.
3. The patient will be given a document outlining the belongings process for them to sign during the admissions process. If the patient arrives with no belongings, this form will be used to document this and the patient will sign it. This form will be placed in the medical record.
4. After the patient is admitted, the belongings bag will be tagged with patient label and placed in the Patient Belongings Closet. Wallets, jewelry, electronic devices, credits cards, money, purses and any other valuables should be placed in the vault in the Patient Belongings Closet.
5. If the patient arrives wearing regular clothes, the patient will be allowed to go to the unit wearing those clothes (if they are appropriate) after the safety search is completed.
6. If the patient arrives wearing scrubs, the patient will be given new scrubs while in ARS
7. Appropriate belongings will be approved by ARS staff. Upon receiving the appropriate belongings that will accompany them to the unit and the list belongings/valuables that are stored, the patient will sign off on the list. One copy will be placed in the medical record, the second copy will be in the belongings binder housed in the ARS Dept. In the event the patient cannot sign, 2 staff will sign.
8. Once the patient has been processed through ARS, they will be accompanied by staff to the appropriate unit. They will receive their approved belongings on the unit after the scheduled belongings search has been completed
Upon receiving their belongings, the patient will sign off on the list of belongings they received and the list of belongings/valuables that are stored.

Process for Patient at Discharge:
1. On date of discharge Milieu Manager or designee will move patient's belongings to the discharge closet to minimize delays at discharge.
2. The discharging MHA or nurse will retrieve the patient's belongings, have the patient verify items that have been received, and then have the patient sign off that all belongings have been returned. The signed belongings sheet at discharge will be placed in the medical record.
3. Patient Advocate and Milieu Manager should be notified of any discrepancies in patient belongings.


A review of the facility's policy titled "Patient Rights and Responsibilities," Policy: RL005, last revised 10/22, revealed that it was the policy of the facility to respect all patients without regard to race, religious creed, color, ancestry, national origin, sex, disability, marital status, familial status, or sexual orientation. The facility supported and protected the fundamental human, civil, constitutional, and statutory rights of the individual patient and recognized and respected the personal dignity of the patient at all times. Rights are restricted only in accordance with applicable law and regulation.

Approximately two days prior to planned discharge, the Social Worker will give the patient another copy of "An Important Message from Medicare" to read and sign as a part of the discharge process. The second notice will be given no more than 2 days prior to discharge and no less than 4 hours prior to discharge. In the event a Social Worker is unavailable to provide the second notice, a nurse will give a copy of the form to the patient.
If patients disagreed with the discharge decision, it was their right to appeal the discharge decision. If the patient exercised his right to contact the local Quality Improvement Organization (QIO) reviewer, staff would immediately contact the physician to rescind the discharge order until the QIO reviewer makes a determination to uphold the treatment team's discharge decision or suspend the discharge.

Patients had the right to be informed about treatment expectations, progress, and outcomes. It was the policy of the facility to fully disclose to the patient and family/significant other as desired, outcomes of care including errors, adverse occurrences, and outcomes that differ significantly from expectations. The attending physician would keep the patient and family/significant other as desired, informed of treatment expectations, progress, and outcomes of care during the course of hospitalization. The physician/designee would promptly inform the patient and family/significant other as desired when an error, adverse occurrence, or outcome of care that differs significantly from expectations occurs.

The facilities provided written notice to all patients at the beginning of an inpatient stay or outpatient visit that there is no Doctor of Medicine or osteopathy present in the hospital 24 hours per day, seven days per week in order to assist the patient in making an informed decision about his/her care. The notice must explain how the hospital meets the medical needs of patients who develop an emergency medical condition at a time when no physician is present in the hospital.


A review of Daily Progress Note dated 8/25/24 at 12:00 p.m. revealed that P#1 ambulated in wheelchair, denied SI/HI (Suicidal Ideations/Homicidal Ideations- to describe the thoughts of wanting to harm oneself or others), vital signs normal, cooperative and compliant with taking medications.


Further review of Daily Progress Notes dated 8/26/24 P#1 denied SI/HI, less agitation and ready to go home.


A review of Progress Record dated 8/27/24 at 2:00 p.m. revealed P#1was discharged to home. P#1 was given discharge instructions concerning medication compliance, suicide prevention, and compliance with aftercare appointments. P#1 verbalized understanding and belongings were returned.


An interview was conducted with the Director of Risk Management (DOR) AA on 11/4/24 at 1:30 pm in the Intake room. DOR AA stated that she remembers P#1 and stated on admission patient was admitted to the Geriatric Unit and patient was very timid. DOR AA also stated that she was very surprised to see that the patient had been moved to the second most acute care unit due to agitation and threatening to harm others with his prosthetic leg. DOR AA stated that the prosthetic leg was electronic, and it was paired to the patient's phone. DOR AA further stated that she does remember P1 had an altercation with a female patient. DOR AA stated that the incident happened at the nurse's station and stated that she spoke with both patients. P1 was later discharged, and the female patient was moved to another unit. DOR stated that P#1 kept asking for his prosthesis and he was told that they were charging it for him. DOR AA stated that she saw the patient prior to discharge but did not see him leave with his prosthetic leg. DOR AA stated that Milieu Manager (MM) EE walked him to his vehicle, and he had his Prosthetic leg on.


An interview was conducted with Mental Health Aid (MHA) CC on 11/ 5 24 at 10:45 a.m. in the intake room. MHA CC stated that she did remember P#1. MHA CC stated that she had two encounters with the patient. MHA CC also stated that in one encounter the patient was very aggressive due to another patient antagonizing him and threw water on him.
MHA CC stated that if a patient had any personal belongings removed from them while on the unit the nurse would be notified, and the belongings would be put behind the nurse's station and logged on the belongings and valuable form. MHA CC stated that she does remember the patient leaving with his prosthetic leg because he had a FILA shoe on the prosthetic foot.


An interview was conducted with the Director of Clinical Services (DCS) DD on 11/5/24 at 12:00 p.m. in the intake room. DCS DD stated that she does remember P1 due to the high quality of his prosthetic leg. DCS DD stated that during a flash (group huddle with employees where discussions are held) meeting, It was discussed that P1 was threatening to remove his leg and hit people with it. The prosthetic leg was removed and taken from P1 and he was given a wheelchair. DCS DD stated that the leg was stored on the unit in a storage area. DCS DD stated that she remembers the leg stored on the unit because it needed to be charged so it would be ready for patient upon discharge. DCS DD stated that Milieu Manager (MM) EE walked P1 to his vehicle upon discharge and the patient was wearing his leg.


An interview with MM EE was conducted on 11/5/24 at 12:50 p.m. in the intake room. MM EE stated that she remembers P1 being verbally aggressive and having a physical altercation with a female patient on the unit and he threatened to harm others with his prosthetic leg. MM EE stated that when P1 Prosthetic leg was removed it was placed in the belongings closet that is locked and only the supervisor on duty has the key. MM EE stated that once the leg was taken from P1 he was given a wheelchair, and the prosthetic leg should have been logged on his Belongings/Valuables Form in his chart. MM EE stated that upon discharge with all his belongings, P1 had his prosthetic leg on and she walked him to the minivan that he was driving parked on the left side of the facility.


An interview was conducted with MHA GG on 11/5/24 at 2:00 p.m. in the intake room. MHA GG stated that she did remember P1 and he was very easily agitated due to not having his leg and verbally aggressive. MHA GG stated that P1 had his prosthetic leg taken because he was threatening to harm others. MHA GG stated that P1 kept reiterating that he needed his leg charged so it would be ready when he was discharged. MHA GG stated that P1 Prosthetic leg was locked in the valuables closet and only supervisors had the keys to that room. MHA GG also stated that anything taken from a patient on admission or while on the unit should be listed on the Belongings/Valuable Form in the patient's chart.


An interview was conducted with Medical Assistant/Social Worker (MASW) HH on 11/5/24 at 3:00 p.m. in the intake room. MASW HH did remember P! and stated that she remembered his leg being taken from him because he was trying to use it as a weapon. MASW HH stated that P1 was given a wheelchair, and he was still showing signs of aggression. MASW HH stated that the Prosthetic leg was at the Nurses station, and it was being charged. MASW HH further stated that P1 would not have left without his leg because he drove himself to the facility.


A telephone interview was conducted with Patient Advocate (PA) LL on 11/8/24 at 11:45 a.m. PA LL stated that he received a message that P#1 wanted to speak with him and when he had his first encounter with P#1 it was very short. PA LL stated that prior to him getting to the unit something took place between P#1 and a new male staff member that had P#1 extremely upset so nothing was established on that visit. PA LL stated that he spoke with P#1 the next day and he was calmer and seemed to need someone to talk to. PA LL stated that P1 did not complain about anything he just seemed to be really depressed about not being able to take care of himself and he appeared to just need someone to talk to.

PA LL stated that on 9/19/24 at 2:00 p.m. he received a call from P#1's Case Manager (CM) stating that P#1 had called her and stated that he was not given his prosthetic leg back when he was discharged from the facility on 8/27/24. PA LL stated that he spoke with nursing staff and MM EE, and everyone stated that P#1 was given his leg back on discharge. PA LL also spoke with DCS DD, and she stated that she made sure his phone was fully charged so it could be used to synchronize with P#1's prosthetic leg upon discharge. PA LL stated that after he spoke with several different staff members, he called P#1's CM and left her a voicemail of his findings and CM never returned or responded to his phone call.