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Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow policy and procedures related to inventory of patient valuables for six (6) of ten (10) sampled patients, Patient's #1, #2, #5, #6, #7, and #10. Patient #1 eloped from the facility when staff could not locate his/her money in his/her stored belongings. Interview with the facility Investigator revealed during his investigation of Patient #1's elopement, he determined staff had not inventoried the patient's personal property correctly causing the patient to get upset and elope from the facility. Interviews with staff revealed no evidence the facility re-educated staff on patient personal property inventory to prevent a similar event from occurring.


The findings include:


Review of the facility's policy, Patient Valuables, revised 07/01/15, revealed patients' valuables and personal items may be stored by the hospital for safekeeping. At the time of admission, staff would search the patient and their belongings. All personal property and valuables kept in the patient's possession would be listed and described on the Patient Personal Belongings Inventory Form. Items considered as contraband or personal items in excess of what may be kept on the unit, would be stored in the designated storage area. Checkbooks, driver's license, insurance cards, food stamps, money, and any other forms of legal tender, as well as non-waivered jewelry, and other small items of value would be placed in a Valuables Envelope. Staff would itemize the patient's belongings on the Patient Valuable Envelope (PVE) and the PVE number would be recorded on the Patient Personal Belongings Inventory Form by each category and placed on the chart. A Business Office staff member would pick up the valuables from Admissions, record the receipt of the envelope, and store the envelope in the business office safe until discharge. Storage boxes would be used for excess clothing, shoes, electronic equipment, appliances, and other large items. Such items would be placed in plastic bags and labeled in the admissions area with the patient's name. Upon completion of the inventory, the bags would be placed into a storage box. A copy of the Patient Personal Belongings Inventory Form would be attached to the outside of the box. During lobby hours, Guest Relations staff would call the patient's unit and inform staff that a visitor had items that required inventorying. The staff would pull the patient's current inventory sheet from the chart and bring it to the lobby. All acceptable items would be inventoried on the Patient Personal Belongings Inventory form and then bagged. The staff person and visitor would sign off on the form and attach the form to the bag of items. The staff person would take the items back to the unit. If a patient wanted to retrieve an item from inventory, a doctor's order would be obtained for the specific item requested and a staff member would accompany the patient to the storage area. The Patient's Personal Belongings Inventory Form should be updated to reflect the change in location/disposition of retrieved items.


Review of the facility's Security Department policy, Patients Property, revised 05/10/17, revealed the following procedure would be followed when handling and securing patients property. The responding officer would take the patient's boxed belongings to the property room and store each item in the proper location. The boxes would be stored on the appropriate shelves that corresponded with the patient's assigned unit. Envelopes were to be stored in the boxes marked patient envelopes that corresponded with the patients unit. The property log sheet was to be completed upon storing the patient belongings, including the patient's name, pin number, date, unit, amount of boxes and envelopes secured, and the officer's initials. If the patient wanted to retrieve personal property and had a doctor's order, the responding officer would retrieve the patient's personal property box or envelope from the appropriate shelf and only the items listed on the doctor's order would be permitted to be taken to the unit. The responding officer would return the box or envelope to their proper location and a copy of the doctors order sheet would be placed with the original admission form.


1. Review of Patient #1's clinical record revealed the facility admitted the patient on 08/10/17, with diagnoses of Schizoaffective Disorder, Antisocial Behavior Disorder, and Narcissistic Personality Disorder.

Review of Patient #1's Admission History and Psychiatric Evaluation, dated 08/11/17, revealed Patient #1's parent obtained a mental inquest warrant after he/she threatened to kill his/her child. The evaluation stated the patient also planned to kill the child after discharge from the facility. In addition, the evaluation noted Patient #1 supposedly got mad while at a bank on 08/03/17, and attempted to jump over the counter when the teller would not cash his/her check. The patient threatened the teller and to hurt police if they were called.

Review of Patient #1's Personal Belongings Inventory Sheet, dated 08/10/17, revealed Patient #1's valuable items were placed in a Patient Valuables Envelope with identification number 1988533 and put in a safe. The valuables envelope description stated one (1) wallet, two (2) gift cards, one (1) debit card, one (1) credit card, and one (1) postal service card was in the envelope. There was no mention of money in the description of valuables. Continued review of an additional Patient Valuables Envelope, dated 08/10/17 and numbered 1580137, revealed a cell phone was in the envelope. There was no mention of money in the description of valuables on envelope numbered 1580137. Continued review of the patient's personal belongings inventory sheet revealed one (1) cell phone, one (1) package of cigarettes, one (1) lighter, one (1) tube of chap stick, and one (1) set of keys was put in a box and stored in the security department.

Review of a Physician Progress Note, dated 08/16/17, revealed Patient #1 was taken to the business office to obtain his/her money but did not find it in his/her stored belongings. The patient immediately became upset and stormed out the front door of the secured facility by breaking the front door. The police found the patient and returned him/her back to the facility.

Review of a Therapy Note, dated 08/15/17, revealed Patient #1 stated he/she was at wits end when his/her money was missing out of the business office. The Therapy Note stated Patient #1 was going to give his/her father one hundred and fifty dollars ($150.00) from his/her wallet to get items out of a pawnshop. The patient reported he/she had no plan when he/she ran away, but felt like he/she had enough bad things happen to him/her and just could not tolerate it any longer.

Interview with Mental Health Technician (MHT) #3, on 10/11/17 at 2:22 PM, revealed she searched Patient #1's belongings during the admission process and must have overlooked the one hundred and fifty dollars ($150.00) and keys. The MHT stated the admission process required her to inventory the patient's belongings and anything not allowed on the unit was stored in the security department or the business office. She stated the process required her to put items of value in an envelope and send it to the business office, and place all other patient items in a cardboard box and send to the security department.

Interview with MHT #4, on 10/11/17 at 9:30 AM, revealed Patient #1 had a doctor's order to retrieve personal items from the business office. She stated nursing staff requested she escort Patient #1 to the business office to retrieve some money out of his/her wallet. The MHT stated she had two (2) other MHTs go with her to see the process of retrieving patient's personal items from the business office. She stated the patient was calm on the way to the business office; however, once he/she looked in the envelope and did not find his/her one hundred and fifty dollars ($150.00), the patient became very upset. MHT #4 stated they tried to calm the patient down and informed him/her they would look in the security department to determine if the money had been put there instead. She stated the patient looked like he/she might start a fight with them and the patient turned and ran out of the business office to the lobby front door. She stated the patient kicked the front door two (2) times breaking it and then ran out. She stated she called a code for additional staff assistance and staff went after the patient.

Interview with the Account Specialist, on 10/11/17 at 11:04 AM, revealed three (3) staff escorted Patient #1 to the business office with a doctor's order to retrieve a wallet and keys from his/her Patient Valuables Envelope. She stated she obtained the envelope for the patient and determined the documentation on the envelope did not include keys or money. She stated the patient became very upset that the wallet did not have one hundred and fifty dollars ($150.00) in it. The Account Specialist stated the patient accused the facility of stealing his/her money and became verbally aggressive. She stated she told the patient they would look in the security department to see if the money had been stored in his/her box; however, the patient got even madder, ran out of the business office to the front lobby, kicked the door open, and ran out.

Interview with the Unit B Nurse Manager, on 10/12/17 at 9:27 AM, revealed after Patient #1 ran from the facility, he and the Risk Manager went to the Security Department to search for Patient #1's money and keys. He stated when they looked in the box; they found Patient #1's one hundred and fifty dollars ($150.00) inside a yellow piece of paper folded in half. He stated the patient's keys were also in the box. The Unit Manager stated the facility policy required them to inventory patient belongings during the admission process and all valuables, including money, should be placed in an envelope and stored in the business office for security reasons. The Unit Manager stated if the facility had inventoried the patient's valuables correctly, the patient would have received his/her money at the time he/she was in the business office.

Interview with the Admissions Manager (AM), on 10/12/17 at 8:25 AM, revealed the admissions area was staffed with mental health workers who were cross-trained to perform admission duties and inventory patient belongings. She stated staff places patient valuables in an envelope, which was sent to the business office, and all other items were placed in a box and sent to the security department. The AM stated all items taken to the unit with the patient, such as clothing, were itemized on the back of the Patient's Personal Belongings Inventory sheet. The AM stated any direct care staff member could be involved in the inventory and logging process of patient's personal belonging. The AM stated her assessment of Patient #1's incident was staff did not inventory all of Patient #1's belongings correctly and the money was not logged in per the policy. She stated staff should have went through the patient's papers and would have found the money. She stated staff should have placed the money in an envelope and sent it to the business office. She stated had staff inventoried the money and sent it to the business office; the situation might have been different. The AM stated prior to Patient #1's elopement, she had not conducted audits of the admission process to determine if patient belongings were inventoried and stored correctly. She stated after Patient #1 eloped, she did not investigate or complete an audit to determine if staff was following the facility's policy and procedures for patient valuables.

Interview with the facility Investigator, on 10/12/17 at 9:12 AM, revealed during his investigation of Patient #1's elopement, he determined staff had not inventoried the patient's personal property correctly. He stated if the admissions staff had inventoried the patient's money, placed it in an envelope, and sent the envelope to the business office per facility policy, the patient would not have gotten upset. The Investigator stated he only focused on the circumstances leading up to Patient #1's elopement and did not investigate to determine if there was a system breakdown regarding the inventory of patient valuables, he looked at the situation as an isolated event.

Interview with the Risk Manager, on 10/12/17 at 1:45 PM, revealed the facility determined staff in admissions did not log patient valuables correctly and that contributed to Patient #1's elopement. The Risk Manager stated the facility needed to look at the admission process to determine if there was a system breakdown in order to be more accountable for patient belongings. He stated after the investigation was completed, recommendations given to administration were for staff to be re-educated on the policy and procedure for inventory of patient valuable; however, he could not produce evidence the re-education occurred.

Interview with the Assistant Director/Medical Director, on 10/11/17 at 10:04 AM and on 10/12/17 at 2:16 PM, revealed Patient #1 had a physician's order to obtain money and keys from his/her inventory of valuables in the admissions office. He stated staff escorted the patient to the business office; however, after staff provided him/her with the envelope, it was determined the patient's money and keys were not in the envelope. He stated the patient got upset, ran to the lobby, kicked the front door open, and left the facility. The Assistant Director stated the police returned the patient to the facility and an investigation into the circumstances surrounding the event was started. The Assistant Director/Medical Director stated the policy and procedure for inventory and storing patient belongings and valuables had been revised a couple of years ago; however, no audits had been conducted since the implementation to determine if the process was working. He stated Risk Management had recommended staff be re-educated on inventory of patients belongings, which he thought occurred; however, there was no documented evidence re-education was completed.

2. Review of Patient #2's clinical record revealed the facility admitted the patient on 10/02/17, with diagnosis of Schizophrenia. Review of Patient #2's Personal Belongings Inventory Sheet, dated 10/02/17, revealed staff failed to document the date, staff name, total number of envelopes used, the property valuables envelope number, and whether items were stored or waived. The back of the Inventory Sheet listed one (1) pack of cigarettes, one (1) lighter, four dollars ($4.00), one (1) pair of gym shoes, a sock, one (1) pair of blue jeans, one (1) blue shirt, one (1) black shirt, and one (1) pink shoelace. The pack of cigarettes, lighter, pink shoelace and four dollars ($4.00) was marked as stored. The rest of the items were marked as waived for storage.

Observation, on 10/12/17 at 12:56 PM, of the Business Office where the facility stored the Patient Valuables Envelopes, revealed Patient #2 had a Patient Valuables Envelope numbered 157999. The valuables described on the enveloped stated there was one (1) pack of cigarettes, one (1) lighter, and one (1) pink shoelace. Under the heading of Cash, staff documented illegibly the amount of currency in the envelope.

Interview with the Account Specialist, on 10/12/17 at 12:56 PM, revealed she received Patient #2's Patient Valuables Envelope and logged the amount of cash in the envelope as one hundred and fourteen dollars ($114.00). She stated it was difficult to discern from the handwriting exactly what amount of cash was in the envelope. She stated it could be four dollars ($4.00) or fourteen dollars ($14.00) but she read it as one hundred and fourteen dollars ($114.00). The Account Specialist stated the envelope was sealed in the Admission area so she was unable to open it and count the money herself. She stated she had to rely on the Admission staff to inventory patients' valuables and document correctly on the forms. She stated the business office staff could not open the envelopes without the patient being present. The Account Specialist stated she received Patient Valuable Envelopes with non-valuable items in them such as cigarettes and lighters and would send the envelopes to the Admission staff for them to log and store the items in the correct area. She stated she had not been re-educated on patient valuable inventory recently.

Interview with the AM, on 10/12/17 at 8:25 AM, revealed she had not identified issues nor did she have concerns with staff not following the Patient Valuables policy and procedure. She stated staff should document legibly on the forms to prevent a mistake in the documentation of patient belongings.

3. Review of Patient #5's clinical record revealed the facility admitted the patient on 10/08/17, with diagnosis of Psychosis.

Review of Patient #5's Personal Belongings Inventory Sheet, dated 10/08/17, revealed during the admissions process, the patient had a cell phone placed in a Patient Valuables Envelope and sent to the business office for storage; however, staff placed his/her watch and bracelet in a box and stored it in the security department.

Interview with the AM, on 10/12/17 at 8:25 AM, revealed the facility considered a watch and bracelet valuables and staff should have placed those items in a Patient Valuable Envelope and sent it to the business office. The AM stated staff did not follow the facility Patient Valuables policy; however, she had not conducted any audits to determine if staff was following the policy.

4. Review of Patient #6's clinical record revealed the facility admitted the patient on 10/05/17, with diagnosis of Impulsive Behavior.

Review of the Personal Belongings Inventory Sheet for Patient #6, dated 10/05/17, revealed the only item listed as a personal belonging was a jail jump suit.

Interview with MHT #3, on 10/11/17 at 2:40 PM, revealed when a patient was admitted wearing a jail jumpsuit; she gave the patient clothing from the facility's inventory. She stated she listed the clothing given to the patient on the Clothing Requisition Sheet in order for the cabinet in admissions to be restocked with additional clothing. She stated she was not trained to list the facility clothing given to patients on the back of the Patient Personal Belongings Inventory sheet. MHT #3 stated she had not received re-education after the incident with Patient #1.

Interview with the AM, on 10/12/17 at 8:25 AM, revealed when patients were received from a jail wearing a jumpsuit, the patient changed into facility clothing and the jumpsuit was returned to the jail transportation staff. She stated patients admitted without clothing were provided clothing from the facility's inventory. She stated staff should list on the back page of the Patient Personal Belongings Sheet the clothing given to the patient. The AM stated staff should not list a jumpsuit on the Personal Belongings Inventory Sheet because the patient did not keep the jumpsuit in their possession. She stated if the sheet did not correctly list the clothing given, staff was not following the policy and procedure for inventorying patient valuables and clothing.

5. Review of Patient #7's clinical record revealed the facility admitted the patient on 09/26/17, from jail, for a mental competency evaluation.

Review of Patient #7's Personal Belongings Inventory Sheet, dated 09/26/17, revealed under clothing, staff listed a jail jump suit.

Interview with the AM, on 10/12/17 at 8:25 AM, revealed staff should return the jumpsuit to jail staff and provide the patient with clothing from the facility's inventory. She stated admission staff should document on the back of the Personal Belongings Inventory Sheet the clothing given to the patient in order to be compliant with facility policy. She stated she had not identified any issues with staff not implementing the Patient Valuables policy correctly.

6. Review of Patient #10's clinical record revealed the facility admitted the patient on 10/05/17, with diagnosis of Schizophrenia.

Observation, on 10/12/17 at 1:15 PM, of Patient #10's Valuables Envelope, revealed the envelope was in a box and locked in a room in the Security Department.

Review of Patient #10's Patient Valuables Envelope revealed staff documented it contained one (1) shoestring.

Interview with the Risk Manager, on 10/12/17 at 1:45 PM, revealed the facility did not have documented evidence that staff inventoried Patient #10's personal belongings or had given the patient clothing from the facility's inventory. He stated staff should have followed the policy and procedure related to patient valuables.

Interview with the AM, on 10/12/17 at 8:25 AM, revealed non-valuable items inventoried during the admission process, no matter how big or small, should be placed in a cardboard box and not on a patient valuables envelope. She stated she was not aware staff was placing non-valuable items in the Patient Valuables Envelopes and sending them to the security department for storage. The AM stated that was not facility policy.