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Based on observations, staff interviews and review of facility's policy and procedures, the hospital failed to maintain an environment that ensured patient's personal property was protected from loss or theft.

The failure created the potential for loss of patient property due to insufficient tracking and storage.

Findings:

FACILITY POLICY

According to the facility's policy, Patient Property Policy No. 18.25, upon admission, the patient's property, if not already secured in a suitcase, is placed in a large paper bag, labeled with the patient's name, and secured in a locked cubicle located in the Admissions, area.
On the unit, patient property is inventoried and items are documented on the Clothing/Property/Medication Record, form 3756, by unit staff or the IFP property Manager. The unit staff shall review the inventoried property with the patient, and the patient shall sign the form.

1. The facility did not have a formal facility wide tracking system or someone in charge of patient property.

a) A tour of the facility on 10/21/13 at 1:45 p.m. revealed each unit of the hospital had a closet for patient property. In four out of four closets it was found there was no organization of patient's personal property. Each closet contained property with different methods of storage and no formal name, number or content on the containers. Each closet contained different storage methods, including two with card board boxes and two with a combination of card board boxes and paper and plastic bags. The closets did not have any consistent method of to identify which patient the bag and property belonged to.

b) A tour of the facility on 10/22/13 at 1:00 p.m. revealed the Community Reintegration Unit (RU) building contained a floor for overflow storage for the rest of the facility. During the tour 5 rooms were toured. Four out of the five rooms contained patient's property strewn in the rooms, no names on some of the items and no formal system of tracking the property. Property was found lying on the floor of the rooms without being in containers or off the floor. Examples include shirts and pants, radios, musical instruments, including a guitar and other items that did not have markings with patient's name or numbers on them.

c) On 10/21/13 at 1:45 p.m. during the tour, the above findings were confirmed with the Director of Nurses (DON) the Director of Quality (DOQ), the Assistant Director of Quality (AQ) and the department's Team Lead. The DON, DOQ, AQ and department's Team Lead admitted there was property on the floor, some property did not have identification on it and there was no consistent way to tell who the property belonged to.

d) On 10/22/13 at 10:00 a.m. a review of the facility's document titled Clothing/Property/Medication Record 375, revealed no active way to track property. The document had areas for glasses, hearing aids, clothing, money and a check mark if a medication list was needed or inventoried. There were no areas for updating if property was exchanged or brought in. The sheet contained no area for staff or patient signatures on the property section of the form.

e) During an interview with the Director of Nurses (DON) on 10/22/13 at 2:00 p.m., the DON stated the tracking form was used on each unit, but no one staff or set of staff was responsible to keep up the form. S/he also stated no one was formally in charge of patient property in the facility. The DON stated the current form was not adequate for the needs of the facility and there needed to be a more standardized procedure for tracking property.

f) In an interview on 10/22/13 at 10:30 a.m. the social worker stated neither nursing nor the social work department was in charge of property in the facility. S/he stated whoever has contact or receives information from the patient fills out the property sheet. The social worker stated no one person or department was in charge of tracking patient's property throughout their stay in the facility and property was frequently misplaced or lost.

g) In an interview on 10/22/13 at 1:00 p.m. with the Clinical Team Lead (CTL) of the CRU unit, the CTL stated property was frequently lost or misplaced and tracking was an issue. The CTL also stated no one person was in charge of property and each area had it's own procedure for handling property which was not always consistent.