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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 three of 30 sampled patients (Patient 17, 18, and 19).

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 March 25, 2025, at 10 a.m., a tour of Unit A was conducted with the Director of Medical/Surgical Unit (DMS 1), the Nurse Coordinator (NC 1), Nurse Coordinator (NC 2), the Executive Director of Medical/Surgical (EDMS), the Charge Nurse (CN), and the Assistant Director (AD). During the tour of Unit A, in the storage room, two bins unlabeled were observed. Inside the bins, there was two bags labeled with patient's names (Patients 17 and 18) and a blue locked bag used in the emergency department for patients' belongings were found on a storage rack, this bag was not labeled with a patient's name. An inventory of belongings was conducted and the following items were found:

For Patient 17, a blue hat (name of a National Baseball League Team), a small baggy of a substance that smelled and resembled (Marijuana, a glass pipe, and lighter), a wallet (community center care, Medicare card, HMO card [health maintenance organization], Senior Citizen Identification card, Visa debit card [Name of a bank branch], Wellcare HMO card, black sweatshirt, and a burgundy colored t-shirt.

For Patient 18, a white pair of white running shoes (name of a shoe brand), a pack of chewing gum, a pair of blue jeans, black colored t-shirt, a brown belt, and a pair of white socks.

For Patient 19, a team member from the BERT (Behavioral Emergency Response Team) the Assistant Nurse Manager BERT (ANMB) came to the unit to unlock the unidentified blue bag. Personal belongings found in this bag, a green jacket, three necklaces (one made of shells, and the other two are silver material), a gray tank top, brown underpants, a phone charger, a cell phone, a blue sweatshirt, two packs of cigarettes, a brunette-colored wig, a camouflaged colored backpack, two scarves, a brown wallet, and twenty-one dollars in cash. The locked blue bag was not labeled on the outside. There was a sticker on a bag inside the blue bag that identified Patient 19.

a. A review of Patient 17's medical record was conducted on March 27, 2025, at 8:49 a.m., with the Regulatory Compliance Specialist (RSC).

A review of the facility's document titled, "History and Physical (H&P)," indicated Patient 17 was admitted to the facility February 17, 2025, for psychosis with homicidal ideations, he was placed on a 5150 hold (allows for the involuntary psychiatric hospitalization of an individual who is deem a danger to self, others, or gravely disabled).

On March 25, 2025, at 10:47 a.m., an interview was conducted with the DMS 1. The DMS 1 stated the belongings should have been returned to the patient upon discharge. The DMS 1 further stated we will try to call the patient three times, if we are unable to contact the patient we discard the belongings. She further stated I do not see any attempts to contact the patient but we are still looking.

A review of the facility's document titled, "The Discharge Navigator Flowsheet," dated February 20, 2025, indicated, "...Patient/Family Belongings were returned [was left blank]..."

There was no documented evidence in the Electronic Medical Record (EMR) that the staff documented any attempts made to return Patient 17's belongings after discharge.

On March 27, 2025, at 9:33 a.m., a concurrent interview and record review were conducted with the RCS. The RCS stated I do not see any documentation that a call was made to return the patients belongings in the chart. The RCS further stated the Navigator Flowsheet, for belongings returned was left blank. She also stated there was no evidence that the patient's belongings went with the patient to the psychiatric facility at discharge.

b. A review of Patient 18's medical record was conducted on March 27, 2025, at 9:21 a.m., with the RCS.
A review of the facility's document titled, "H&P," indicated Patient 18 was admitted to the facility March 10, 2025, for self-harm, extremity laceration, and placed on a 5150 hold.

On March 25, 2025, at 11 a.m., an interview was conducted with the DMS 1. The DMS 1 stated the belongings should have been returned to the patient upon discharge. The DMS 1 further stated I do not see any attempts to contact the patient after discharge, but we are still looking.

There was no documented evidence in the EMR a Belonging List was completed for this patient during his hospitalization.

A review of the facility's document titled, "The Discharge Navigator Flowsheet," dated March 12, 2025, indicated, "...Patient/Family Belongings were returned [was left blank]..."

There was no documented evidence in the EMR that the staff documented any attempts made to return Patient 18's belonging after discharge.

On March 27, 2025, at 11:08 a.m., a concurrent interview and record review were conducted with the RCS. The RCS stated there was no belonging list completed for this patient in the EMR. The Discharge Navigator Flowsheet, Patient/Family Belongings returned, was left blank. She stated there was no documentation for a follow up call attempting to return the belongings.

c. A review of Patient 19's medical record was conducted on March 27, 2025, at 11:10 a.m., with the RCS.

A review of the facility's document titled, "H&P," indicated Patient 19 was admitted to the facility January 12, 2025, for psychosis, danger to self, and placed on a 5150 hold.

On March 25, 2025, at 10:41 a.m., an interview was conducted with the DMS 1. The DMS 1 stated I am not sure what is in the locked blue bag, this bag usually stays in the emergency room, someone will unlock the bag, and the belongings will come upstairs. The DMS 1 stated we will store the patient's belongings in the bins.

On March 25, 2025, at 2:53 p.m., an interview was conducted with ANMB. The ANMB stated the blue locked bag should have stayed in the emergency department (ED) when the patient is being moved up to the floor, the charge nurse will unlock the bag, and the labeled bags will go with the patient and the staff transporting patient up to the unit. He further stated it is also the responsibility of the admitting floor nurse to question the blue bag.

On March 27, 2025, at 10:42 a.m., a concurrent interview and record review were conducted with the DMS 1. The DMS 1 stated the blue locked bag should not have made it to the floor, the ED nurse should have unlocked it and gave the belongings to the nurse on the floor. She stated the primary nurse should have questioned why the blue bag was on the unit. She further stated the nurse did not check the storage room for the patients belongings before the patient was discharged home, the blue locked bag was sitting on the unit for over a year.

A review of the facility's document titled, "Multidisciplinary Progress Note," dated January 28, 2025, at 7:30 a.m., indicated "...1800 [6 p.m.] Went over discharge paperwork with pt. [patient] Medications delivered at bed side. Pt has no IV. Pt given 2 bus passes. States they will go to their dads home. Pt. states they have a backpack, but willing to leave without it..."

A review of the facility's document titled, "The Discharge Navigator Flowsheet," dated January 28, 2024, indicated, "...Patient/Family Belongings were returned [was left blank]..."

There was no documented evidence in the EMR that the staff documented any attempts made to return Patient 19's belongings after discharge.

On March 27, 2025, at 12:27 p.m., an interview was conducted with the RCS. The RCS stated there was no documentation found in the EMR making any attempts to contact the patient about her personal belongings left behind, the policy was not followed.

A review of the facility's P&P titled, "Patient Belongings," dated May 15, 2024, indicated, "...Patients transferred to other patient care unit shall have all belongings that are retained at the bedside transferred with them by the sending unit...When patient belongings are found in a patient care unit after a patient's discharge and staff can identify the owner, staff shall attempt to contact the patient and ask him/her of their designee to pick up his/her belongings..."

A review of the facility's P&P titled, "Suicidal Prevention," dated December 6, 2024, indicated, "...Patient's personal belongings will be examined and recorded by a trained staff member and will be stored appropriately in designated areas..."

Based on observation and interview, the facility failed to provide a safe environment for patients when there were no functioning call lights in the Post Anesthesia Care Unit (PACU).

These failures had the potential to compromise patient safety, a delay in medical care and/or death.

Findings:

On March 25, 2025, at 10:08 a.m., a tour of the PACU unit was conducted with the Regulatory Nurse Supervisor (RNS), the Clinical Director of PACU (CDP), and the Perioperative Clinical Director (PCD).

On March 25, 2025, at 10:14 a.m., an observation of the call light switch on the wall was conducted in bay A. An observation of the nurse call light cord was observed wrapped around another object against the wall behind bay A. When the button on the end of the nurse call light cord was pressed, no sound was observed in the unit or at the nursing station. There was a light observed over the front of bay A.

On March 25, 2025, at 10:15 a.m., an interview was conducted with Patient 9. Patient 9 stated she was not given a call light when she was placed in PACU. Patient 9 stated she can yell for her nurse if needed.

On March 25, 2025, at 10:15 a.m., an interview of the PCD was conducted. The PCD stated the nurse call light system does not work and is obsolete. The PCD stated there has been a work order placed a long time ago and they tried to fix it but was told they are unable to repair. The PCD stated they have tried to look for something to replace the nurse call lights in the meantime but have not found anything that would work.

On March 25, 2025, at 10:18 a.m., an interview of the CDP was conducted and stated the nurses are in the direct line of sight of the patient and the nurses are able to see their patients at all times.

On March 25, 2025, at 2 p.m., an interview was conducted with the Chief Clinical Integration Officer (CCIO). The CCIO stated there was no nurse call light work order placed for PACU at this this time.

On March 26, 2025, at 11 a.m., an interview was conducted with the PACU RN. The PACU RN stated the call lights have not been functioning since she started working there seven years ago. The PACU RN stated she does not know if a work order had ever been placed, but her director was aware of the issue.

On March 27, 2025, at 10 a.m., an interview was conducted with the PCD. The PCD stated, "...I was aware of one or two of the call light devices not working a couple of days ago...I found out that there was never a work order submitted...they should have created a work order when they discovered the nurse call light system was not working...isolated the device and not use it..." The PCD stated the only person notified of the issue was the CDP. The PCD stated no one from administration was notified of the nurse call light system not functioning. The PCD stated they normally would enter a work order in the HEMS (Hospital Equipment Maintenance System) system and then they receive a confirmation of their submission in their email.

On March 27, 2025, at 12 p.m., an interview was conducted with the CCIO. The CCIO stated, "...the person who found the broken device or issue should have made a report in the HEMS system and then it would get assigned to someone to repair..." The CCIO stated, "...it should have been escalated properly per policy and the issue could have been fixed...it was never escalated or told to her or HEMS..."

A review of the facility undated document titled, "Elsevier Performance Manager...Skills: Admission...," was conducted and indicated, "...Show the patient how to use the nurse call system or device. Ensure that the device is placed in a convenient location. Have the patient demonstrate use of the device...Ensure that the nurse call system or device is within easy reach of the patient..."

A facility policy and procedure (P&P) document titled, "Reporting Broken & Malfunctioning Equipment," dated July 18, 2023, indicated, "...Procedures...Reporting suspected non-working piece of equipment where there has NOT been patient harm nor possible patient harm...Telephone Reporting Procedure...During business hours telephone reporting procedure: the reporting party shall call hospital extension [extension number]. Plant Operations will dispatch a Bio-Medical Technician and/or Maintenance Mechanic depending on the type of the equipment..."

50122

Based on interview and record review, the facility failed to implement their policy and procedures (P&P) when:

1. For Patient 1, pain was not assessed prior to or after administration of pain medication; and

2. A designated utility sink was not made accessible while dialysis services (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) were in progress. This failure resulted for the (name of dialysis center) to "dumped" used and contaminated items in the handwashing sink.

These failures had the potential to compromise patient safety resulting in poor pain management, increase the risk of spreading infections or bloodborne pathogens in the hospital dialysis setting, and delay in medical care and/or cause death.

Findings:

1. On March 24, 2025, at 9:53 a.m., a review of Patient 1's record was conducted with the Regulatory Nurse Supervisor (RNS).

A facility document titled, "History and Physical (H&P)," dated March 24, 2025, at 3:30 p.m., indicated Patient 1 had a history of Diabetes (a chronic disease that occurs when the body can't produce or use insulin properly, resulting in high levels of blood sugar), Seizures (sudden, temporary disruptions of the brain's normal electrical activity, potentially causing changes in behavior, movement, sensation, or awareness), and Tracheal stenosis (a narrowing or constriction of the trachea that can restrict breathing). It further indicated Patient 1 was admitted to the facility for Respiratory distress (difficulty breathing).

A facility document titled, "Medication," dated March 24, 2025, at 5:02 p.m., indicated an order for acetaminophen [medication used for relief of pain]...tablet 650 mg [milligrams-unit of measurement]...Ordered dose...650 mg...Route...Oral...Frequency...Every 6 hours PRN [as needed] for Mild Pain 1-3, Moderate Pain 4-6...Admin Dose...650 mg..."

A facility document titled, "MAR [Medication Administration Record] Report," dated March 24, 2025, at 4:46 p.m., indicated, acetaminophen 650 mg was administered to Patient 1 at 4:46 p.m.

There was no documented evidence of Patient 1's pain level prior to or after pain medication was administered.

An interview was conducted on March 26, 2025, with the RNS. The RNS stated there was no documentation found for Patient 1's pain assessment prior to or after administration of pain medication. The RNS stated, "the policy should have been followed."

A review of the facility P&P titled, "Pain Assessment and Management," dated March 15, 2024, indicated, "...Pain shall be assessed when new pain is reported and when procedures or activities that are expected to cause pain...Pain reassessment...After PO [by mouth] medication intervention reassessment shall take place approximately 60 minutes after administration..."

A review of the facility P&P document titled, "Patient Rights and Responsibilities," dated March 1, 2023, indicated, "...You have the right to...Appropriate assessment and management of your pain..."

2. On March 25, 2025, at 2:25 P.M., a tour of the nursery was conducted with the Clinical Director (CD). During the tour, the Dialysis Coordinator (DC) and Dialysis Nurse (DN) stated they use the handwashing sink to "dump" waste water from dialysis services.

A record review and concurrent interview was conducted on March 25, 2025, at 4:22 p.m., with the Labor and Delivery Director (L&DD). The facility policy titled, "INFECTION CONTROL IN THE HOSPITAL DIALYSIS SETTING", was reviewed. The L&DD stated, "Sinks are for hand washing and dirty contaminated items should be handled in designated utility sinks".

A review of the facility policy titled, "Hospital Services Policy and Procedure," #1 (name of Dialysis Center), Policy: 7-03-01, titled, "INFECTION CONTROL IN THE HOSPITAL DIALYSIS SETTING", dated October 2023, indicated, "TREATMENT AREA INFECTION CONTROL...Dedicated hand washing sinks should be for hand washing purposes and remain clean. Avoid placing, cleaning or draining used items in dedicated hand washing sinks...Used or contaminated items should be handled in designated utility sinks...Clean areas should be designated for the preparation, handling, and storage of unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where supplies and equipment are handled..."