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Based on document review and interview, the facility nursing staff failed to follow facility policies by staff not signing and dating an addition to P1's authorized visitor list, and failing to document an item on the patient belongings inventory for 1 (P1) of 10 medical records reviewed.

Findings Include:

1. Facility policy titled, "Documentation Protocol," last reviewed 01/31/2023, indicated under Procedure: 1. All patient medical records entries are to be: legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided, and consistent with facility policies and procedures.3. Authentication: Medical record entries are to be authenticated by the author of the entry. Entries are to be confirmed by written signature, credentials, date and time. Staff authorized to sign a medical record entry shall "NOT" authorize or instruct anyone to sign his/her name on any type of document, paper or electronic, when that document is part of a patient's medical record.

2. Facility policy titled, "Valuables and Belongings, Patient," last reviewed 01/2024, Procedure: 1. Patient Valuables c. Valuables left in the hospital will be stored in the safe. d. Patient's valuables shall be placed in a valuables envelope. The valuables will be placed in the envelope by the staff and signed by the patient and staff member. 2. Patient Belongings a. Patient belongings shall be inventoried and itemized on the patient belongings form. d. Belongings will be listed on the patient belongings form in three ways: Belongings remaining with the patient, belongings placed in storage, and belongings placed in the safe. e. Once all belongings are inventoried and listed the form is signed by the employee completing the inventory and patient/legal representative.

3. P1's medical record indicated on 08/31/2024, an individual was added to the authorized visitor/caller list, and had no signature by the individual staff member who added the name, or a guardian authorization. On admission, 08/27/2024, FM2, Family Member, signed the admission patient belongings form, and upon discharge FM2 signed the disposition/release of property form. Neither forms included a cell phone on the inventory. After being informed by FM2 on 09/04/2024, that a cell phone was missing, a cell phone belonging to P1 was found on 09/04/2024, secured in the facility safe.

4. S1, Director, Risk and Process Improvement confirmed that a name was added to the medical record authorized caller/visitor sheet, without staff signature or documentation that authorized guardian's (FM1 or FM2) had provided consent. S1 confirmed the facility intake staff incorrectly documented the patient belongings form by not adding P1's cell phone to the personal items inventory, resulting in a delay in the item's return.