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Based on document review and interview, facility staff failed to schedule a care conference involving family in 1 of 10 medical records reviewed. (P1)

Findings include:

1. Facility policy titled,"Team-Family Conference", PolicyStat ID 12197127, last revised 01/2020, indicated under PROCEDURE: Family Care Conference. The hospital will make every attempt to schedule a care conference involving the family, guardian/POA (Power of Attorney), and patient (if possible) as well as the interdisciplinary care team within the first week of the patient's admission.

2. Review of P1's MR (Medical Record) lacked documentation of facility staff making every effort schedule a family care conference with P1's family/POA/guardian within the first week of admission.

3. In interview on 9/3/25 at approximately 4:00 pm with A1 (Chief Executive Officer) confirmed there was no family care conference with the interdisciplinary team for P1 during hospitalization. Confirmed a care conference should have been offered but P1's MR lacked documentation of an offer and/or refusal by P1's POA/family/representative. Confirmed a care conference should have been offered to the POA but was not.

Based on document review and interview, facility nursing staff failed to complete documentation on the patient effects inventory form upon discharge for 2 of 10 medical records reviewed (P1 & P2), and failed to notify a provider of abnormal patient vital signs in 1 of 10 medical records reviewed. (P1)

Findings Include:

1. All Staff Meeting minutes dated 8/8/24 at 7:30 am, 1:30 pm, and 4:00 pm indicated that Inventory Patient Belongings, At discharge, BHAs can gather the patient belongings but IT IS THE NURSES RESPONSIBILITY TO ENSURE THE DISCHARGING PATIENT HAS THEIR BELONGINGS AND HAS SIGNED THEIR INVENTORY SHEET PRIOR TO LEAVING THE UNIT.

2. Facility policy titled, "Provider Communication", PolicyStat ID 92275841, last revised 01/2025, indicated under POLICY: Licensed nursing staff are responsible for notifying providers of any changes in patient conditions that may negatively impact treatment or medical well-being. Communication ensures timely interventions to support patient safety and care. PROCESS: 2. Notification Process: Primary Notification: Notify the in-house medical and/or psychiatric provider immediately. Document the notification and result in the patient's chart. On-Call Notification: If the in-house provider is unavailable, notify the on-call provider. Document the notification and result. Escalation to Medical/Psychiatric Director: If the first provider cannot be contacted or fails to respond within 15 minutes, place a second call to the same provider. If no response is received within an additional 15 minutes, contact the second listed provider. Allow 15 minutes for the second provider to respond. If neither the in-house nor on-call provider responds, escalate the issue to the Medical/Psychiatric Director.

3. Review of P1's MR (Medical Record) Personal Effects Inventory form dated 5/21/25 indicated an itemized inventory of P1's personal effects were documented by nursing staff. Vital signs documentation dated 5/26/25 at 8:00 am indicated P1's temperature was 103.7 degrees Fahrenheit, pulse was 117 beats per minute, respirations of 13 breaths per minute, blood pressure of 146/64 mmHg (millimeters of mercury), no pain score documented. No provider notification was documented for abnormal vital signs. P1's MR lacked documentation of discharge patient effects inventory by nursing staff that should have included nursing staff signature, signature of patient and/or patient representative, date and time of returning P1's effects to the patient and/or representative. Lacked notification to a provider of P1's abnormal vital signs from 5/26/25 at 8:00 am.

4. Review of P2's MR indicated the patient personal effects inventory documentation dated 8/16/25 at 8:00 pm indicated an inventory of P2's effects were taken by nursing staff upon admission. P2's MR lacked documentation of a completed exit inventory of P2's personal effects that included a signature by discharge nursing staff, patient and/or representative, with date and time.

5. In interview on 9/3/25 at approximately 2:30 pm with A4 (Director of Quality) confirmed P1 and P2's patient effects inventory form should have been completed at discharge containing signature(s) of both nursing personnel and/ or family/representative, date, and time but was not.