HospitalInspections.org

Based on document review and interview, nursing services failed to ensure completion of the Patient Personal Effects Inventory form in the patient chart for 7 of 10 (patient's 1, 2, 3, 5, 7, 8, and 9) medical records (MR) reviewed.

Findings include:

1. Facility policy titled, "Management of Patient Belongings," PolicyStat ID: 13950524, last approved 07/2023, Procedure: Admission 4. Upon admission, staff will inventory all patient belongings, and sign the Personal Belongings Inventory Form. Patient will then sign the form.

2. Review of P1's MR indicated the following:
a. The patient was admitted on 07/30/24.
b. MR lacked documentation of the patient signature on the Patient Personal Effects Inventory form upon admission.
c. Patient was a current patient.

3. Review of P2's MR indicated the following:
a. The patient was admitted on 07/29/24.
b. MR lacked documentation of the patient signature on the Patient Personal Effects Inventory form upon admission.
c. Patient was a current patient.

4. Review of P3's MR indicated the following:
a. The patient was admitted on 05/19/24.
b. MR lacked documentation of the patient having a Patient Personal Effects Inventory form.

5. Review of P5's MR indicated the following:
a. The patient was admitted on 04/16/24.
b. MR indicated P5 arrived with their personal wheelchair per Nursing Admission Assessment and Interdisciplinary Discharge Plan. MR indicated P5's Patient Personal Effect Inventory form indicated the following personal effects listed: Texas True large pink long sleeve shirt, large red long sleeve shirt, Terry Sky 2X pink long sleeve shirt, Joy Spin 2X stripped long sleeve shirt, Time true XL blue stretch pants, Buck and Buck XL brown stretch pants, Time true XL purple sweat pants, baby doll, glasses, and gold diamond ring which was also listed on the Security Receipt for Patient Belongings. MR lacked documentation of the patient signature or signature of 2nd witness on the Patient Personal Effects Inventory form on discharge on 05/03/24.

6. Review of P7's MR indicated the following:
a. The patient was admitted on 06/08/24.
b. MR lacked documentation of the patient signature on the Patient Personal Effects Inventory form upon discharge, on 06/17/24.

7. Review of P8's MR indicated the following:
a. The patient was admitted on 07/10/24.
b. MR lacked documentation of the patient signature on the Patient Personal Effects Inventory form upon admission and discharge, on 07/20/24.

8. Review of P9's MR indicated the following:
a. The patient was admitted on 05/04/24.
b. MR lacked documentation of the patient signature on the Patient Personal Effects Inventory form upon admission and discharge, on 05/11/24.

9. Interview with A7 (Scheduler/trainer) on 08/01/24 at approximately 1:25 pm indicated, staff are educated if a patient is unable to sign their inventory form, staff are to sign the form and have another staff sign as a witness upon admission and/or discharge.

10. Interview with A1 (Chief Executive Officer) and A4 (Director of Nursing) on 08/01/24 at approximately 4:10 pm confirmed the Patient Personal Effects Inventory form, was not complete and in patient chart, and/or signed by the patient, or witnessed by a 2nd staff member on admission and/or discharge in 7 of 10 (patient's 1, 2, 3, 5, 7, 8, and 9) MR's reviewed.