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Based on review of medical records, observation, policies and procedures, and staff interviews, it was determined that the staff failed to document and secure the belongings of one patient (P) (P#1) of four patients (P#1, P#2, P#3, and P#4) reviewed, when P#1 was discharged without the personal belongings that they arrived with.


Findings included:


A review of medical records revealed that P#1 was admitted to the facility involuntarily on 8/9/25.


Review of the valuables and belongings note within the discharge information dated 8/14/25 at 1:43 p.m., failed to reveal an inventory of P#1's belongings. P#1 was sent home with no personal belongings.


A video review took place in the facility ' s office on 8/19/25 at 1:20 p.m. with Director of Risk Management (DRM) LL.

During the video review, it was observed that on 8/9/25, at:

11:49 a.m. - P#1 was brought in on a stretcher by two Emergency Medical Service (EMS) personnel into the intake lobby. P#1 was observed to be in green scrubs.

11:50 a.m. - One of the EMS personnel handed over a plastic bag that appeared to contain some regular clothing to Mental Health Technician (MHT) JJ.

11:51 a.m. - P#1 was observed sitting on the chair.

11:52 a.m. - MHT JJ was seen exiting the door that led to the lobby with the two EMS personnel. MHT JJ was observed still holding onto the plastic bag.

11:54 a.m. - MHT JJ was observed still holding onto the plastic bag that contained P#1 ' s belongings and was observed to be speaking to P#1 before going back to the intake office with the plastic bag.

11:58 a.m. - MHT JJ was observed coming back to the intake lobby without the plastic bag containing P#1 ' s belongings.

12:52 p.m. - P#1 was observed going to an intake room with Assessment Counsellor (AC) KK.

1:16 p.m. - P#1 was observed coming out of the intake room.


A tour to the facility ' s Sub-Acute, Acute Unit, and Intake office/area took place on 8/20/25 at 12:15 p.m. with DRM LL.

During the tour of the Acute unit, a couple of brown paper bags were observed lying on the floor at the nursing station with no labels on them. One of the brown bags had some clothing, which Nursing Supervisor (NS) OO stated belonged to a patient, but there was no patient ' s name or room number on the brown paper bag, and another brown paper bag with no patient's name or room number was stated to be trash by NS OO.


A review of the facility ' s policy titled "Patient Belongings and Valuables," Policy #RI.038, last issued 12/24, stated that it was the policy of the facility to provide safe storage of valuable patient possessions during inpatient treatment.


An interview took place in the facility ' s conference room on 8/19/25 at 9:45 a.m. with Nurse Practitioner (NP) AA, who stated that the mental health technicians (MHTs) should check and document any patient ' s belongings on admission and put the patient ' s belongings in a locker with each locker having an identification number assigned to each patient.


An interview took place in the facility ' s conference room on 8/19/25 at 11:00 a.m. with Mental Health Technician (MHT) CC, who stated that when P#1 was discharged, he (MHT CC) could recall asking her (P#1) if she had any belongings, and P#1 had stated she had ' clothes ' , but there were no belongings documented or labelled with P#1 ' s name. MHT CC stated that he could recall P#1 had on hospital clothing when she was discharged, and he (MHT CC) walked her (P#1) to the front with a family member present.


An interview took place in the facility ' s conference room on 8/19/25 at 12:00 p.m. with Registered Nurse (RN) EE, who stated that she could not recall P#1. RN EE stated that the MHTs should document patients ' belongings on admission and keep them in a safe place as per protocol.


An interview took place in the facility ' s conference room on 8/19/25 at 12:30 p.m. with Director of Patient/Family Advocacy (DPFA) FF, who stated that he remembered going to P#1 and asking her if she had any clothing, and P#1 stated that she was waiting on the staff to give it to her. DPFA FF stated that he went to look for P#1 ' s clothing and could not find anything. DPFA FF stated that he would continue to investigate and find out if P#1 came in with any personal clothing, and what may have happened to it.


A telephone interview occurred in the facility ' s conference room on 8/19/25 at 2:00 p.m. with Mental Health Technician (MHT) JJ, who stated that he could not really recall P#1, but it seemed P#1 had a bag containing clothing, amongst other things on arrival to the facility. MHT JJ stated that the intake staff would take the patient ' s belongings alongside when taking the patient to the unit, and the intake staff would hand over the patient ' s belongings to the staff on the unit; However, he (MHT JJ) could not recall if he was the one who accompanied P#1 to the unit on that day.


An interview occurred in the facility ' s conference room on 8/20/25 at 11:40 a.m. with Assessment Counsellor (AC) KK, who stated that the intake staff did not open patients ' belongings but only kept them in a safe place in the intake room and transported the patients with their belongings to the unit. AC KK stated that the intake staff would give a report to the unit staff, and the patient ' s belongings would be dropped on the floor in the designated area on the unit for the staff to document and out in the designated storage room on the unit. AC KK further stated that she could not recall who accompanied P#1 to the unit.


An interview took place during the tour to the Intake room on 8/20/25 at 12:30 p.m. with Intake Director (ID) NN, who stated that whenever patients arrived at the facility, the MHTs and the Assessment Counsellors should take the patients ' paperwork and all the patients ' belongings into a storage room ensuring the belongings are adequately labelled pending the time the patients are taken to the unit with their belongings.


A telephone interview took place on 8/21/25 at 8:30 a.m. with Registered Nurse (RN) MM, who stated that she could recall P#1 ' s face, but she (RN MM) did not work directly with P#1 nor had any interaction with her (P#1).

Based on the review of medical records, observation, policies and procedures, and staff interviews, it was determined that the facility's staff failed to perform a nutritional needs assessment and ensure dietary preferences were respected and accommodating for one patient (P) (P#1) of four patients (P#1, P#2, P#3, and P#4) reviewed.


Findings included:


Review of medical records revealed that P#1 was admitted to the facility involuntarily on 8/9/25 at 4:29 p.m.


Documentation on 8/10/25 at 2:08 p.m. revealed that P#1 denied having any issues with appetite but reported she has changed her diet to deal with stomach issues. Documentation failed to reveal the specific type of diet/diet orders for P#1.


A review of the initial nursing treatment plan documentation by Registered Nurse (RN) MM on 8/10/25 at 1:25 a.m., revealed the initiation of a dietitian consultation intervention with P#1 about/to determine appropriate weight. Further review of the medical record failed to reveal any assessment/consultation notes from the dietitian.

A revi
ew of the physician ' s progress notes on 8/11/25 at 9:00 p.m. revealed that P#1 complained of headache and severe abdominal pain, noted constipation for two days, and also stated that the pain was worse with direct pressure. Documentation by the physician revealed that P#1 was sent to the emergency department for further evaluation due to the acuteness of P#1 ' s abdominal pain; however, documentation failed to reveal the specific time P#1 went to the ED and returned to the facility. A continued review of the medical record failed to reveal any ED notes/documentation for 8/11/25.


A review of the discharge summary documentation on 8/14/25 at 10:04 a.m. under the post-discharge care and the discharge orders/instructions revealed a regular diet.


A review of the facility ' s policy titled "Diet Orders," Policy #TX.070, last revised 10/21, revealed that all patients must have a diet ordered by the physician upon admission. The diet order would be communicated to the Food Service Department through the use of the Census Form. The nursing staff was responsible for including the following information on the form:
- Unit
- Patient Name
- Diet Order (as ordered by physician)
- Allergies (to food).


A review of the facility ' s policy titled "Food Preferences," Policy #TX.072, last revised 10/21, stated that patient food preferences would be honored for all patients admitted to the facility, within budgets for staffing time and cost. Personal food preferences/intolerance based upon cultural, religious, and ethnic background would be honored with consideration of time, cost, and staffing.


A review of the facility ' s policy titled "Plan for the Provision of Care," Policy #CC.001, last revised 12/24, stated that Nutrition Assessment would be performed by a Registered Dietitian within 24 hours of a written order by the physician or notification by nursing that nutritional screening criteria established by the medical staff have been met, which included dietary needs, assessment of lab results, preferences, habits, and recommendations. Individual patient food preferences and nutritional needs should also take be into consideration. Consultation and education for patients on special diets should be provided by the dietitian.


A review of the facility ' s policy titled "Identification of Patients on Special Diets," Policy #TX.071, last revised 10/21, stated that the nursing staff would complete a daily census list of all patients and their diet orders. Dietary staff would keep the list in a designated area behind the serving line for use when preparing trays. Nursing Staff would be responsible for ensuring that patients on special diets were identified using patient identification before receiving their food tray.


An interview took place in the facility ' s conference room on 8/19/25 at 9:45 a.m. with Nurse Practitioner (NP) AA, who stated that if a patient stated he/she was a vegan, the dietitian would be informed, who would let the cafeteria staff know about the patient ' s diet. NP AA further stated that she could not recall P#1 because she only did the discharge paperwork, as she only filled in for a nurse who called out.


An interview took place in the facility ' s conference room on 8/19/25 at 10:30 a.m. with Mental Health Technician (MHT) BB, who stated that the only encounter she had with P#1 was when she (MHT BB) had to take her (P#1) alongside other patients from one unit to another unit, and then to the cafeteria. MHT BB stated that she had noticed P#1 was not really eating her food when they were at the cafeteria, and she (MHT BB) asked her (P#1) why, and P#1 had stated that it was because she was vegan. MHT BB stated she reported it to the nutritionist (dietitian) and a second nutritionist during one of the nutrition classes. MHT BB stated that she could not recall what day P#1 told her that she was vegan, and she (MHT BB) also could not recall if the two nutritionists she reported to did anything about it.


An interview took place in the facility ' s conference room on 8/19/25 at 12:00 p.m. with Registered Nurse (RN) EE, who stated that she could not recall P#1. RN EE stated that the intake staff and the admitting nurse should ask patients about diet preferences, and if the patient was on a special diet or had an allergy, the dietitian would be notified.


An interview took place in the facility ' s conference room on 8/20/25 at 9:20 a.m. with Dietitian (DT) II, who stated that she could not recall P#1. DT II stated that if a staff member had reported to her that P#1 was vegan, she (DT II) would have assessed P#1 to get more clarification, as sometimes patients used the word " vegan " misappropriately, and she (DT II) would also notify the kitchen regarding P#1 ' s diet preference.
DT II also stated that P#1 would have had access to something unless she (P#1) reported something specific, but she (DT II) never got any notification/report.


An interview occurred in the facility ' s conference room on 8/20/25 at 11:40 a.m. with Assessment Counsellor (AC) KK, who stated she could recall that when P#1 was in the intake lobby, she (AC KK) observed that P#1 did not eat the food (protein) the facility provided, and MHT JJ had to give her (P#1) a salad. AC KK also stated that the intake staff only asked patients about their food allergies during the intake assessment, and not their food preferences.


A telephone interview took place on 8/21/25 at 8:30 a.m. with Registered Nurse (RN) MM, who stated that she could recall P#1 ' s face, but she (RN MM) did not work directly with P#1. RN MM stated that P#1 was not among the patients she (RN MM) assessed, and she could not explain how her (RN MM) name was listed as the nurse who assessed P#1.