Millwood Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 33579 Based on Interview, Observation and Record Review the hospital failed to provide care in safe setting for 2 of 2 Patients (Patient #1 and Patient #2), by failing to place appropriate precautions in place and separate the patient after engaging in altercations. Findings Include Based on Interview with Staff #8 on 04/16/2025 at 11:00 AM, indicated that Patient #1 was experience a Psychosis episode and is IDD. Staff #8 indicated that Patient #1 was requesting to discharge upon admission and verbally and physically aggressive upon arriving on unit. The Patient engaging in self-injurious behavior by banging head against wall, throwing items and pulling mattress off of bedframe. These behaviors took place on 04/10/2025. This information was reported but not thoroughly documented in the record. Based on Interview with Staff #10 04/16/2025 at 11:30 AM was asked to elaborate as to why staff is not documenting thoroughly in the medical record of the incident. Staff #10 indicate that they were unsure. Based on Interview with Staff #10 04/16/2025 at 1:30 PM was about why Staff #9 failed to exit nursing station stating ‘Patient #2 verbally threatened to cause harm to Staff #9.’ Staff #10 indicated that is not okay, and would be addressed. Based on Observation with hosptial Staff #4 video footage was reviewed, on 04/12/2025 and it revealed Patient #1 was experiencing a pychosis by appearing in the hallway fully nude and refusing to put clothing on when prompted. Patient #1 was banging the telephone up and down on the wall and receiver not following directives and waking peers up. Patient #2 was woken up and heard Patient #1 banging the telephone on the wall. Patient #1 and Patient #2 began exchanging words. Patient #1 and Patient #2 then approached one another and started punching each other. Staff #11 and Staff #12 intervened separating the patients but did nothing to put precautions in place. Patient #1 and Patient #2 remained in the hallway, Patient #1 obtained a cup of water and started throwing it at Staff #11, and Staff #12. Patient #1 then spit on Staff and Patient #2 and they began exchanging punches again. Staff #11 separated the patients again, but nothing was put in place. Patient #1 sat on the bench in the hallway with another cup of water. Staff #12 was moping the water previously thrown. Patient #1 and Patient #2 were at the opposite end of the hallway and started to exchange punches again. At this time Staff #13 exits nursing station and is able to communicate with Patient #1 and she sat on the hallway and floor infront of the telephone. Patient #1 was the encouraged to put some clothing on. Policy: The hospital Policy on Patient Rights 11/2021 reflected, “It is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of the Patient handbook, which includes the Patient Bill of Rights as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed, ethnicity, gender, age, sexual orientation or handicap. Millwood Hospital and Excel Centers shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times.” The hospital Policy on Abuse 04/2025, “It is the policy of Millwood Hospital to report all incidents of patient abuse, neglect and exploitation as soon as possible after the time the incident is identified.” The hospital Policy on Nursing Services 12/2022, “IT is the policy of Millwood Hospital to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medications errors, infection rates, patient complaints and grievances, as well as other types of incident occurrences. The staffing plan for Nursing Services is designed to comply with all applicable regulatory standards and is reviewed annually.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 33579 During Record Review, Interview and Observation, the hospital failed 4 of 4 Patients, (Patient #1, #2, #3, #4), the right to receive care in a safe setting by allowing Patients #1 and #2 to engage in inapropriate sexual activity intercourse. As well as Patient #3 and Patient #4 to participate in inapropriate sexual activity intercourse. Findings Include: During Record Review the hospital Standardized Intake Assessment, on 08/05/2024 3:01PM, revealed, “Patient #1 presents reporting active SI, does not disclose his plan, CAH to kill self, visual hallucinations of brother and ‘rainbow people’ chasing Patient #1. Patient #1 is extremely paranoid. Delusional, sexually inappropriate by making lewd comments and exposing himself. Patient #1 reports using oxycodone he got from lady at a park last night.” During Record Review Patient #1 was placed on Q15 minute observations. During Interview with Hospital Staff #3, the hospital had not completed all assessments and Patient #1 was moved on from Intake to PICU. During Observation of video footage Patient #1 was observed entering Patient #2’s assigned room at 5:38PM and exits Patient #2’s room at 5:43PM. During Observations of video footage Patient #2 was observed in her assigned room seated on her bed by MHT at 5:40PM but the MHT failed to observe the entire enviornment and did not enter the room. Patient #1 was in Patient #2’s bathroom. During Record Review in the hospital Daily Nursing Notes 07/22/2024 , at 11:00AM House Supervisor reported that Patient #3 claimed to have had sexual misconduct with another peer (Patient #4) on 07/19/2024. During Interview Staff #3 was asked if this incident was reported to the department. Staff #3 responded thatt these Patients #3 and Patient #4 consented to inappropriate sexual behavior. Staff #3 indicated that corporate officals have informed them not report incidents of consensual agreement. During Record Review Patient #3 the hospital nursing notes on 07/21/2024 at 10:00AM was observed at 11:30PM, Patient #3 was observed by MHT kissing another Patient #4. Patients #3, and #4 were immediately separated and were given expectation over boundaries. During Record Review in the hospital Psychiatric Nursing Notes 07/20/2024 at 3:00PM, At 11:00PM Patient#3 was found to have a personal cell phone and vape device in his possession. During Record Review of Patient #4’s medical record and Psychiatric Physician Progress Note 07/21/2024, staff found Patient #4 kissing a peer (Patient #3). During Record Review of Patient #4’s medical record the hospital Psychiatric Nursing Notes 07/22/2024, “Therapist reported that Patient had sex with another patient she did not deny it and refused to press charges. During Record Review the hospital Incident Reports were review; 1. Patient #3 engaging in Sexual Boundary Verbal/Physical non Aggressive Breach. Involving female Patient #4 on 07/21/2024. 2. On 07/19/2024, involving Patient #4 Sexual Intercourse. 3. On 07/20/2024, Contraband, found/Used other (vape, cellphone) During Interivew with hospital Staff #4 it was reported that these two patient (3, and 4) consented to having sex and both wanted it to happen. Patient #4 indicated wanting it to happen and allowed it to. When Staff #4 interiviewed Patient #4 it was reported by Patient #4 insisted she wanted to have sex with Patient #3. Indicated not wanting to press charges against the patient. Staff #4 indicated that there were no prior incidents reported on behalf of Patient #4 or boundary violations During Itnerview with Staff #4 it was reported that the incidents with Patient #3 and Patietn #4 actually occurred on 07/20/2024. but it was reported that the incident took place on 07/19/2024. During Timeline video footage review on 07/20/2024 at 7:24 PM Patient #3 enters Patient #4’s room, Patient #3 still in the room MHT does not see him when rounding. At 7:27 PM Patient #3 EXIT’s Patient #4’s room while MHT is in room across hall rounding Policy The hospital Policy on Patient Rights 11/2021 reflected, “It is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of the Patient handbook, which includes the Patient Bill of Rights as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed ethnicity, gender, age, sexual orientation or handicap. Millwood Hospital and Excel Centers shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times. The hospital Policy on Abuse, Neglect 08/2023, reflected, “It is the Policy of Millwood hospital to report all incidents of patient abuse, neglect, and exploitation as soon as possible after the time the incident is identified.” The hospital Policy on Nursing Service 12/2022, “IT is the policy of Millwood Hospital to ensure that the appropriate numbers of qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances as well as other types of incident occurrences. The staffing plan for Nursing Services is designed to comply with all applicable regulatory standards and reviewed annually.’ The hospital Policy Assessment of Safety Risk Factors/Patient Precautions Preventions, 05/2023 reflected, “On admission to all levels of care, Millwood Hospital screens patients for history of sexual aggression and/or victimization history/behaviors. Patients who have a history of sexual aggression or who are exhibiting sexually aggressive behaviors will be placed on an appropriate observation level and unit precautions to provide safe, therapeutic environment. The admission clinician is responsible for completing the initial risk assessment regarding sexual aggression/victimization and documenting it on the admission assessment screen. The physician and nurse place the patient on the appropriate precaution and observation level. Patients should be educated regarding their responsibility to report verbal or physical sexual threats, abuse and the consequences of prohibited behavior on the unit. Patients at risk for sexual victimization should be evaluated for level of functioning and need for addition protection, i.e., developmentally disabled sedated, post-ECT, or medically compromised patients.” The hospital Policy Patient and Visitor Search and Contraband Policy 11/2023, reflected, “Millwood Hospital is committed to the Provisions of a safe environment for all Patients, visitors and staff by preventing the entry of dangerous items on patient care units.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 33579 Based on Record Review and Interview the hospital failed to ensure that the medical staff is accountable to the governing body for the quality of care provided to Patients. The hospital failed 1 of 1 Patient (Patient #1). Findings Include During Record Review in the Complaint of Patient #1, had to be prompted for ADL’s, this including the Patients last day in the hospital. The hospital Psychiatric Physician Progress Notes reflected that the Patient was Discheveled on 01/22/24, 01/24/24,. On 01/25/2024, Neat and Clean, 01/26/24, Neat and Clean. On 01/27/2024 Poor Hyfiene, 01/28/2024 Discheveled, 01/29/2024 Discheveled, 01/30/2024 Discheveled, Neat and Clean on 01/31/2024 and 02/01/2024 at Discharg Neat and Clean. There is no evidence that Patient received a bath on the hospital Observation Sheets. The hospital was unable to verbal advise if the Patient received a bath, or washed the Patients clothing. The receiving ER described Patient as being malodorous, wearing the same dirty thin clothing upon arrival. During Interview and Record Review hospital Staff #3 reported completing the Patient #1’s Discharge. Patient #1 was discharged in an Uber. Staff #3 does not recall if the patients hygiene was unkept or if her clothings were dirty. Staff #3 reported that “I don’t know why that happened.’ When asked why wasn’t the Patients medical record reviewed for an ROI or a previous address or telephone number.”I dont know why that the medical record was not reviewed.’ to ensure all efforts were exhausted to obtain collateral ifnormation as Patient #1 was non-verbal almost mute. “ Staff #3 was asked if they were knowledgeable about the discharge process and could present it to the surveyor. Staff #3 was able to state the Discharge Risk Assessment protocols to the surveyor. During Interview was hospital Staff #2, was informed of Staff #1’s responses and Staff #2, indicated that Staff #3 was properly trained, and was aware of the hospital discharge Processes. Staff #2 reported that hospital Staff #7 assured Staff #3 was properly trained in the discharge process. Staff #2 further stated, “Upon further review, we have located the policy document outlining our organization’s protocol for employee orientation and competencies. As per the policy, employees are granted a 90-day period to complete all required orientation sessions and competency assessments. The employee file you reviewed, pertaining to Staff #3, falls within the designated 90-day timeframe. Although not all training requirements were completed at the time of your review, it is important to emphasize that the employee remains within the stipulated timeline for compliance according to our organization’s policy. We understand the significance of ensuring that all employees undergo comprehensive training within the specified timeframe to maintain regulatory compliance and uphold quality standards. Rest assured, we are committed to facilitating the timely completion of all necessary training components for our employees. However, Staff #3 was already working independently on the unit and discharging patients. Policy The hospital Policy on Patient Rights 11/2021 reflected, “It is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of the Patient handbook, which includes the Patient Bill of Rights as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed ethnicity, gender, age, sexual orientation or handicap. Millwood Hospital and Excel Centers shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times. The hospital Policy on Abuse, Neglect 08/2023, reflected, “It is the Policy of Millwood hospital to report all incidents of patient abuse, neglect, and exploitation as soon as possible after the time the incident is identified.” The hospital Policy on Nursing Service 12/2022, “IT is the policy of Millwood Hospital to ensure that the appropriate numbers of qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances as well as other types of incident occurrences. The staffing plan for Nursing Services is designed to comply with all applicable regulatory standards and reviewed annually.’ The hospital Policy Assessment of Safety Risk Factors/Patient Precautions Preventions, 05/2023 reflected, “On admission to all levels of care, Millwood Hospital screens patients for history of sexual aggression and/or victimization history/behaviors. Patients who have a history of sexual aggression or who are exhibiting sexually aggressive behaviors will be placed on an appropriate observation level and unit precautions to provide safe, therapeutic environment. The admission clinician is responsible for completing the initial risk assessment regarding sexual aggression/victimization and documenting it on the admission assessment screen. The physician and nurse place the patient on the appropriate precaution and observation level. Patients should be educated regarding their responsibility to report verbal or physical sexual threats, abuse and the consequences of prohibited behavior on the unit. Patients at risk for sexual victimization should be evaluated for level of functioning and need for addition protection, i.e., developmentally disabled sedated, post-ECT, or medically compromised patients.” The hospital Policy on Discharge Process 09/2022, “Discharge/Aftercare Planning shall be provided to all patients and shall reflect a coordinated effort of all disciplines involved in the treatment of the patient. The development of a Discharge Plan begins on admission. Prior to the patient discharging, Social Services and Nursing staff will re-evaluate and document that the discharge plan meets the needs of the patient and that the patient has achieved the discharge criteria. The patient’s demonstrated readiness for discharge should be linked to the achievement of treatment goals, although some longer-term goals may be continued at another level of care following hospital discharge. Long-term goals represent the highest level of functioning which the patient is expected to achieve during this current episode of care. The longer-term goals may not be accomplished completely by the time of discharge from current level of care. These goals should reflect the expectation for the patient’s highest level of functioning. Discharge goals represents achievements expected to the identified problem by the time of discharge when the patient is ready to move into a less intensive level of care. Shorter-term objectives represent the steppingstones toward achieving the discharge goals. They are much more specific, objective, and measurable in comparison to discharge and long-term goals.” The hospital Assessing an Emergency 09/2022, “It is the policy of Millwood Hospital to Assess, stabilize and/or appropriately transfer individuals who present with an emergency medical condition. Qualified Medical Personnel should provide an appropriate screening examination for any individual who comes to the facility and request an examination to determine whether the person has an emergency medical condition. An individual who is determined to have an emergency medical condition should be stabilized with the fullest capability of the facility, or transferred pursuant to this facility’s policy and procedure to another facility which can appropriately meet the person’s needs.” The hospital UHS Compliance Program 11/2023, “The mission of UHS is to provide superior quality health care services. In fulfilling this mission, UHS is dedicated to adhering to ethical standards and recognizes the importance of compliance with applicable state and federal laws. Accordingly, the UHS Board of Directors and management have adopted this Compliance Program.” The hospital Quality Assurance & Performance Improvement (QAPI), “Millwood Hospital is committed to providing high quality and efficient care of its patients and other consumers. The Quality Assurance & Performance Improvement Plan (QAPI) developed by Millwood Hospital guides the facility’s efforts in achieving excellence in patient care and is in accordance with the mission and vision of the organization and that of Universal Health Services, Inc.””

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 33579 Based on Interview, Record Review and Observation, the hospital failed one of one Patient (Patient #1) in failing to Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. Psychiatric Medication Invega Sustenna IM 156mg. Findings Include: During Record Review of Patient #1’s medication administration record. Patient #1 recieved IM on 02/01/2024. The record did not reflect that there was proper consent for this medication. Patient #1 did have a Psychiatric Medication Consent for Invega Sustenna in the record, but it was for the initial Invega Sustenna dosage of 234mg. During Interview with hospital Staff #4 reviewed Patient #1’s medical record and verified there was no consent in the record for a second dose on 02/01/2024 for Invega Sustenna 156mg. During interview with hospital Staff #4 it was verified that a different dosage requires a second consent. During Interview with hospital Staff #5, Staff #5 was asked to review Patient #1’s medication administration record. During this review. Staff #5 verified giving Patient #1 the injection of Invega Sustenna 156 mg. Staff #5 was asked did she have a Psychiatric Medication Consent signed by the Patient to administer this medication. Staff #5 reported that Patient #1 did not decline the injection and reports she thought she had a Medication Consent already in the record to administer the medication. Policy The hospital Policy on Patient Rights 11/2021 reflected, “It is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of the Patient handbook, which includes the Patient Bill of Rights as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed ethnicity, gender, age, sexual orientation or handicap. Millwood Hospital and Excel Centers shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times. The hospital Policy on Abuse, Neglect 08/2023, reflected, “It is the Policy of Millwood hospital to report all incidents of patient abuse, neglect, and exploitation as soon as possible after the time the incident is identified.” The hospital Policy on Nursing Service 12/2022, “IT is the policy of Millwood Hospital to ensure that the appropriate numbers of qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances as well as other types of incident occurrences. The staffing plan for Nursing Services is designed to comply with all applicable regulatory standards and reviewed annually.’ The hospital Policy Assessment of Safety Risk Factors/Patient Precautions Preventions, 05/2023 reflected, “On admission to all levels of care, Millwood Hospital screens patients for history of sexual aggression and/or victimization history/behaviors. Patients who have a history of sexual aggression or who are exhibiting sexually aggressive behaviors will be placed on an appropriate observation level and unit precautions to provide safe, therapeutic environment. The admission clinician is responsible for completing the initial risk assessment regarding sexual aggression/victimization and documenting it on the admission assessment screen. The physician and nurse place the patient on the appropriate precaution and observation level. Patients should be educated regarding their responsibility to report verbal or physical sexual threats, abuse and the consequences of prohibited behavior on the unit. Patients at risk for sexual victimization should be evaluated for level of functioning and need for addition protection, i.e., developmentally disabled sedated, post-ECT, or medically compromised patients.” The hospital Policy on Discharge Process 09/2022, “Discharge/Aftercare Planning shall be provided to all patients and shall reflect a coordinated effort of all disciplines involved in the treatment of the patient. The development of a Discharge Plan begins on admission. Prior to the patient discharging, Social Services and Nursing staff will re-evaluate and document that the discharge plan meets the needs of the patient and that the patient has achieved the discharge criteria. The patient’s demonstrated readiness for discharge should be linked to the achievement of treatment goals, although some longer-term goals may be continued at another level of care following hospital discharge. Long-term goals represent the highest level of functioning which the patient is expected to achieve during this current episode of care. The longer-term goals may not be accomplished completely by the time of discharge from current level of care. These goals should reflect the expectation for the patient’s highest level of functioning. Discharge goals represents achievements expected to the identified problem by the time of discharge when the patient is ready to move into a less intensive level of care. Shorter-term objectives represent the steppingstones toward achieving the discharge goals. They are much more specific, objective, and measurable in comparison to discharge and long-term goals.” The hospital Assessing an Emergency 09/2022, “It is the policy of Millwood Hospital to Assess, stabilize and/or appropriately transfer individuals who present with an emergency medical condition. Qualified Medical Personnel should provide an appropriate screening examination for any individual who comes to the facility and request an examination to determine whether the person has an emergency medical condition. An individual who is determined to have an emergency medical condition should be stabilized with the fullest capability of the facility, or transferred pursuant to this facility’s policy and procedure to another facility which can appropriately meet the person’s needs.” The hospital UHS Compliance Program 11/2023, “The mission of UHS is to provide superior quality health care services. In fulfilling this mission, UHS is dedicated to adhering to ethical standards and recognizes the importance of compliance with applicable state and federal laws. Accordingly, the UHS Board of Directors and management have adopted this Compliance Program.” The hospital Quality Assurance & Performance Improvement (QAPI), “Millwood Hospital is committed to providing high quality and efficient care of its patients and other consumers. The Quality Assurance & Performance Improvement Plan (QAPI) developed by Millwood Hospital guides the facility’s efforts in achieving excellence in patient care and is in accordance with the mission and vision of the organization and that of Universal Health Services, Inc.””

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 47061 Based on record review and interview, the facility failed to have a well-organized medical staff accountable to the governing body for the quality of the medical care provided to one of one patients (Patient #1). Patient #1 had been admitted to the facility on 10/31/2023 for DMDD (disruptive mood dysregulation disorder) and PTSD (post-traumatic stress disorder). Patient #1’s medical condition required the administration of three controlled substances for seizure disorder-Lacosamide, Clonazepam, and Phenobarbital. The patient was discharged on 11/13/2023 with the controlled medications to be continued. There was no evidence that the medical bylaws addressed the process of electronic discharge prescription of controlled medicinal substances for a patient’s medical condition. The medically necessary prescriptions were not electronically communicated to a pharmacy for at least 4 days. Patient #1 suffered multiple seizures after discharge and required inpatient hospitalization for her condition at a local acute pediatric medical hospital on 11/16/2023. Findings Included: The “Discharge Medication Summary for Patient” form that was provided to the case worker upon discharge listed the following medications to be taken after discharge: Clonidine for impulsivity, Lacosamide for seizures, MiraLax for constipation, Clonazepam for seizures, and Phenobarbital for seizures. A review of the medical record revealed a copy of a paper prescription completed on 11/13/2023 by Personnel #6 for the following controlled medications: Lacosamide, Phenobarbital, and Clonazepam. During a personal interview on 11/28/2023 at 11:00 AM, Personnel #1 stated “The problem was her discharge prescriptions were controlled substances and were written on a paper prescription. Controlled substances cannot be written on paper, they must be sent in electronically. Personnel #5 told me she is not set up for e-scribe (electronic prescriptions) and does not have the capability to order medications electronically. It’s not that she wasn’t willing, but that she just was not able. Unfortunately, it looks like it fell through the cracks since no one called the psychiatrist to ask them to send in the patient’s controlled substance medications electronically.” During a personal interview on 11/28/2023 at 11:18 AM, Personnel #5 stated “I received a Tiger Text (text messaging in a HIPAA [Health Insurance Portability and Accountability Act] compliant manner) from our team that this patient was on seizure medications and asked if we could call them in. I remember I specifically stated in the text that they are controlled substances, and they cannot be called in. I do not have access to electronic scripts so I asked if one of the psychiatric doctors could order the medications since they can all send prescriptions electronically. I never heard anything back, so I assumed it was taken care of. I don’t know if anyone followed up with psych for the e-scripts.” During a telephone interview on 11/28/2023 at 2:00 PM, Personnel #6 stated she had written the three controlled medications for seizure disorder on a paper prescription to go home with the patient. Personnel #6 stated she was not aware that a paper prescription could not be used for controlled substances. During a personal interview on 11/28/2023 at 2:50 PM, Personnel #2 stated “Our medical staff does have a formal organized structure with bylaws, rules, and regulations. The MEC (medical executive committee) is made up of internal medicine physicians and psychiatrists. The medical staff is held accountable to the governing body for the quality of medical care provided to the patients by reviewing performance improvement data, peer review done by physicians and nurse practitioners, feedback analysis from patient complaints, discharge chart audit process, and physician score cards. We do a discharge chart audit process quarterly that includes a full chart review. We don’t audit 100% of the charts, but hopefully if someone had picked this patient’s chart, they would have identified that three controlled substances were ordered on a paper prescription and a corrective action plan would have been developed. We had an MEC meeting today, and the issue has been discussed and addressed. Our Medical Director and Personnel #5 were both present. Personnel #5 is getting e-scribe privileges today. We will also provide education with attestations to our nurse practitioners regarding the use of paper prescriptions for controlled substances.” Medical Staff Bylaws approved by the Medical Staff on 3/24/2020 reflected the following, “ ...Medical Executive Committee (MEC) ...11.2.2 The duties of the MEC shall be to ...account to the Board and to the Staff for the overall quality, uniformity, and efficiency of medical care rendered to patients ...11.4.5 Bylaws, Rules and Regulations ...The duties involved in this function are to ...recommend any changes deemed necessary or desirable in the Bylaws, the Rules and Regulations, and the procedures and forms; and develop and implement the Rules and Regulations to establish standards of patient care and ensure that these Rules and Regulations are consistent with Medical Staff Bylaws and with Facility Policy and Procedure ...” Per the Texas Medical Board website, “Controlled Substance Electronic Prescribing Requirement Effective January 1, 2021, Texas Health and Safety Code, §§481.0755 requires that prescriptions for controlled substances to be issued electronically, except in limited circumstances, or unless a waiver has been granted by the appropriate agency.””