Mayhill Hospital

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 33579 Based on Interview and Record Review the hospital failed 3 of 3 Patients (Patient #1, Patient #2 and Patient #3). By failing to have a well-organized service with a plan of administrtive authority and delienation of responsibilities for patient care. Patient #1 was admitted into the hospial ambulating with a cane. A walker was provided for the Patient after admission, including the explanation and necessary use of the walker. The Patient did not receive walker. Patient declined at discharge and due to being placed in wheelchair throughout duration of hospital stay. Patient #2 was admitted with an Abrasion to the back. There is no treatment documentation that there was treatment for the abrasion or med consult/follow-up treatment. Patient #3 was provided a wheelchair with faulty breaks. The patient fell in her room thinking the wheelchair was behind her and stable. Findings Include: During Interview with Complainant 11/4/2024 12:15 PM, Patient #1 admitted into the hospital ambulating with cane. The Patient #1 received a walker after admission brought in by the Complainant, as well as the explananation why Patient #1 needed the walker. The patient never received the walker. At discharge the Complaint reported the patient’s condition had deteriorated and was weak and unable to ambulate with walker on own to transfer into automobile. The Patient indicated the Patient was rolled out leaning over the wheelchair, and dragging her feet under the wheelchair. During Record Review for Patient #1, there are no orders for a wheelchair, there is no treatment for physical therapy or physical treatment noted. During Interview with hospital Staff #4, It was reported Patients are placed in wheelchairs that oversized, and do not have breaks that work on them. Staff #4 reported that not being aware that Patient #1 had a walker in the facility, some patients have walkers but Patient #1 was in a wheelchair. During Interivew with hosptial Staff #5 11/29/2024 at 2:00PM Indicated that if a patient has marks bruises/Superficial Scratches and cuts and an Abraision what should be done. Staff #5 reported a Medical Consult would be requested and noted. Staff #5 was asked did she submit a Medical Consult. Staff #5 indicated, ‘No I did not.” During Interview with hosptial Staff #6 on 11/29/2024 at 2:30PM. Staff #6 reported that not reviewing the initial Standardized Skin Assessment at Intake and take note that Patient #2 had an abrasion on the back. Staff #6 was asked why there was no documentation on the skin assessment on her note. Staff #6 indicated ‘I missed that one.” During Interivew with hospital Staff #4 11/29/2024 2:44PM, Staff #4 was asked about Patient #3 falling. Staff #4 indicated I did not witness the fall, but a lot of the wheelchairs do not have breaks on them that work. Staff #4 indicated that Patients are placed in oversized wheelchairs at times. Policy Policy The hospital Policy on Patient Rights dated 03/2023 reflected, “For the purposes of this policy, a grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patients representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare.” The hospital Policy on Neglect 07/2024, “Mayhill hospital will maintain an environment free of abuse and neglect. All potential employees will be screened for a history of abuse, neglect or mistreatment of patients. Screening of employees includes requesting information from previous and or current employers and verifying information through background checks...It is the policy of Mayhill hospital to report alleged and suspected abuse and neglect to the state of Texas Department of health and appropriate authorities in accordance with state and federal statutes.” The hospital Policy on Nursing Standards of Practice 10/2024, “Psychiatric nursing is the process through which the nurse assesses, plans intervenes and evaluates to assist individuals, families, and groups to enhance more positive self-concepts, more harmonious patterns of interpersonal relationships, and more productive roles in society. This process is based upon the nurse’s ability to empathize with the persons perception and to develop therapeutic interpersonal relationships.” The hospital Policy on Quality of Care and Treatment “Plan of Patient Care,” 07/2024, “IT is the policy of Mayhill Hospital to provide a plan for all patients. As the human body is a complex system, the plan of care will include development and action by all disciplines appropriate to the patient’s needs and condition.” The hospital Policy on Nursing Standards of Practice 10/2024, “Psychiatric nursing is the process through which the nurse assesses, plans intervenes and evaluates to assist individuals, families, and groups to enhance more positive self-concepts, more harmonious patterns of interpersonal relationships, and more productive roles in society. This process is based upon the nurse’s ability to empathize with the persons perception and to develop therapeutic interpersonal relationships ...The nursing staff of the hospital seeks to provide the highest quality psychiatric nursing services to all individuals in treatment on a 24-hour basis in a consistent, safe, and caring manner.” The hospital Policy on Injuries and Wound Care 08/2024, “All wounds will be assessed upon admission or occurrence. Wounds will be assessed each shift, during dressing changes and with any significant change. Weekly assessments will be conducted by the RN and Wound Care Nurse and documented on the nursing progress note. Pressure ulcers will be classified according to stage as delineated in the procedure section. All wounds will be classified as either ‘partial thickness’ or ‘full thickness’ of skin loss.””

“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 Record Review and Interview, the hosptial failed 2 of 2 Patients (Patient #3 and Patient #5) by failing to ensure a safe patient environment was provided for two of 2 patients (Patient #3). Patient #3 required an assisted device (walker or wheelchair) for safe moving about as noted during the admission process but did not receive any mobility assistive device until two days into her hospital stay with the potential for a fall. Patient #5 was not provided with her medication Clozapine after admission into the hospital on 07/26/2029 until 07/29/2024. FINDINGS INCLUDE: During Record Review the hospital Supplemental Contact Note on 08/16/2024 at 1:23PM, “Staff #4 spoke with complainant to inform of discharge on 08/19/2024. Complainant discussed several complaints including other patients (Patient #3) mistreatment and not having a wheelchair for several days.” During Interview with Staff #4 “It was reported that Patient #4 did not have a wheelchair. There were no wheelchairs available, and we do not use walkers because they can be thrown.” During Interview with Hospital Staff #6 10/01/2024 at 11:00AM, “It was reported the hospital did not have any available wheelchair’s at the time of the Patient #3’s admission into the hospital. We would assist the Patients if they were not already walking and using the wall railings for assistance. There was no available wheelchair for Patient #3, until late the second day she was in the hospital. During Record Review Patient #5 reflected, “The hospital preadmission evaluation and medical clearance screening Mayhill Hospital 07/26/2024, 3:03PM, “Patient admitted voluntary, for medication stabilization...medication deferred reconciliation to attending MD.” During Interview with hospital Staff #10, 10/02/2024 at 2:50PM. “Staff #10 indicated working the front desk, and the complaintant brought Patient #5’s home medication into the hospital. Staff #10 indicated taking them to the unit informing the staff of the home medications, where they were in the brown bag. Staff #10 indicated there was no documentation done on their accord.” During Interview with hospital Staff #8 on 10/01/2024 11:40AM. “Staff #10 reported Patient #5 should have received their Clozapine no later than 07/27/2024. The medication was listed on the Medication Administration Record. The nurse should have notified the on call doctor since it was the we weekend to ensure the administration of the home medications were done. Staff #10 verified the medications were administered on 07/29/2024 at 11:12 AM for the first time while in the hospital. During Record Review Patient #5 was sent out to the ER on July 29, 2024 due to be evaluated at Medical City Denton for possible stroke. Policy The hospital Policy on Patient Rights dated 03/2023 reflected, “For the purposes of this policy, a grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patients representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 41 CFR 489. A complaint is defined as a form of verbal communication from the patient or the patient’s representative individual’s dissatisfaction with services and the dissatisfaction is able to be resolved by the staff present at the time of the verbal complaint.” The hospital Policy on Pharmaceutical Services 09/2024, “Pharmaceutical services are provided in accordance with state and federal regulations. When there are variations between local, state, and federal regulations, the more stringent regulations are followed.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 33579 Based on Intrview and Record Review the hospital failed 1 of 1 Patient Patient #5, by failing to administer Clozaril for two days, Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. FINDINGS INCLUDE: During Record Review Patient #5 reflected, “The hospital preadmission evaluation and medical clearance screening Mayhill Hospital 07/26/2024, 3:03PM, “Patient admitted voluntary, for medication stabilization...medication deferred reconciliation to attending MD.” During Interview with hospital Staff #10, 10/02/2024 at 2:50PM. “Staff #10 indicated working the front desk, and the complaintant brought Patient #5’s home medication into the hospital. Staff #10 indicated taking them to the unit informing the staff of the home medications, where they were in the brown bag. Staff #10 indicated there was no documentation done on their accord.” During Interview with hospital Staff #8 on 10/01/2024 11:40AM. “Staff #10 reported Patient #5 should have received their Clozapine no later than 07/27/2024. The medication was listed on the Medication Administration Record. The nurse should have notified the on call doctor since it was the we weekend to ensure the administration of the home medications were done. Staff #10 verified the medications were administered on 07/29/2024 at 11:12 AM for the first time while in the hospital. During Record Review Patient #5 was sent out to the ER on July 29, 2024 due to be evaluated at Medical City Denton for possible stroke. “The National Alliance for Mentally Ill (NAMI) noted that “for clozapine to work properly, it should be taken every day as ordered by your health care provider” (https://www.nami.org/NAMI/media/NAMI-Media/Research/Clozapine.pdf) “The Food and Drug Administration warned that “Patients should be informed that if they miss taking CLOZARIL for more than 2 days, they should not restart their medication at the same dosage, but should contact their physician for dosing instructions.”(https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/019758s062lbl.pdf). Policy The hospital Policy on Patient Rights dated 03/2023 reflected, “For the purposes of this policy, a grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patients representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 41 CFR 489. A complaint is defined as a form of verbal communication from the patient or the patient’s representative individual’s dissatisfaction with services and the dissatisfaction is able to be resolved by the staff present at the time of the verbal complaint.” The hospital Policy on Pharmaceutical Services 09/2024, “Pharmaceutical services are provided in accordance with state and federal regulations. When there are variations between local, state, and federal regulations, the more stringent regulations are followed.””

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 33579 The hospital failed 1 of 1 Patient (Patient #1) the right to personal privacy. Findings Include During record review, “The hospital Psychiatric Progress Note 06/23/2024, “Patient was assessed in the dayroom. Privacy was maintained. Patient was watching television.” During telephone Interview with hospital Staff #10, Staff #1, and Staff #2 present on 07/17/2024 at 3:45PM, “Staff #10 was asked if he it could be explained why would an assessment take place in the dayroom and indicated that privacy was maintained. Staff #1 and Staff #2 verified that this information is documented in the record and informed the Date June 5, 2024 as being one. There was another assessment recorded as being completed in the hallway, and then when the patient was asleep in the bed. Staff #10 denied doing this and stated that the patient would be reassessed in the room in a private area. This was just the initial assessment. There was no document further assessment in patient’s room. Policy The hospital Policy on Patient Rights dated 03/2023 reflected, “For the purposes of this policy, a grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patients representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 41 CFR 489. A complaint is defined as a form of verbal communication from the patient or the patient’s representative individual’s dissatisfaction with services and the dissatisfaction is able to be resolved by the staff present at the time of the verbal complaint.” The hospital Policy on Quality of Care and Treatment “Plan of Patient Care,” 07/2024, “IT is the policy of Mayhill Hospital to provide a plan for all patients. As the human body is a complex system, the plan of care will include development and action by all disciplines appropriate to the patient’s needs and condition.” The hospital Privacy 18.0 Patient Rights Under the HIPAA Privacy Rule 07/2024, “Recognizing the importance of a patient’s privacy rights, UHS maintains a comprehensive system of policies and procedures to help ensure that a patient’s privacy rights are protected. Below is a summary of patient rights and the policies that address them. Patients will receive a description of their individual privacy rights in the Facility’s notice of privacy practice, as described under UHS Privacy 4.0 Notice of Privacy Practices.””

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 33579 The hospital failed 1 of 1 Patient (Patient 1). The hospital failed to provide Patient #1 skin assessments were properly document. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement). The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. Findings Include: During Record Review Patient #1 received 2 bed baths in an 8 day period. The shower log revealed he did not refuse any other baths or a shower. Staff #7 was unable to explain why Patient #1’s shower record revealed he only had 2 bed baths in 8 days. There was no record that reflected the patient refused.” During Record Review Patient #1 is noted to have on “The hospital Psychiatric Nursing Notes 06/23/2024 11:00AM, Skin Assessments: Alteration in Integrity/wound. Superficial scratches/cuts.” or “Superficial scratches/cuts.” noted on each daily nursing note. During Interview with hospital Staff #7 on 07/17/2024 1:00PM, reported, “Patients are assessed every day, and they receive skin assessments daily. There is not always something we could do for them after assessments are done.” Patient #1 record revealed there were superficial scratches, cuts and bruising and redness on his legs everyday, Why wasnt there a medical consult to address what was taking place and or why. Did the staff not look at his legs day and make proper assessments. Staff #7 responded, “I cant tell you cause this was not my direct patient. There was documentation by Staff #10, Patient #7 was odorous is disheveled and has poor ADLs. Patient #7 was discharged with a pressure sore on the back of leg and was not assessed prior to Discharge.”” Policy The hospital Policy on Patient Rights dated 03/2023 reflected, “For the purposes of this policy, a grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patients representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 41 CFR 489. A complaint is defined as a form of verbal communication from the patient or the patient’s representative individual’s dissatisfaction with services and the dissatisfaction is able to be resolved by the staff present at the time of the verbal complaint.” The hospital Policy on Neglect 07/2024, “Mayhill hospital will maintain an environment free of abuse and neglect. All potential employees will be screened for a history of abuse, neglect or mistreatment of patients. Screening of employees includes requesting information from previous and or current employers and verifying information through background checks ...It is the policy of Mayhill hospital to report alleged and suspected abuse and neglect to the state of Texas Department of health and appropriate authorities in accordance with state and federal statutes.” The hospital Policy on Nursing Services 02/2024, “All patients admitted to Mayhill hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary treatment team to prioritize identified problems within the interdisciplinary Treatment Plan.” The hospital Policy on Skin Wound Injury Documentation, 11/2013, “It is the policy of Mayhill Hospital that when a patient arrives with any injuries they will be documented by photograph upon admission and discharge.” The hospital Policy on Wound Assessment and Classification 04/2021, “All wounds will be assessed upon admission or occurrence. Wounds will be assessed each shift, during dressing changes and with any significant change. Weekly assessments will be conducted by the RN and Wound Care Nurse and documented on the nursing progress note. Pressure ulcers will be classified according to staff and delineated in the procedure section.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 33579 During Record Review and Interview the hospital failed 1 of 1 Patient (Patient #2), by discharging Patient #2 back to his residence without thorough placement sought for patient. The hospital ’ s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient ’ s representative, or patient ’ s physician. Finding Include: During Record Review on 07/17/2024, “PASRR Level 1 Screening for Gary Brazier completed on 05/29/2024. PASRR was completed but not thoroughly.” During Record Review, on 07/17/2024, an Email thread reflecting a Discharge for Patient #2 to one agency. During Interview on 07/17/2024 at 10:40am with Staff #4 the staff that was in charge of this case did contact over 25 placements for this patient and they were all denying the patient due to his violent behaviors. During Interview on 07/17/2024 at 3:40PM with Staff #11, “Staff #11 was asked why he discharged this patient, because it appears that the patient was discharged due to his aggressive behaviors. Staff #11 indicated he was discharged home, and the surveyor inquired if he had any communication with the patients mother. Staff #11 did not have any communication with the mother. The Patient mother was described as elderly with Dementia. Patient #2 is 61. Policy The hospital Policy on Patient Rights dated 03/2023 reflected, “For the purposes of this policy, a grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patients representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 41 CFR 489. A complaint is defined as a form of verbal communication from the patient or the patient’s representative individual’s dissatisfaction with services and the dissatisfaction is able to be resolved by the staff present at the time of the verbal complaint.” The hospital Policy on Transfer and Discharge 04/2021 reflected, “All patients are to be discharged from the unit via written or verbal order from the physician primarily responsible for patent’s care (or his/her designee). All orders discontinued upon discharge. Discharged patients must be accompanied to the lobby by a hospital staff member. Except when discharged per ambulance.” The hospital Policy on Discharge 07/2023, “To ensure the safety and therapeutic success of the patient by providing the appropriate referrals to the next level of care.” The hospital Policy on Discharge Types and Processes 07/2021, “Two principal types of patient discharges occur at Mayhill Hospital; (1) routine, planned discharged, (2) unplanned, patient -initiated discharge occurring prior to the completion of treatment, also referred to as an AMA discharge, and (3) discharges to a more appropriate level of care, whether on an emergent or non-emergent basis. The hospital Policy on Quality of Care and Treatment “Plan of Patient Care,” 07/2024, “IT is the policy of Mayhill Hospital to provide a plan for all patients. As the human body is a complex system, the plan of care will include development and action by all disciplines appropriate to the patient’s needs and condition.””

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 33579 The hospital Failed 1 of 1 Patient (Patient #1) by failing to re-evaluate the patient’s condition to identify changes that require modification of the discharge plan. Findings Include: During Record Review Patient #1 received 2 bed baths in an 8 day period. The shower log revealed he did not refuse any other baths or a shower. Staff #7 was unable to explain why Patient #1’s shower record revealed he only had 2 bed baths in 8 days. There was no record that reflected the patient refused.” During Record Review Patient #1 is noted to have on “The hospital Psychiatric Nursing Notes 06/23/2024 11:00AM, Skin Assessments: Alteration in Integrity/wound. Superficial scratches/cuts.” or “Superficial scratches/cuts.” noted on each daily nursing note. During Interview with hospital Staff #7 on 07/17/2024 1:00PM, reported, “Patients are assessed every day, and they receive skin assessments daily. There is not always something we could do for them after assessments are done.” Patient #1 record revealed there were superficial scratches, cuts and bruising and redness on his legs everyday, Why wasnt there a medical consult to address what was taking place and or why. Did the staff not look at his legs day and make proper assessments. Staff #7 responded, “I cant tell you cause this was not my direct patient. There was documentation by Staff #10, Patient #7 was odorous is disheveled and has poor ADLs. Patient #7 was discharged with a pressure sore on the back of leg and was not assessed prior to Discharge.”” Policy The hospital Policy on Patient Rights dated 03/2023 reflected, “For the purposes of this policy, a grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patients representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 41 CFR 489. A complaint is defined as a form of verbal communication from the patient or the patient’s representative individual’s dissatisfaction with services and the dissatisfaction is able to be resolved by the staff present at the time of the verbal complaint.” The hospital Policy on Neglect 07/2024, “Mayhill hospital will maintain an environment free of abuse and neglect. All potential employees will be screened for a history of abuse, neglect or mistreatment of patients. Screening of employees includes requesting information from previous and or current employers and verifying information through background checks ...It is the policy of Mayhill hospital to report alleged and suspected abuse and neglect to the state of Texas Department of health and appropriate authorities in accordance with state and federal statutes.” The hospital Policy on Nursing Services 02/2024, “All patients admitted to Mayhill hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary treatment team to prioritize identified problems within the interdisciplinary Treatment Plan.” The hospital Policy on Skin Wound Injury Documentation, 11/2013, “It is the policy of Mayhill Hospital that when a patient arrives with any injuries they will be documented by photograph upon admission and discharge.” The hospital Policy on Wound Assessment and Classification 04/2021, “All wounds will be assessed upon admission or occurrence. Wounds will be assessed each shift, during dressing changes and with any significant change. Weekly assessments will be conducted by the RN and Wound Care Nurse and documented on the nursing progress note. Pressure ulcers will be classified according to staff and delineated in the procedure section.”