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The hospital failed 1 of 3 patients. Patient #2 by failing to ensure the Patients Rights were met, by failing to provide the patients entire medical record to the requesting hospital.

Findings Include:

Through record review, findings reflected that the patients medical records were requested from an outside facility in order to properly continue long term medication care.

Through interivew hospital staff #5 indicated that medical records were no submitted in full. Staff #5 reported, "I do not send the complete MAR to the requesting facility. I only send the incoming medications and outgoing medications to the requesting facility."

The hospital Policy on Patient Rights dated 04/2018, reflected, "Is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of the Patient Handbook which indicates 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 failed 1 of 3 patients during the Discharge, and Transfer of Patient #2 by failing to provide documentation to sufficient preparation and orientation to residents to enure safe and orderly transfer of Patient records.


Findings Include

Through Observation and Record Review the surveyor observed a request for Patient #2's medical records. The request of medical request should have included Patient #2's MAR. Patient #2 is recieiving Long term Intravenous Injections. That require timely administration of the next dosage. The hospital failed to inform the receiving hospital in a timely fashion of Patients Medication and time table for the next administration.

Through Interview with Hospital Staff #5, the surveyor was informed that the Patients entire medical record is never sent to the hospital. The hospital only sends the patient's incoming and outgoing medications. The surveyor asked Patient hospital staff #5 is the MAR apart of the medical record. Staff #5, responded, "Yes it is."

The hospital Policy on Pharmaceutical Services (Medication Administration) dated 03/2018 reflected, "Licensed nurses at Millwood Hospital carry out medication preparation, administration, and documentation in a consistent and safe manner."

The hospital Release of Information to Copy Service dated 03/2018, reflected, "Patient authorization shall be obtained prior to release of information in non-emergency situations. Reference telephone request for unauthorized emergency information. Information may be released to other healthcare facilities in a bona fide emergency situation in which the patient's health and safety are at risk without patient authorization. Patient authorization shall be documented and maintained."

The hospital Policy on Falsification of Records, reflected, "This documentation is a comprehensive evaluation, risk assessment and prevention and control plan which is completed annually, however at any time, based on significant changes, the risk assessment and plan can be revised."

The hospital Policy on Admission, Transfer, and Discharge dated 03/2018 reflected, "A registered nurse will complete a nursing assessment of the patient within 8 hours of admission. If the patient's condition is such that accurate information cannot be obtained, this should be so noted and the assessment completed as soon a patient's condition permits.

The hospital Emergency Services and Transfer dated 09/2019 reflected, "The governing body at Millwood Hospital has adopted the following policy in accord with the rules adopted by the Texas Department of State Health Services regarding the provision of emergency services and the transfer of patients between hospital and another hospital. In medically appropriate manner. The transfer of patient may not be predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition or economic status.

The hospital Discharge Progress Policy dated 03/2018 reflected, "Three types of discharges occur at Millwood Hospital. The greatest number of discharges takes place as planned events at the conclusion of inpatient treatment. Another category or discharge titled, 'Against Medical Advice' is unplanned and occurs prior to or when the physician and hospital staff consider the optimal period of inpatient treatment. The third type is of discharge titled 'Administrative discharge' and occurs when a patient fails to return within a 24hour period of time from an elopement, it also occurs in the even of patient death."