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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."

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."