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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."