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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."

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."