HospitalInspections.org

The hospital failed 1 of 1 Patient (Patient #1) by failing to ensure that clear expectations for safety are established.

Findings Include:

During Record Review Patient #1 was diagnosis of Dementia. The patient was transported to nursing facility and not checked into the hospital by an escort. The patient was dropped off and left to enter the building on their own accord. The patient was found by a hospital employee seated out side on the side of the building, not have recall that she was to enter into the nursing home.

During Interview with hospital Staff #2 reported that Patient #1 was placed in the hospital contracted cab service.

During Interview with hospital Staff #2 reported that Patient #1 was transported without a translator or an escort to ensure safety or proper admission into the transferring hospital.

During Interview with hosptial Staff #6 reported that discharge and setting up placement and admission is the responsibility of the therapist.

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 Admission, Discharge, Continued Stay Criteria 03/2022 reflected, "It is the policy of the Excel Center to follow criteria for admission, continued stay and discharge to all programs to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level ...
Discharge Criteria:
To be applied across all programs and age groups
A. The goals of the treatment have been substantially met at this level of care (unless transfer to another hospital setting is indicated.), and a discharge plan is in the place that meets any continuing is the place that meets any continuing needs.
B. Follow-up goals and treatment plans for a lesser level of care have been established.
C. Releasing or transferring the patient to a less intensive level of care does not post a threat to him/her others or property.
D. The client has decompensated to a level of emotional or mental instability requiring a higher level of care.

The hospital Discharge Process 12/2021 reflected, "Three types of discharge occur at Millwood Hospital. The greatest number of discharges takes place as planned events at the conclusion of inpatient treatment. Another category of discharge titled 'Against Medical Advice' is unplanned and occurs prior to when the physician and hospital staff consider the optimal period of inpatient treatment. The third type of discharge is titled, 'Administrative Discharge' and occurs when a patient fails to return within a twenty-four hour period of time from an elopement. It also occurs in the event of patient death."

The hospital Policy on Administration/Personnel 'Organizational Reporting Structure' 03/2022 reflected, "Millwood hospital maintains current organizational charts showing the internal and external relationships."

The hospital Policy Administration/Personnel 'Communication with Leadership' 03/2022 "This policy establishes the expectation that the facility maintains current communication with hospital leadership on issues of safety and quality of care."

The hospital Policy on Assessment Safety Risk Factors/Patient Precautions 09/2022 reflected, 'Patients assessed to be at heightened risk of suicide as determined in the conclusions of either the Intake Assessment, Nursing Assessment, Psychiatric Evaluation, or based upon patient statements and or behavior, may bee have placed on suicide precautions commensurate with assessed level of risk. Staff responsible for monitoring patients on suicide precautions shall maintain the patient in a safe environment and take measures to protect the patient from self-harm."

The hospital Policy Communicating with Patients with Limited English Proficiency 03/2022, "Millwood Hospital will take reasonable steps to ensure persons with Limited English Proficiency (LEP) or who are deaf/hard of hearing have equal access to and equal participation in their care and treatment. The Policy of Millwood Hospital is to ensure meaningful communication with these patients and their guardians/authorized representatives involved in their care and treatment. All interpreters, translators and other aids needed to comply with this policy shall be provided without cost to the person being served, and patients and their families will be informed of the availability of such assistance. Language interpretation will be provided by Qualified Interpreters (competent/trained bilingual staff or contract interpreting services). The hospital will conduct a regular review of the language/communication needs of our patient population, as well as update and monitor the implementation of this policy and procedures as necessary."

The hospital Policy on Transportation dated 12/2021 reflected, "Patients needing to leave the hospital and transition to community placements or other treatment facilities for continuing care may need assistance in obtaining transportation. The patient's current needs and self-sufficiency are assessed to determine what type of transportation is needed."

The hospital failed 1 of 1 Patient (Patient #1) by failing to properly arrange discharge planning arranging for safe arrival for follow-up care and developing mechanishms for exchange of approrpirate information with sources outside the hospital.

Findings Include:


During Record Review Patient #1 was diagnosis of Dementia. The patient was transported to nursing facility and not checked into the hospital by an escort. The patient was dropped off and left to enter the building on their own accord. The patient was found by a hospital employee seated out side on the side of the building, not have recall that she was to enter into the nursing home.

During Interview with hospital Staff #2 reported that Patient #1 was placed in the hospital contracted cab service.

During Interview with hospital Staff #2 reported that Patient #1 was transported without a translator or an escort to ensure safety or proper admission into the transferring hospital.

During Interview with hosptial Staff #6 reported that discharge and setting up placement and admission is the responsibility of the therapist.

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 Admission, Discharge, Continued Stay Criteria 03/2022 reflected, "It is the policy of the Excel Center to follow criteria for admission, continued stay and discharge to all programs to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level ...
Discharge Criteria:
To be applied across all programs and age groups
A. The goals of the treatment have been substantially met at this level of care (unless transfer to another hospital setting is indicated.), and a discharge plan is in the place that meets any continuing is the place that meets any continuing needs.
B. Follow-up goals and treatment plans for a lesser level of care have been established.
C. Releasing or transferring the patient to a less intensive level of care does not post a threat to him/her others or property.
D. The client has decompensated to a level of emotional or mental instability requiring a higher level of care.

The hospital Discharge Process 12/2021 reflected, "Three types of discharge occur at Millwood Hospital. The greatest number of discharges takes place as planned events at the conclusion of inpatient treatment. Another category of discharge titled 'Against Medical Advice' is unplanned and occurs prior to when the physician and hospital staff consider the optimal period of inpatient treatment. The third type of discharge is titled, 'Administrative Discharge' and occurs when a patient fails to return within a twenty-four hour period of time from an elopement. It also occurs in the event of patient death."

The hospital Policy on Administration/Personnel 'Organizational Reporting Structure' 03/2022 reflected, "Millwood hospital maintains current organizational charts showing the internal and external relationships."

The hospital Policy Administration/Personnel 'Communication with Leadership' 03/2022 "This policy establishes the expectation that the facility maintains current communication with hospital leadership on issues of safety and quality of care."

The hospital Policy on Assessment Safety Risk Factors/Patient Precautions 09/2022 reflected, 'Patients assessed to be at heightened risk of suicide as determined in the conclusions of either the Intake Assessment, Nursing Assessment, Psychiatric Evaluation, or based upon patient statements and or behavior, may bee have placed on suicide precautions commensurate with assessed level of risk. Staff responsible for monitoring patients on suicide precautions shall maintain the patient in a safe environment and take measures to protect the patient from self-harm."

The hospital Policy Communicating with Patients with Limited English Proficiency 03/2022, "Millwood Hospital will take reasonable steps to ensure persons with Limited English Proficiency (LEP) or who are deaf/hard of hearing have equal access to and equal participation in their care and treatment. The Policy of Millwood Hospital is to ensure meaningful communication with these patients and their guardians/authorized representatives involved in their care and treatment. All interpreters, translators and other aids needed to comply with this policy shall be provided without cost to the person being served, and patients and their families will be informed of the availability of such assistance. Language interpretation will be provided by Qualified Interpreters (competent/trained bilingual staff or contract interpreting services). The hospital will conduct a regular review of the language/communication needs of our patient population, as well as update and monitor the implementation of this policy and procedures as necessary."

The hospital Policy on Transportation dated 12/2021 reflected, "Patients needing to leave the hospital and transition to community placements or other treatment facilities for continuing care may need assistance in obtaining transportation. The patient's current needs and self-sufficiency are assessed to determine what type of transportation is needed."