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MILLWOOD HOSPITAL

1011 NORTH COOPER STREET

ARLINGTON, TX 76011

PATIENT RIGHTS: EXERCISE OF RIGHTS

Tag No.: A0129

Based on review of records and interview the hospital failed to provide a 4 hour letter after 1 of 1 patient (patient #1) requested to be discharged from the hospital.

Findings Included:

The nursing progress notes dated 09/17/15 at 0918 reflected, "Pt is alert and orinted. Pt reported that she wants to be discharged. Pt is tearful and stated that her parents also wants her home..." There was no 4 hour letter included within Patient #1's medical records.

On 12/03/15 at 10:40 a telephone call was made to Personnel #1. Personnel #1 indicated that there was a four hour letter provided to the Patient #1. Personnel #1 could not provide the 4 hour letter for patient #1.

Policy

The hospital Discharge Against Medical Advice dated 11/2014 reflected, "The voluntary patient's right to leave the hospital against medical advice is addressed in an appropriate and timely manner...All voluntary patients who have signed themselves into the hospital for treatment have the right to terminate their stay with or without consent of the Attending Physician."

PATIENT RIGHTS: ACCESS TO MEDICAL RECORD

Tag No.: A0148

Based on interview and record review the hospital failed to provide 1 of 1 patient (patient #1) with a copy of their complete hospital medical record.

Findings Included

During an interview on 11/23/15 at 1515 with Personnel #8. Personnel #8 was asked if he was aware of how many pages were in Patient #1's record. Personnel #8 provided the surveyor with the letter of request which indicated 85 pages. Personnel #8 was informed that there was well over 85 pages. Personnel #8 reviewed the record and agreed that there was well over 85 pages excluding the 3 pages from the patient's discharge summary that was not received. Personnel #8 agreed that Patient #1 did not receive their complete hospital medical record.

Policy

The Hospital Policy on Release of Information dated 06/2013 included, "To provide fair access to the medical record."

The Hospital Policy on Record request and retrieval 07/2014 reflected, "Records will be retrieved as promptly as possible, no matter the reason for use."