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The hospital failed 1 of 1 Patient (Patient #1) the right to personal privacy.


Findings Include

During record review, "The hospital Psychiatric Progress Note 06/23/2024, "Patient was assessed in the dayroom. Privacy was maintained. Patient was watching television."

During telephone Interview with hospital Staff #10, Staff #1, and Staff #2 present on 07/17/2024 at 3:45PM, "Staff #10 was asked if he it could be explained why would an assessment take place in the dayroom and indicated that privacy was maintained. Staff #1 and Staff #2 verified that this information is documented in the record and informed the Date June 5, 2024 as being one. There was another assessment recorded as being completed in the hallway, and then when the patient was asleep in the bed. Staff #10 denied doing this and stated that the patient would be reassessed in the room in a private area. This was just the initial assessment. There was no document further assessment in patient's room.

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 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 Privacy 18.0 Patient Rights Under the HIPAA Privacy Rule 07/2024, "Recognizing the importance of a patient's privacy rights, UHS maintains a comprehensive system of policies and procedures to help ensure that a patient's privacy rights are protected. Below is a summary of patient rights and the policies that address them. Patients will receive a description of their individual privacy rights in the Facility's notice of privacy practice, as described under UHS Privacy 4.0 Notice of Privacy Practices."

The hospital failed 1 of 1 Patient (Patient 1). The hospital failed to provide Patient #1 skin assessments were properly document. The hospital's governing body must ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement). The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.


Findings Include:

During Record Review Patient #1 received 2 bed baths in an 8 day period. The shower log revealed he did not refuse any other baths or a shower. Staff #7 was unable to explain why Patient #1's shower record revealed he only had 2 bed baths in 8 days. There was no record that reflected the patient refused."

During Record Review Patient #1 is noted to have on "The hospital Psychiatric Nursing Notes 06/23/2024 11:00AM, Skin Assessments: Alteration in Integrity/wound. Superficial scratches/cuts." or "Superficial scratches/cuts." noted on each daily nursing note.

During Interview with hospital Staff #7 on 07/17/2024 1:00PM, reported, "Patients are assessed every day, and they receive skin assessments daily. There is not always something we could do for them after assessments are done." Patient #1 record revealed there were superficial scratches, cuts and bruising and redness on his legs everyday, Why wasnt there a medical consult to address what was taking place and or why. Did the staff not look at his legs day and make proper assessments. Staff #7 responded, "I cant tell you cause this was not my direct patient. There was documentation by Staff #10, Patient #7 was odorous is disheveled and has poor ADLs. Patient #7 was discharged with a pressure sore on the back of leg and was not assessed prior to Discharge.""

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 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 Services 02/2024, "All patients admitted to Mayhill hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary treatment team to prioritize identified problems within the interdisciplinary Treatment Plan."

The hospital Policy on Skin Wound Injury Documentation, 11/2013, "It is the policy of Mayhill Hospital that when a patient arrives with any injuries they will be documented by photograph upon admission and discharge."

The hospital Policy on Wound Assessment and Classification 04/2021, "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 staff and delineated in the procedure section.

During Record Review and Interview the hospital failed 1 of 1 Patient (Patient #2), by discharging Patient #2 back to his residence without thorough placement sought for patient. The hospital ' s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient ' s representative, or patient ' s physician.

Finding Include:

During Record Review on 07/17/2024, "PASRR Level 1 Screening for Gary Brazier completed on 05/29/2024. PASRR was completed but not thoroughly."

During Record Review, on 07/17/2024, an Email thread reflecting a Discharge for Patient #2 to one agency.

During Interview on 07/17/2024 at 10:40am with Staff #4 the staff that was in charge of this case did contact over 25 placements for this patient and they were all denying the patient due to his violent behaviors.

During Interview on 07/17/2024 at 3:40PM with Staff #11, "Staff #11 was asked why he discharged this patient, because it appears that the patient was discharged due to his aggressive behaviors. Staff #11 indicated he was discharged home, and the surveyor inquired if he had any communication with the patients mother. Staff #11 did not have any communication with the mother. The Patient mother was described as elderly with Dementia. Patient #2 is 61.

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 Transfer and Discharge 04/2021 reflected, "All patients are to be discharged from the unit via written or verbal order from the physician primarily responsible for patent's care (or his/her designee).
All orders discontinued upon discharge. Discharged patients must be accompanied to the lobby by a hospital staff member. Except when discharged per ambulance."

The hospital Policy on Discharge 07/2023, "To ensure the safety and therapeutic success of the patient by providing the appropriate referrals to the next level of care."

The hospital Policy on Discharge Types and Processes 07/2021, "Two principal types of patient discharges occur at Mayhill Hospital; (1) routine, planned discharged, (2) unplanned, patient -initiated discharge occurring prior to the completion of treatment, also referred to as an AMA discharge, and (3) discharges to a more appropriate level of care, whether on an emergent or non-emergent basis.

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 Failed 1 of 1 Patient (Patient #1) by failing to re-evaluate the patient's condition to identify changes that require modification of the discharge plan.


Findings Include:

During Record Review Patient #1 received 2 bed baths in an 8 day period. The shower log revealed he did not refuse any other baths or a shower. Staff #7 was unable to explain why Patient #1's shower record revealed he only had 2 bed baths in 8 days. There was no record that reflected the patient refused."

During Record Review Patient #1 is noted to have on "The hospital Psychiatric Nursing Notes 06/23/2024 11:00AM, Skin Assessments: Alteration in Integrity/wound. Superficial scratches/cuts." or "Superficial scratches/cuts." noted on each daily nursing note.

During Interview with hospital Staff #7 on 07/17/2024 1:00PM, reported, "Patients are assessed every day, and they receive skin assessments daily. There is not always something we could do for them after assessments are done." Patient #1 record revealed there were superficial scratches, cuts and bruising and redness on his legs everyday, Why wasnt there a medical consult to address what was taking place and or why. Did the staff not look at his legs day and make proper assessments. Staff #7 responded, "I cant tell you cause this was not my direct patient. There was documentation by Staff #10, Patient #7 was odorous is disheveled and has poor ADLs. Patient #7 was discharged with a pressure sore on the back of leg and was not assessed prior to Discharge.""

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 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 Services 02/2024, "All patients admitted to Mayhill hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary treatment team to prioritize identified problems within the interdisciplinary Treatment Plan."

The hospital Policy on Skin Wound Injury Documentation, 11/2013, "It is the policy of Mayhill Hospital that when a patient arrives with any injuries they will be documented by photograph upon admission and discharge."

The hospital Policy on Wound Assessment and Classification 04/2021, "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 staff and delineated in the procedure section.