The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MAYHILL HOSPITAL 2809 SOUTH MAYHILL ROAD DENTON, TX 76208 May 22, 2013
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review and interviews, the hospital failed to provide a safe care environment in that

1) Emergency equipment of AED (Automated External Defibrillator) pads was not available on the crash cart on 05/16/13 and
2) Physician ordered medical equipment necessary for Patient #7's sleep apnea was not available for patient use four days later on 05/22/13.

Findings included

On 05/16/13 at 16:45 Registered Nurse (Hospital Personnel #8) was requested to demonstrate the use of the AED. Hospital Personnel #8 removed two pads from an opened package and stated he would not use those in an emergency because they were "for training." Hospital Personnel #8 denied there were other pads available on the crash cart at that time for use in an emergency. The Director of Nursing (Hospital Personnel #7) stated at that time pads for use with the AED were in her office.

The emergency system check document provided to the surveyor on 05/16/13 at 17:00 was dated 05/11/13 at 19:06. The first floor crash cart log provided by the Director of Nursing (Hospital Personnel #7) on 05/16/13 around 17:00 reflected the emergency cart was last checked on 05/11/13. The second floor crash cart log obtained 05/16/13 at approximately 17:05 had a last check date of 05/12/13. There is no indication that availability of emergency AED pads was checked.

The Director of Nursing (Hospital Personnel #7) verified the above finding on 05/16/13 at 17:25 and stated it was the house supervisor's responsibility to check the crash carts and emergency equipment every night but "it fell through the cracks."


2) Patient #7"s admission diagnoses dated 05/17/13 included Major Depressive Disorder, Recurrent, Severe, with Psychosis. The patient's medical diagnoses included Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Hypertension.

The Nurse to Nurse Report dated "09/17/13" reflected Patient #7 had a "Bipap [machine] for sleep" (Biphasic Positive Airway Pressure ventilation machine allowing unrestricted spontaneous breathing during patient's sleep).
Patient #7's History and Physical dated 05/18/13 at 09:45 AM included diagnoses of Chronic Obstructive Pulmonary Disease and Sleep Apnea. The physician planned to add a CPAP machine (Continuous Positive Airway Pressure machine) for sleep apnea.

Physician orders dated 05/18/13 reflected Patient #7 to have a CPAP machine "for sleep apnea."

Patient #7's assessment dated [DATE] at 23:00 noted Patient #7 received anti-anxiety medication and was "unable to go to sleep." The 05/21/13 nursing documentation reflected the patient was short of breath and stated she "was awake most of [the] night." On 05/21/13 at 17:10 nursing noted the patient had "difficulties concentrating" and isolated in her room "often, sleeping."

Hospital Personnel #16 was asked about Patient #7's CPAP machine on 05/22/13 at 10:35 AM. Hospital Personnel #16 stated she would look for it. Hospital Personnel #16 was observed searching the room adjacent to the nurses' station and stated, "It must be in her [the patient's] room." Hospital Personnel #16 walked into Patient #7s room and did not find the CPAP machine.

Patient #7 was observed receiving a breathing treatment on 05/22/13 at 10:40 AM. When asked about her CPAP machine, Patient #7 stated she had not "had it in a week." Hospital Personnel #16 stated at that time she "did not know that." Upon surveyor inquiry, Patient #16 stated she had a CPAP machine at home but her family had not brought it to the hospital yet. Patient #7 stated without the machine "I wake up catching my breath."

The hospital Medical Director (Hospital Personnel #15) was interviewed on 05/22/13 at 11:00 AM and stated "A CPAP machine should be available for the patient..." Hospital Personnel #15 stated the hospital "could have rented a unit" for Patient #7.

Hospital Patient Rights and Responsibility Policy A100.200 dated 05/06/11 reflected patient rights to include "...the right to receive care in a safe setting..."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review and interviews, nursing staff failed to administer narcotic drugs in accordance with approved medical staff policies and procedures in that licensed nursing staff members exchanged passwords to mutually witness narcotic medication wastage in the electronic medication administration system instead of witnessing the narcotic medication wastage in person.

Findings included:
The Director of Nursing (Hospital Personnel #7) was interviewed on 05/16/13 at 15:50. When asked if nurses obtained other nurses' passwords ahead of time in order to complete the requirement of co-signatures witnessing narcotic medication wastage, Hospital Personnel #7 stated, "I am sure they do. Nurses tell me they exchange passwords."

The Pharmacy Director (Hospital Personnel #17) stated during an interview on 05/16/13 at 18:00 he was aware of nursing staff exchanging passwords for the automated medication dispensing system and had discussed the issue with nursing administration "about three weeks ago." Hospital Personnel #17 denied any actions were initiated to correct that practice prior to the survey.

The hospital Medical Director (Hospital (Personnel #15) was interviewed on 05/22/13 at 11:00 AM and stated nursing exchanging passwords for use in the medication dispensing system (Pyxis System) would be "unsafe practice."

Hospital Policy titled Dispensing Controlled Medications issued 01/2011 reflected "If a narcotic medication is ever to be wasted two system operators MUST be present to witness the narcotic waste ..."

Hospital Policy titled Electronic Media Communication System issued 04/01/13 noted "All ...Electronic Media system passwords are strictly confidential. Passwords provide employees safeguards from the system being misused in their name. Employees are not permitted to attempt to obtain passwords from another user."