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||Jan. 18, 2017|
|VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS||Tag No: A0469|
|Based on interview and record, the hospital failed to complete a discharge summary within 30 days, in that 1 of 10 (Patient #4) patient's discharge summary was not completed within 30 days following discharge.
Patient # 4's medical reflected no order for discharge, the last time Patient #4 had any information charted was on 11/7/16. As of 1/18/17 there was not a discharge summary in the medical record.
During an interview on 1/18/17 at 10:30 AM, Personnel #1 was informed of the above findings. Personnel #1 verfied there was not a discharge summary in the medical record.
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility's registered nurse (RN) did not supervise and evaluate the nursing care for 2 of 2 patients (Patients #2 and #3) in that:
A. Patient #2's RN did not promptly reassess the patient after administering medications twice on 11/6/16, citing 1 of 2 RNs (Personnel #11).
B. Patient #3 did not have an RN admission assessment within 8 hours of admission. Citing 1 of 2 RNs (Personnel #12).
A. Patient #2 was admitted on [DATE] for alcohol detoxification.
Medication Administration Record (MAR) dated 11/6/16 at 1:00 AM and at 9:35 AM indicated Patient #2 received Tylenol 650mg for pain. The nurse's notes reflected no reassessment for pain medication effectiveness by Personnel #11
During an interview on 1/17/17 at 1:05 PM Personnel #8 confirmed there was not any follow up after the medication was administored.
The Pain Assessment and Management policy dated 1/23/06 and revised 7/09 reflected... Patients shall be reassessed within 45 minutes following any pain relief interventions ...
B.Patient #3 was admitted on [DATE] for Schizoaffective disorder, Bipolar type; Schizophrenia, catatonic type.
Patient #3's medical record reflected an admission date of [DATE] at 5:45 PM. The Admission Nursing Assessment reflected"...11/19/16 9:30 PM, Patient refused". Patient #3's admission assessment did not reflect any other attempts to complete the admission assessment.
During an interview on 1/17/18 at 3:15 PM Personnel #8 confirmed the admission assessment was not completed within 8 hours of admission. Personnel #8 was asked how many times the nurse is required to attempted to complete the admission assessment. Personnel #8 responded "we are required to try 3 times within 8 hours."
The Patient Assessment/Reassessment policy dated 1/23/06, and revised 7/09 reflected "...The nursing assessment is initiated and completed within the first 8 hours of admission..."
|VIOLATION: ADMINISTRATION OF DRUGS||Tag No: A0405|
|Based on interview and record review, the facilities Registered Nurse (RN) did obtain a physician's order for a drug for 1 of 1 patients (Patient #2), in that Personnel #10 did not obtain a physician's order to change Patient #2's oxygen from a nasal cannula to a face mask.
Nurses notes dated 11/6/15 at 1:25 AM reflected...Patient indicated he did not like the nasal cannula up his nose. Patient was switched to a face mask...
During an interview on 1/17/17 at 1:05 PM Personnel #8 was informed of the above findings. Personnel #8 verified there was no physicians order to change the oxygen from a nasal cannula to a face mask.
The Drug Administration, General Guidelines policy, dated 1/23/06; revised 3/16 reflected...b. Drugs should be administered to patients only upon the receipt of the order from a practitioner who has clinical privileges and is legally authorized to prescribe/order drugs.