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 Nov. 22, 2017
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0116
Based on record review, interview and observation the hospital failed to ensure that the notice of rights requirements are met for 1 of 1 patient (patient #16). The hospital failed to discharge the patient after the physician signed the discharge order at 0900.

Findings include

Through record review the surveyor discovered the Physician's Discharge Order signed on 11/27/17 at 0900 hours for Patient #16 to be discharged .

Through interview the surveyor discovered the Physician stated she only rounds in the mornings at the hospital. The Physician stated that she did sign the discharge order at 0900.

Through observation of the hospital video footage, Patient #16 did elope the facility at 1400, due to the hospital failing to discharge the patient with the assistance of her family.


Policy

The hospital Patient Rights Policy dated 06/2016 reflected, "It is the policy of the hospital to ensure that all patients receive a copy of the Patient's Bill of rights form, 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 ..."

The hospital Discharge and Transfer Procedure Policy 04/12 reflected, "All patients are to be discharged from the unit via a written or verbal order from the physician primarily responsible for patient's care ...All orders are discontinued upon discharge ...discharged patients must be accompanied to the lobby by a hospital staff member.

The hospital Elopement Policy 07/2017 reflected, "It is the intent of Mayhill Hospital to maintain a safe environment for all patients/ In the event that a patient elopes form the hospital, the staff will take all reasonable measures to maintain the safety of the patient by facilitating the patient's return to the hospital and/or notifying the authorities and relevant family members, if appropriate. Nursing department staff are trained to identify patients at high risk for elopement. This patient specific training is providing during the initial orientation and annual re-training."

The hospital Discharge Against Medical Advice Policy 06/2016, reflected "It is the policy of Mayhill Hospital to encourage all patients to continue treatment until treatment goals are met, the treatment team can assist in determining appropriate discharge and continuing care plans, and a physician's discharge order has been signed. Eligible patients have the right to request discharge from the hospital at any time. When such a request is made while the physician has determined the patient's treatment goals have not been met and /or that maximum therapeutic benefit has not been achieved at this level of care, the discharge request shall be referred to as being made 'against medical advice,' or 'AMA ...Patients eligible to request discharge: All patients who have voluntarily admitted to Mayhill Hospital have the right to request to be discharged at any time during their treatment. The only exceptions to the above are in instances when the patient is:
a. a minor as defined by law
b. admitted involuntarily or on a legal hold
c. under the legal guardianship of another person. In this instance, the legal guardian shall have the right to request AMA discharge on behalf of the patient ...
If the attending physician is unavailable, the physician on-call will then determine the safety of the patient to discharge. If the patient is to be placed on a 24 hour hold for commitment, the charge nurse or nursing supervisor must document the physician's order of such, and rationale as related to risk factors. The attending must be notified of the commitment hold order, as legal commitment papers have to be filed by 1:00 PM the proceeding business day."
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**





The hospital failed to reassess its discharge planning process and failed 1 of 1 patient Patient #16 to ensure the discharge needs of Patient #16.

Findings Included:

Based on record review interview and observation Patient #16 was not discharged after the physician signed the discharge order on 03/27/17 at 0900.

Based on record review the Patient #16 was oriented x4 (person, place, situation and time). Although patient admitted to taking 10 Ibuprofen, the patient refused to take any psych-medication prescribed by the physician. The patient requested to be discharged from the hospital on [DATE], but decided to stay until 03/27/17 after her visit with the hospital physician.

Based on observation of the video footage Patient #16 did elope from the hosptial with the assistance of her family.

Based on interview the Personnel #12 reported that she did sign the hospital's discharge form on 03/27/17 at 0900. Through interview Personnel #12 verified that she only rounds patients during the morning hours.

Based on interview Personnel #1 verified that Personnel #12 rounds only in the mornings. Personnel #1 verified the Physican's Discharge Order was in fact signed on 03/27/17 at 0900.

Policy:

The hospital Patient Rights Policy dated 06/2016 reflected, "It is the policy of the hospital to ensure that all patients receive a copy of the Patient's Bill of rights form, 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 ..."

The hospital Discharge and Transfer Procedure Policy 04/12 reflected, "All patients are to be discharged from the unit via a written or verbal order from the physician primarily responsible for patient's care ...All orders are discontinued upon discharge ...discharged patients must be accompanied to the lobby by a hospital staff member.

The hospital Elopement Policy 07/2017 reflected, "It is the intent of Mayhill Hospital to maintain a safe environment for all patients/ In the event that a patient elopes form the hospital, the staff will take all reasonable measures to maintain the safety of the patient by facilitating the patient's return to the hospital and/or notifying the authorities and relevant family members, if appropriate. Nursing department staff are trained to identify patients at high risk for elopement. This patient specific training is providing during the initial orientation and annual re-training."

The hospital Discharge Against Medical Advice Policy 06/2016, reflected "It is the policy of Mayhill Hospital to encourage all patients to continue treatment until treatment goals are met, the treatment team can assist in determining appropriate discharge and continuing care plans, and a physician's discharge order has been signed. Eligible patients have the right to request discharge from the hospital at any time. When such a request is made while the physician has determined the patient's treatment goals have not been met and /or that maximum therapeutic benefit has not been achieved at this level of care, the discharge request shall be referred to as being made 'against medical advice,' or 'AMA ...Patients eligible to request discharge: All patients who have voluntarily admitted to Mayhill Hospital have the right to request to be discharged at any time during their treatment. The only exceptions to the above are in instances when the patient is:
a. a minor as defined by law
b. admitted involuntarily or on a legal hold
c. under the legal guardianship of another person. In this instance, the legal guardian shall have the right to request AMA discharge on behalf of the patient ...
If the attending physician is unavailable, the physician on-call will then determine the safety of the patient to discharge. If the patient is to be placed on a 24 hour hold for commitment, the charge nurse or nursing supervisor must document the physician's order of such, and rationale as related to risk factors. The attending must be notified of the commitment hold order, as legal commitment papers have to be filed by 1:00 PM the proceeding business day."