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 June 8, 2018
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
Based on record review, interview the hospital failed 1 of 1 patient (Patient #1) to have a family member or representative of his choise notified promptly at his admission to the hospital.

Findings Include:

During the record review of Patient #1's medical record documentation from the referring facility was not present in the record.
When the record was obtained by the surveyor the record revealed Patient #1 was not his own legal guardian.

During the interview of Personnel #7 it was reported that the family was not notified. Personnel #7 reported he thought Patient #1 was his own legal guardian. Personnel #7 reported that a question he asks during the screening process for admission to the facility was "Are you your own guardian?" Personnel #7 did not verify this information by review of Patient #1's medical record at Ashford Hall prior to admission into Mayhill. Personnel #7 did not verify the medical record was transferred to Mayhill Hospital at admission. Personnel #7 stated "I did not verify we recieved the medical record by fax as it should have been."

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 ...Procedure; 4. When the individual receiving services is unable or unwilling to sign the document which confirms that rights have been orally communicated, a brief explanation of the reason should be entered onto that document along with the signature of the person who explained the rights and third-party witness, preferably by a family member, legal guardian ...5. A copy of the Patient's Bill of Rights form also shall be provided to the patient and to the individual's family member, legal guardian ..."

The hospital Policy and Procedure on Admission Involuntary Process date 06/2016 reflected, "Patients will only be involuntarily admitted to Mayhill Hospital for mental health treatment in accordance with Texas Mental Health Code 573 for emergency detention ...On any type of emergency detention order, the form must be completed by a peace officer or the legal guardian of the person ...D. A guardian of a person of a ward who is 18 years of age or older without the assistance of a peace officer, may transport the ward to an inpatient mental health facility for a preliminary examination in accordance with Section 573.021."

The hospital Admission Discharge and Continued stay Policies and Procedures dated 09/2017 reflected, "It is the policy of Mayhill hospital to follow criteria for admission, continued stay and discharge to all programs to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level ...Discharge criteria; Releasing or transferring the patient to a less intensive level of care does not post a threat to him/her, others or property."
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on record review and interview the hospital failed one of one patient (Patient #1) of being transfered to the appropriate facilities.

Findings includded:

During interview with personnel #4, personnel #1, they were unware that the facility in which the patient was referred to was unlicensed. The hospital personnel #4 reported they were not aware the group home was unlicensed. Personnel #1 was asked if they were aware the group home was unlicensed.

During record review the medical record of Patient #1 did not have the documentation from Patient #1's previous placement. The patient was not his own legal guardian as the paperwork revealed from his previous placement.


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 ...Procedure; 4. When the individual receiving services is unable or unwilling to sign the document which confirms that rights have been orally communicated, a brief explanation of the reason should be entered onto that document along with the signature of the person who explained the rights and third-party witness, preferably by a family member, legal guardian ...5. A copy of the Patient's Bill of Rights form also shall be provided to the patient and to the individual's family member, legal guardian ..."

The hospital Policy on Abuse and Neglect dated 07/2017 reflected, "Mayhill Hospital will maintain an environment free of abuse and neglect. All potential new employees will be screened for a history of abuse, neglect or mistreatment of patients ...Neglect ...1. Failure to establish or carry out an appropriate individual treatment plan"

The hospital Policy and Procedure on Admission Involuntary Process date 06/2016 reflected, "Patients will only be involuntarily admitted to Mayhill Hospital for mental health treatment in accordance with Texas Mental Health Code 573 for emergency detention ...On any type of emergency detention order, the form must be completed by a peace officer or the legal guardian of the person ...D. A guardian of a person of a ward who is 18 years of age or older without the assistance of a peace officer, may transport the ward to an inpatient mental health facility for a preliminary examination in accordance with Section 573.021."

The hospital Admission Discharge and Continued stay Policies and Procedures dated 09/2017 reflected, "It is the policy of Mayhill hospital to follow criteria for admission, continued stay and discharge to all programs to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level ...Discharge criteria; Releasing or transferring the patient to a less intensive level of care does not post a threat to him/her, others or property."

The hospital Patient Assessment Process date 02/2017 reflected, "May hospital provides assessments to determine what type of care is required to meet a patient's initial needs as well as his needs as they change in response to care. The assessment process is individualized according to the patient's age, development level, and needs. Information is obtained from the patient, and if appropriate and consent is obtained, the family members/significant others, referral source, and/or primary care physician.
1. Collecting data about each patient's health history, physical, functional ...and circumstance."


The hospital Policy Pre-Employment Assessment Policy dated 06/2016 reflected, the facility is committed to selecting qualified candidates for open positions while complying with all applicable Federal, State and local as well as other regulations."

The hospital Policies and Procedures Assessment of Patient dated 06/2016 reflected, "All patients admitted to Mayhill Hospital will receive a thorough assessment and evaluation ...29. Family relationships ...36. Discharge criteria. Psychosocial Evaluation ...9. Legal History ...discussion as to the nature and urgency of the patient's legal difficult and the extent."