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Based on interview and record review the facility failed to ensure that the legal representative for 1 of 1 (#29) legally incapacitated patient's from a total sample of 30 patients, was provided the right to informed decision regarding patient care resulting in insufficient information provided to the legal guardian. Findings include:
On 07/07/2011 at 0945 a.m., review of patient #29's medical record revealed that the patient was admitted into the inpatient psychiatric facility on 06/05/2011 with diagnoses that included Bipolar, Schizoaffective disorder, colon cancer, and anemia.
Upon admission into the in-patient psychiatric facility, the legally incapacitated patient was provided several forms to read and sign acknowledging her understanding of the documents. The patient was given the following documents to read and sign, even though she had a legal guardian to make decisions on her behalf:
-Adult formal voluntary application ( legal document), signed 06/05/11
-Inpatient conditions of admission, signed 06/05/11
-Confidentiality/Recipient Rights/Medicaid/HIPPA/Application acknowledgement/Notice of Privacy practices &Advance Care Directives application acknowledgement, signed 06/05/11
-Restraint and/or seclusion & Recipient Rights Notification,signed 06/05/11
-Client Notice of Confidentiality: Recipient Rights, signed 06/05/11
-Important Message from Medicare, signed 06/11/11
-Discharge Instructions, signed 06/11/11
It is unclear if the patient actually read the documents and fully understood them, particularly the Important Message from Medicare and the Discharge instructions that were signed on the day of the patients discharge.
Further review of the patient's medical record revealed that the patient's sister/ legal representative was provided irrelevant information from the facility staff at the time of the patients discharge.
The legal representative was informed that arrangements were made for the patient to be transferred to a medical facility for a scheduled procedure, however on the day of discharge the hospital (that the patient was transferred to) did not expect the patient and was unaware that the transfer was to occur, additionally the hospital reportedly did not have a bed available for the patient. The sending hospital (the inpatient psychiatric facility) was made aware of the situation, but did not accept the patient back.
The patients' legal guardian reported, "I was very upset and dismayed about the situation. The patient was dumped and left in limbo. "

Based on observation, interview and record review the facility failed to follow doctors' orders and provide a timely x-ray to rule out fracture for 2 of 2 patients (#8 & #9) who experienced falls in the facility from a total sample of 30 patients; resulting in a delay in detecting the fractured right lateral malleolus (lower end of the fibula) for Patient #9.

Findings include:

On 07/06/2011 at 1100 a.m., interview with patient #9 who was alert and oriented and sitting in a wheel chair in the day room with his right foot elevated. The patient's right foot appeared to be swollen. The patient stated, "I fell in the facility and injured my right foot last week, but the facility did not x-ray my foot until this morning." The patient reported having severe pain in his right foot and did not understand why they took so long to have the x-ray done when the doctor ordered it on 07/01/11. When asked why he was using a wheel chair, the patient reported that he could no longer ambulate the way that he did when he was admitted into the facility, he needed the wheel chair for ambulation. The patient further stated that he filed a recipient rights complaint that morning related to the delay in the x-ray.

Review of Incident Report Summary dated 06/29/11 revealed, "Patient stood up and then fell to the floor striking his buttocks and then fell backwards. he did not strike his head. He stated that he felt dizzy prior to standing up and has been feeling dizzy for the past 2 days. Patient assessed for injuries from head to toe no injuries observed...Doctors were both notified with no injuries observed."

Review of Patient #9's medical record on 07/06/11 at 11:30 a.m. revealed a physician order dated 07/01/11 at 1200 p.m. which indicated "X-ray right foot and ankle rule out fracture."

Progress notes dated 07/01/11 revealed "..right foot injury. Awaiting x-ray of right foot and ankle to rule out fracture."
It is unclear why it took two days for the patient to be assessed by a physician and an x-ray order written.

Review of a document entitled, "BCOM (Behavioral Center of Michigan) Patient results" faxed to this surveyor on 07/11/11 revealed that patient #9 - "right ankle and right foot has fracture lateral malleolus minimal widening of ankle mortise."

Thus, patient #9 had a slip and fall in the facility on 06/29/11; the physician assistant wrote an order for an x-ray on 07/01/11 but the x-ray was not completed until 07/06/11 (5 days later) X-ray results revealed that the patient sustained a fracture as a result of the fall.It was unclear if the facility did anything further for the patient.

On 07/06/2011 at 11:45 a.m.., review of Patient #8 medical record revealed a physician's order dated 07/01/11 at 1205 which indicated "X-ray right forearm and hand rule out fracture s/p (status post) fall,"

There was no documentation in the patients chart describing the incident that occurred which required the need for an x-ray and there was no x-ray results in this patients chart either. Incident reports for both patients were requested from staff.

Interview with the Nurse Manager who verified that the x-ray results were not in the patients chart on 07/06/11 even though the order was written on 07/01/11 at 1205 p.m. Nurse Manager stated, "It takes four days for the x-ray results to come back." When asked when the x-ray was done for patient #8 the Nurse Manager said, "this morning." The Nurse Manager was not able to explain what happened to the patient causing the need for an x-ray.

Interview with patient #8 on 07/06/11 at 11:55 a.m. inquire what happened to her. The patient explained, "I had a slip and fall in the shower last week on Tuesday (06/28/11), my arm and hand was swollen a lot but now the swelling has gone down some but my hand feels stiff." Observation of the patient's right hand and forearm revealed that it was slightly swollen compared to her other arm and the skin on her right hand knuckles were pink.

On 07/06/11 at 1:00 p.m. , interview with the Physician Assistant who wrote the orders for the x-rays. She reported that the x-rays orders were written late in the day on Friday, (07/01/11) then came the weekend, and Monday was a holiday and she (the PA) didn't believe that the injuries were serious enough for the patients to be sent out for an x-ray. The PA further stated that she didn't know that patient #8 had fallen in the shower, yet the order indicated s/p fall.

Review of the facility policy entitled, "Fall Prevention and Intervention" revised June 2011 revealed, "6. In the event of a fall, with or without injury: . . The attending Physician and/or Resident will be promptly notified to determine the need for further evaluation, the nurse follows the physician's treatment orders post-fall..."

Based on QAPI program review and interview, the facility failed to have an on-going QAPI program implemented. Findings include:

Review of QAPI program information provided revealed that the QAPI plan had just been approved on 6/1/11. Some data was provided without analysis or action plans. No QAPI meeting minutes were documented. Interview with the CEO, Chief Quality Officer and Chief Human Resources Officer, on 7/7/11 at approximately 1300, verified that no QAPI meetings with analysis and action plans had taken place in the past year. The CEO was queried if the Governing Body (GB) had discussed QAPI in the GB minutes in the past year, and the CEO stated that they had not.

Based on record review and interview it was determined that the facility to provide adequate staffing for the patient unit A. Findings include:
On 07/06/11 at approximately 1400, it was determined during record review that the facility did not have adequate staffing according to the facility ' s matrix (needed staff according to census) for the following days:
06/12/11: Unit A, Day Shift
34 patients
2 RN (Registered Nurses)
1 LPN (Licensed Practical Nurse)
3 MHT (Mental Health Technicians) Needed 5

06/12/11: Unit A, Afternoon Shift
34 patients
2 RN
1 LPN
3 MHT (Needed 5)

06/12/11: Unit A, Midnight Shift
34 patients
2 RN (Needed 3)
3 MHT (Needed 5)

06/16/11: Unit A, Midnight Shift
31 patients
2 RN
2 MHT (Needed 3)

06/17/11: Unit A, Afternoon Shift
34 patients
2 RN
1 LPN
3 MHT (Needed 5)

06/19/11: Unit A, Midnight Shift
35 patients
2 RN
2 MHT (Needed 3)

06/21/11: Unit A, Midnight Shift
35 patients
2 RN
2 MHT (Needed 3)

06/24/11: Unit A, Afternoon Shift
31 patients
2 RN
1 LPN
3 MHT (Needed 4)

06/26/11: Unit A, Afternoon Shift
31 patients
2 RN
1 LPN
2 MHT (Needed 4)

06/27/10: Unit A, Day Shift
1 RN
1 LPN
3 MHT (Needed 5)

06/27/11: Unit A, Afternoon Shift
31 patients
2 RN
1 LPN
2 MHT (Needed 5)

07/01/11: Unit A, Afternoon Shift
31 patients
2 RN
1 LPN
2 MHT (Needed 5)

07/01/11: Unit A, Midnight Shift
35 patients
2 RN
2 MHT (Needed 3)

On 07/06/11 at approximately1330 it was confirmed during an interview with the Director of Nursing, that the facility failed to schedule the appropriate number of RN ' s and MHT ' s according to their staffing grid.
On 07/06/11 at approximately 1530, during policy review it was noted while reviewing a document titled " Plan for Nursing Organization and Delivery of Services " the facility did not follow their own policy for the services of care.

Based on observation, interview, record review, and policy review the facility failed to provide the monitoring of vital signs and monitoring of laboratory results for two of three patients (#7, #24) resulting in the potential of inappropriate medication dosing, failed to recognize patient's electrolyte needs, and failure to recognize low/high blood pressures in a known hypertensive patient.

On 7/6/2011 at approximately 1047 during chart review it was revealed that patient #7 failed to have vital signs upon entry to the facility on 6/24/2011. The charge nurse was queried about why the patient had not had vital signs and he stated that "the patient refuses on a daily basis to have her vitals done". The patient then was interviewed and asked if she would allow for her vitals to be obtained. Vitals were obtained on 7/6/2011 at 1120. The patient's blood pressure was 89/48. When questioned the nurse manager about the patient's blood pressure being low, the nurse manager responded that the physician would be contacted.

On 7/7/2011 at approximately 1040 the charge nurse was queried about if the physician was contacted about patient #7 blood pressure the prior day. The charge nurse responded that he had contacted the physician, but failed to document that he had made that contact because "we had a lot going on and several people we were getting discharged".

On 7/6/2011 at approximately 1700 during review of patient records for patient #7 revealed that the patient had been sent to an outlying hospital for abnormal labs on 6/26/2011. The charge nurse was asked for the laboratory results. The charge nurse replied the results were not present in the patient's chart. The patient had a lab draw on 6/28/2011 at 0550 as shown by the laboratory order sheet. When asked where the patient's laboratory results were for that lab draw the charge nurse replied that the results could be shown online. When staff L was asked to pull up the results they could not be obtained. A phone call took place to the laboratory facility where labs are processed. The facility stated that they had never received the lab specimen. When asked how missing lab results were dealt with the charge nurse replied "there really isn't a system in place for that".

On 7/7/2011 at approximately 1320 during review of patient #24's chart it was revealed that the patient's laboratory results of 7/1/2011 were not documented in the patient's chart. When asked to provide those results the charge nurse stated "it is a deficiency of the unit secretary on third shift not filing lab results". The charge nurse then located the lab result page and stated "here they are. What is that lab value anyway?" The laboratory test that had been conducted was that for valproic acid to determine therapeutic drug level for treatment.

On 7/7/2011 at approximately 1400 is was revealed during record review that staff failed to follow facility policy number 5.30 recording laboratory work. The policy states that "all laboratory work is recorded in an accurate and consistent manner".

Based on record review and interview the facility failed to ensure that medical records are completed within 30 days of a patients discharge. Findings include:

During record review and interview with the director of health information technology on 07/7/2011 at 1400, revealed that the facility had 20 medical records greater than 30 days post discharge with one or more documents still requiring a physicians' signature to close out the record.

Based on observation and interview the facility failed to ensure that all controlled substances were accounted for and the use of each narcotic was documented according to the facility's policy. Findings include:

On 07/06/11 at approximately 1030 during the initial tour of the Nursing Unit A it was determined that the narcotic count for the morning shift of the same date was incorrectly documented. The narcotic medication by the name of "Norco" was " off count" according to Registered Nurse #1 .When Registered #1 was queried what the policy was for "missing narcotics" she stated that an incident report is made out and the Nurse Manager is notified.". When asked for the incident report Register Nurse #1 stated that she "had not made it out yet." When queried which Nurse Manager was made aware of the discrepancy Registered Nurse #1 stated that she "had not made any of them aware yet."

On 07/07/11 at approximately 1100 during a phone interview with Pharmacist #1 it was determined that there was a "documentation problem that involved the narcotic medications." When queried Pharmacist #1 stated that he was "aware of the problem" and was "putting a plan into action to make sure that the narcotics are documented according to our facility's policy." At approximately 1111 during a phone interview with Pharmacist #1, it was confirmed that the facility's nursing staff improperly document patient narcotic usage.

Based on record review and interview the facility failed to ensure the correct prescribed diet was being followed for one of three (# 7) patients resulting in the potential for nutritional compromise and electrolyte imbalance.

On 7/6/2011 at 1130 during medical chart review it was revealed that the patient #7 was not receiving the correct diet as prescribed. The physician initial order sheet dated 6/25/2011 specifies a regular diet for the patient. On patient care sheets dated 6/27/2011 to 7/2/2011 it is documented that the patient received cardiac no added salt diet. On 7/6/2011 it was confirmed that the patient receives a mechanical soft - no added salt diet by the charge nurse. The charge nurse confirmed that the patient was not receiving the regular diet that was ordered and that no orders had been received to change the diet.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated July 12, 2011 for Life Safety Code.

Based on review of the facilities infection control program and interview, the facility failed to ensure that there was an active program for the prevention, control and investigation of infections and communicable diseases. Findings include:

During review of the Infection Control Program on 7-7-11 at approximately 0930 it was found that the facility failed to initiate an Infection Control Program and had no evidence past or present to prove that a program had ever been in place at the facility.

During an interview with the CEO (Chief Executive Officer) and the CNO (Chief Nursing Officer) on 7-7-11 at approximately 1145 they confirmed that the facility had an infection control committee designated, but none of the individuals had advanced infection control training, there was no log of incidents related to infection and communicable diseases, infection control was not integrated into the QAPI (Quality Assurance, Performance Improvement) program and that there were no infection control meetings held, therefore no meeting minutes available.

Based on interview and record review the facility failed to ensure that one of nine patients (#29) discharged from the inpatient psychiatric facility from a total sample of 30 had an effective discharge plan; resulting in an improper discharge from the facility and the refusal to accept the patient back. Findings include:

On 07/07/11 review of the facility policy entitled, "Transfer of patients to other facilities" dated 07/01/10 revealed, "It is the policy of the Samaritan Behavioral Center to transfer patients to other facilities . . . when the inpatient units are unable to provide the psychiatric and/or medical services necessary for the care of the patients."

On 07/07/2011 at 0940 a.m. review of patient #29's medical record revealed a History and Physical (H&P) report dated 06/07/11 that indicated the patient was a 48 year old female who was admitted into the facility on 06/05/11 for agitation and aggression. The patient had medical history of colon cancer status post chemotherapy and was currently undergoing chemotherapy. The patient also had a colostomy in place. The H&P further indicated the assessment and plan for the patient's colon cancer "required outpatient follow-up."

On 07/07/11 at 0945 a.m.., review of the Social Workers (SW) note dated 06/07/11 at 0940 a.m. revealed, "SW spoke with patients sister/guardian . . . who informed patient has stage 4 colon cancer and is scheduled for surgery to have her port sutured down on Monday June 13 at . . . hospital in Southfield. Patient is also scheduled for chemotherapy on Wednesday, June 15 at 10:30 a.m. for 3 hours. SW informed guardian that we were not med-psych and patient may need to be transferred."

SW note dated 06/07/11 at 1200 p.m. revealed, "SW updated guardian on our plan to transfer patient on Sunday, June 12 to . . . hospital for surgery on Monday and then have her evaluated for psychiatric needs and admit her into their inpatient psychiatric program." The Social Worker did not document who authorized the transfer or who she had spoken with at the medical hospital.

Review of nurses notes dated 06/12/11 at 1100 a.m., revealed "Discharge note, order received to discharge patient to . . . hospital for a direct admit. . . Discharge instructions given to patient with verbal understanding received from patient."

Review of the Letters of Guardianship dated 02/11/08 revealed that patient #29 was "A legally incapacitated individual." However, the patient's legal guardian was not present at the time of discharge and there was no documented evidence indicating that the legal guardian was phoned at the time of discharge. Review of the discharge instruction revealed that thee legally incapacitated patient signed herself out, and there was no documentation on the discharge papers indicating follow up psychiatric care for the patient.

Nurse's notes dated 06/12/11 at 1130 a.m., revealed "received a call from universal ambulance that . . . hospital has no beds for the patient. Patient's procedure is at 0730 on 06/13/11. Made arrangements to have patient picked up in am. Called doctor (U) and received order for discharge to be cancelled and precautions to be restarted."

Review of afternoon shift nurses notes on 06/12/11 at 1640 revealed "patient's sister/legal guardian called stating that she was at . . . hospital with her sister and was waiting for an ambulance to transfer her sister back to Samaritan. She asked writer that she wanted to make sure that Samaritan would accept her sister back. Director of Nursing was called, Doctors (U) and (V) were called . . . who informed writer that hospital cold not accept patient back. Dr.(U) stated that patient did not meet the criteria for admission, that she was not a threat to herself or others."

It was unclear why Dr. (U) would refuse to accept the patient back into the facility when he gave an order for the discharge to be canceled and precautions to be restarted at 1130 that same day.

On 07/07/2011 at 1015 a.m., interview with Recipient Rights Advisor who reported that she received a complaint from the patient's legal guardian regarding problems that she experienced associated with her sister's transfer.

On 07/07/2011 at 1130 a.m., interview with Social Worker assigned to the patients case. The SW reported that she spoke to someone in the Psychiatric department at the Medical Hospital prior to the transfer, and arranged for the patient to have a surgical and psychological assessment done at the hospital. She said that "the Psychiatric department did not want to admit the patient to Psychiatry but to the medical floor on Sunday, I spoke to the guardian and she was aware of the transfer plans." The SW also stated that the patient was scheduled to have her port sutured down on Monday and she also had a follow up appointment to have chemotherapy on Wednesday of that same week.

When the SW asked why the transfer was arranged for Sunday when the patients appointment was scheduled for Monday, and what was the name of the person who authorized the transfer to the Medical Hospital the SW did not know.

On 07/07/2011 at 11:50 p.m., interview with the Nurse Manager who reported, "I was told by the SW that all arrangements were made regarding the patients discharge. The patient had an issue with her port and her colostomy so surgery was needed. I handled the case as a regular discharge and not a transfer, at around 1 o'clock I got a call from universal ambulance saying that there was no bed available for the patient, so I phoned the DON but was unable to reach her, then I phoned the doctor who said that it was okay for the patient to return to the facility."

On 07/07/2011 at 12:15 p.m., interview with the DON who reported that the facility was unable to accept the patient back because a bed was not held for her and the unit was full. She went on to say that the facility was not equipped to handle a patient with multiple medical issues. When asked why the facility accepted the patient in the first place, she said that sometimes the intake department just sends patient to the unit and the facility has no knowledge of the admissions before hand."

Review of the complaint from the legal guardian revealed:
"I spoke to the Social Worker with Patient and staff. Social worker indicated that she had arranged for the patient to be transferred to the hospital on Sunday June 12 . . . she would be evaluated for intake into . . . Psych department.
On Friday, June 10 SW indicated that, "the transfer was in place."
At 12:00 p.m., Sunday June 12, I received a call from the hospital nurse that the patient had arrived at ER via ambulance. I told him that I would arrive by 1 p.m.. Upon arrival the nurse asked me why was se there on Sunday since her surgery wasn't scheduled until Monday . . Nurse indicated that hospital could not locate any paperwork or doctor's orders regarding a transfer. The E.R. paged the patient's surgeon to see if he was aware of the transfer The doctor had no knowledge of the transfer and said that he was never contacted about such an arrangement. He also did not agree to admit the patient into the hospital as her surgery was on an outpatient basis. The medical hospital considered the situation to be a "dump" as the proper doctor to doctor hand off policy had not taken place."
The facility policy entitled, "Transfer of patients to other facilities" dated 07/07/2010 revealed,
b. the attending physician ensures he/she or his/her designee makes arrangements with the receiving physician/facility for transfer of the patient.