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Based on document review, and interview the facility failed to inform Adult Protective Services of Vulnerable Adult Abuse in 1 of 1 (#31) medical records reviewed. This has the potential to impact the right to be free from abuse for all patients treated at this facility. Findings include:

On 7/21/2015 at 1000 during meeting with staff I, the recipients rights officer, it was revealed that patient #31 had been injured by a staff member. Staff I stated, "I resolved the allegation when the employee was terminated. I did not know that I had to report the incident to anyone else. The patient did not want me to call the police."

On 07/21/2015 at 1030 during review of the complaint/grievance log, an allegation: Mental Health Technician (MHT) pushed patient, #15-6-179 was logged on 5/30/15, it is dated as resolved 6/2/2015. "Action Taken: Investigation Interviewed pt (patient), staff, and accused. Camera review conducted. Pt denied allegation. Camera review indicates MHT pushing pt. MHT terminated following investigative findings. Substantiated"

On 7/21/2015 at 1100 the medical record for patient #31 was reviewed. On 5/30/2015 at 1855 patient #31 was transferred to St. John Hospital Emergency room for evaluation "Fracture or concussion to head....fracture to coccyx ..."

On 7/21/2015 at 1400, during review of the Policy titled, "Identifying Abuse and Neglect" #MH-05 effective date 1/2005 on page 2 of 9 stated under Vulnerable Adult: 1. Vulnerable adult is an individual age 18 or over who, because of age developmental disability, mental illness....requires supervision or personal care........b. Physical harm means any injury to a vulnerable adult's physical condition....".
On page 8 of 9 stated under Other Reporting Requirements...."B. Adult Protective Services Law requires the reporting of suspected cases or incidents of abuse, neglect, exploitation or endangerment to the department of Human Services....to Adult Protective Services."

Based on document review and interview, the facility was unable to show evidence that 2 of 4 (Staff L & T), agency nurses had received training in the application of restraints resulting in the potential for injury for all 55 patients and the two untrained staff. Findings include:

In an interview and review of four agency nurses' files on 07/21/2015 at 1415, Staff R (Director of Human Resources) was unable to locate an employee file for staff L (Registered Nurse). Staff L had been present and working on unit A on 07/20/2015 on the day shift. When staff R was queried about the lack of a file for the staff he stated, "I am unable to locate it." When staff R was queried then are you saying that you don't have documentation that staff L has received training related to restraints, he stated, "I am telling you I can not locate it."
Further review of the employee file for staff T, revealed no training/orientation regarding the application of restraints.

In an interview on 07/21/2015 at 1445 with staff G (Chief Operating Officer), when queried about what staff are expected to have Crisis Intervention training, he stated, "All direct care staff."

On 07/22/2015 at 0800, review of the facility's policy titled, "Non-Violent Crisis Intervention, # 2.5, Effective Date: August 22, 2012," read, "V. Procedures 1. All staff engaging in the physical management of patients will have first successfully completed the hospital training in Non-Violent Physical Crisis Intervention."

Based on document review and interview, the facility failed to ensure that the Human Resource Office kept information of current valid licensure for 2 of 4 agency nurses (Staff L and S) resulting in the potential for poor patient outcomes. Findings include:

In an interview and review of four agency nurses' files on 07/21/2015 at 1415, Staff R (Director of Human Resources) was unable to locate an employee file for staff L (Nurse). Staff L had been present and working on unit A on 07/20/2015 on the day shift. When staff R was queried about the lack of a file for the staff he stated, "I am unable to locate it." When staff R was queried then are you saying that you don't have documentation that staff L has a valid nursing license, he stated, "I am telling you I can not locate it."
Further review of the employee file for staff S (Nurse), revealed no evidence of current licensure.

In an interview on 07/21/2015 at 1445 with staff G (Chief Operating Officer), when queried about ensuring that all personnel for whom licensure is required is completed, "He stated, that is his job." When staff G was queried if staff R has enough time to complete his job, staff G stated, "He has help, he is not the only one."

On 07/22/2015 at 0945, review of two nursing job titles for the Registered Nurse and the Licensed Practical Nurse, both with Revision Dates of : "6/3/2011" in the sections titled "Qualifications: Current status as a licensed practical nurse in the State of Michigan" and Current status as a registered nurse in the State of Michigan." A further review of the facility's policy titled "Licensure, # HR-7.65, Effective Date: January 2010, III. It a requirement and expectation that all Center employees and temporary agency staff will provide and maintain a current license, credential, registration or certification if required by their respective position to perform their regular responsibilities."

Based on document review and interview, the facility failed to ensure nursing staff maintained an updated plan of care (POC) for 4 out of 5 current patients (#14, #15,
#25 & #26) resulting in the potential for ineffective patient care and poor outcomes.

Findings include:

On 7/20/15 at 1200, review of patient # 14's medical record revealed incomplete documentation on the "Treatment Plan Update." Patient #14 was admitted to the facility on 7/6/15 with a diagnosis of suicidal and homicidal ideation. His "Master Treatment Plan" was developed and initiated on 7/9/15. Review of the document titled "Treatment Plan Update" dated 7/16/15 revealed the patient and staff had signed and dated the back page. On the front page, the sections on the form for "Problem #1 Danger to others (violence)" and "Problem #2 Danger to self" were blank. Staff C was queried on 7/20/15 at 1210 as to the blank spaces on the form and if an update to the treatment plan was available for review. Staff C replied, "I don't see another one in here (referring to the medical record), let me check on that." On 7/20/15 at 1220 staff C stated "It looks like they forgot to document. I checked with the nurse and she said she just forgot to write it down, they did have a meeting. I had her make a late entry on the record."

On 7/22/15 at 0930 review of the document titled "Treatment Plan" dated 12/12/13 revealed "...The treatment needs of each patient are assessed and an individualized (patient-centered) interdisciplinary treatment plan (Master Treatment Plan - MTP) is initiated upon admission and reviewed and updated at least weekly..."


29314

On 7/20/15 at approximately 1200 during medical record review it was revealed that the Medical Care Plan for patient #15 did not have specific interventions and goals for the problems identified. The Medical Care Plan indicated "Problem: Pain, shoulder generalized. Goal: No complications. Interventions: NSAID's" For the problem "Tobacco cessation/Polysubstance abuse" The intervention identified was "evaluate and treat" and the goal was "no complications".

On 7/20/15 at approximately 1210 during an interview with staff C and E agreed that the interventions and goals were not specific. Staff C stated, "Yes, we could do better with that. I am not sure how the staff know what to do to "treat the problem".

On 7/21/15 at approximately 0830 during review of medical record #25 it was revealed that the Treatment Plan did not have specific interventions and goals identified, the intervention section was left blank.

On 7/21/15 at approximately 1030 during review of medical record #26 it was revealed that the Treatment Plan did not have specific interventions and goals identified.

On 7/21/15 at approximately 1145 during an interview with staff J findings for patient #25 and #26 were confirmed. Staff J stated, "Yeah, I see what you mean. It's hard to tell what we are actually doing for these two."

Based on observation and interview, the facility failed to ensure that outdated medications and supplies are not available for patient use resulting in the potential for poor patient outcomes for all 55 patients receiving treatment at the facility. Findings include:

On 07/20/2015 at 1430, during observation of the medication room on Unit A, revealed a cupboard that contained laboratory specimen tubes for drawing blood. The cupboard contained 78 blue top laboratory tubes that had outdated on 6/2015. In a drawer that contained syringes were four tubes of ointment (Biofreeze, Hydrocortisone, Bacitracin and Betamethasone) that were all label with a patients name. When staff B was queried about the tubes of ointment being in the drawer with clean syringes, she stated, "They shouldn't be there." When queried if the patients that were named on the labels were still inpatients, staff J (Registered Nurse) stated, "They are not." Staff B then stated, "They should be placed into that bin for pharmacy returns."


29314

On 7/20/15 at approximately 1100, during a tour of Unit B in the supply room the following items were found outdated:
~ One case of Xeroform expired 5/2015
~ Five Staple remover kits expired 6/2013
~ Eight Fecal Immunochemical Tests expired 6/10/13
~ 24 blood collection tubes expired 5/2015

On 7/20/15 at approximately 1100 on Unit B in the supply room two boxes of colostomy drainage bags from May and September 2014 were labeled with patient names that were not current patient's and available for use.

On 7/20/15 at approximately 1100 during an interview with staff C and E the outdated items and available patient care items were confirmed. Staff C stated, "These should not be in here."

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tag dated July 22, 2015.

K-0018

Based on observation and interview the facility failed provide and maintain and provide a sanitary environment (A749) resulting in the potential for the spread of infectious disease to all patients served by the facility.

Based on observation and interview the facility failed provide and maintain a clean environment resulting in the potential for the spread of infectious disease to all patients served. Findings include:

On 7/20/15 between 1030 and 1200 while touring unit A the following observations were noted:
a. The clean utility room had accumulated dust in the drawers.
b. The clean supply room had 2 boxes of supplies stored on the floor and generalized debris on the floor.
c. The nourishment room had debris and dried spills in the drawers, debris and dried spills in the microwave, brown stains in the cabinets, a box of oranges stored on the floor, and a box of Styrofoam cups stored on the floor.
Findings were confirmed at the time of observation with staff C. Staff C was queried as to whose responsibility it was to clean the nourishment room, supply room and utility room. Staff C replied, "I think staff are assigned but obviously no one has been doing it."





25992


On 7/21/2015 during a facility tour of Unit A and Unit B between 0930 and 1100 revealed the following:

a) The exhaust vent in the soiled utility room as well as the patient toilet rooms had a large accumulation of dust.

b) The laundry rooms located on both units had an accumulation of dust and lint on the wall and floor, as well as the exhaust vents.

c) The walls throughout the facility had multiple areas where the drywall had been damaged and was therefore, not cleanable.


28273

On 07/20/2015 between 1000 and 1230, tour of unit A revealed the following:

Observation in the restraint seclusion room revealed a mattress that contained several cracks along the bottom edge. The under side of the mattress contained several long (approximately 12-24 inches) torn areas. The bed frame was also missing part of the wood covering. The mattress and the bed can not be cleaned in a way that ensures food debris cleanliness. The bed frame also contained food debris around all four sides. The floor of the room also contained areas of paper debris. When staff B (Chief Nursing Officer) present on the tour, was queried as to when the room was last used, she stated, "I am not sure." It was then learned from staff K that the room was last used on 07/18/2015.

Further down the hallway was a door that when and unlocked opened revealed a small closet area that contained a sink. The floor of the small closet was covered with thick dust and up against the wall were two pairs of rubber gloves. The gloves were noted to have the fingers part way inside out as if to have been removed from someone's hands. When staff A was queried about the closet, she stated, "I didn't even know that this was here." When staff B asked staff K about the closet and sink, staff K stated, "I don't think that anyone ever uses that."

At the end of the hall was a room identified by both staff A and K as the" intake room." Observation of the bathroom located inside of the area revealed a toilet stool that was covered with a black plastic bag and part of the plumbing was dismantled. The room was noted to have a heavy sewer odor. When staff B was queried about the stool, she stated, "I will need to check into it."

Observation of the nourishment room, revealed a very unclean area. The refrigerator had spills, the freezer had very thick ice build up approximately 4-5 inches thick. The room contained a rolling cart and an area with two shelves that were all visibly soiled. On one of the shelves was a plastic container with four compartments that contained sugar, salt, pepper and coffee stir sticks. All 4 of the compartments contained accumulated dust and mixed contents from the salt, pepper and sugar packets. The three draws that were in the room were all soiled with spilled coffee down the front of them and inside the drawers. The drawers also contained accumulated dust and debris. The area under the sink contained a black plastic bag that when removed exposed a stain on the bottom sink shelf, a pest control container and in the back corner was two packages of cookies. When staff B and K was queried as to who's job it was to clean the area, staff K stated, "Housekeeping is supposed to take care of it."

On 07/22/2015 at 0900, staff M (Maintenance Director) stated, "I was embarrassed with what you found on the unit Monday. The sewer odor that you smelled in the bathroom probably came from the shower drain not the toilet."


29314

On 7/20/15 at approximately 1130 during a tour of Unit B in the laundry room it was revealed that the ADL Closet was soiled with dust and residue from toiletries and dirty patient clothes were in 2 piles on the floor.

On 7/20/15 at approximately 1130 during an interview about the laundry room staff E stated "Yes, this room needs to be cleaned up."

On 7/20/15 at approximately 1140 during a tour of the patient exam room on Unit B moldy food, salt and drinks were setting on a table. The exam table had a cracked open hard boiled egg in the drawer and the drawers were soiled with dust residue.

On 7/20/15 at approximately 1140 during an interview with staff C this surveyor asked "Who is responsible for cleaning the exam room?" Staff C stated "I'm not sure but this is embarrassing."




30988

On 7/20/2014 at 1130 during tour of unit A the following was found: The seclusion room was dirty, there was food wrappers on the floor, leather restraints were tied to the bed, the mattress was worn with cracks and rips in the washable covering, there was dirt, moldy food and sticky residues under the mattress. Staff A and K were asked when the last time the isolation room was used? Staff K looked it up on the log and stated "It was used on 7/18/2015 at 2030." Staff K was asked "Is it the expectation that the room would be cleaned after use and ready in case it would be used again?" Staff K stated "Yes it should be clean and available for use."


On 7/20/2015 at 1230 during continued tour of unit A the Exam room was observed. In the corner of the room was an EKG machine, it had a stack of old papers sitting on the top, further inspection revealed that it was dusty and the cable had dried brown splatters." Staff A stated "I do not know when we used that last."

On 7/20/2015 at 1330 during observation of a medication pass on unit A, the needle box was full to over flowing and medications in unopened packages could be seen and easily retrieved. Staff A stated "We have called maintenance to come and replace the box." Further review of the medication cart revealed that the cart was dirty with dried brown splashes, sticky brown substances around the bottom ledge, and cracks and crevices had dirt and debris. Staff A was asked if the medication cart was on a scheduled cleaning rotation of any kind, she stated "not to my knowledge."

Based on medical record review, interview, and policy review the facility failed to ensure that discharge planning assessments including discharge goals were completed in a timely manner for 18 (#14, #15, #16, #17, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, & #32) out of 19 patients resulting in the potential for poor patient outcomes. Findings include:

On 07/21/2015 between 0800 and 1500, during review of the medical records for discharged patients #14, #15, #16, #17, #18, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, & #32 the discharge goals on the discharge summary form, were not resolved and the box for the date resolved was left blank.

On 7/21/2015 at 1530 during interview of staff Q, the Masters [degreed] Social Worker (MSW) the lead for discharge planning, was asked if discharge goals are expected to be resolved prior to discharge. Staff Q stated, "Yes, goals are expected to be resolved at the time of discharge."

On 7/22/2015 at 0800 during review of the policy titled, "Discharge Planning" #3.15 effective date 8/24/2012 it states on page 1 of 3 "Discharge planning begins at the time of admission......a discharge plan is developed.......Information may include:....The patients home environment....ability to function independently.....what situation the patient will be discharged to..optimal level of functioning..current support system..follow up needed.."...on page 2 of 3 it states "The social worker documents on the discharge summary form...the patients discharge status..."




28273

On 07/21/2015 at 1400, during review of the medical record for patient #20 revealed that the patient was admitted to the facility on 05/02/2015 and a treatment plan was initiated on 05/03/2015. The patient's discharge goals were identified as "Patient will be reality orientated to person, place, time and event. Patient will be free from delusional thoughts that interfere with functioning." The patient was discharged from the facility on 05/13/2015. The area of the treatment plan for documenting a date that the discharge goals were resolved was blank.

On 07/21/2015 at 1500, during review of the medical record for patient #21 revealed that the patient was admitted to the facility on 04/16/2015 and a treatment plan was initiated on 04/16/2015. The patient's discharge goals were identified as "Patient will verbalize a lack of thoughts/feelings to harm self. Patient will have a written plan for ensuring their own safety outside the hospital." The area of the treatment plan for documenting a date that the discharge goals were resolved was blank.

In an interview with staff H on 07/21/2015 at 1530, he confirmed that the areas were blank. When queried if the staff are supposed to complete the treatment plan and fill in the dates when the goals are met, he stated, "They are."