HospitalInspections.org

This CONDITION was not met as evidenced by:

Based on record review, policy review, observation and interview, it was determined the facility failed to establish a process for prompt resolution of patient grievances for 3 of 3 abuse allegations (patients #6, #8 and #9), and failed to provide care in a safe setting for 4 of 4 patients.
Findings include;


-The facility failed to investigate patient allegations of abuse resulting in increased risk of patient injury (A-0118).

-The facility failed to provide a safe environment by enforcing time and attendance policies or assessing patients at increased risk of falls (A-0144).

The cumulative effect of which compromises the safety of all patient's served by the facility.







This CONDITION is not met as evidenced by:

Based on record review, policy review, observation and interview, it was determined the facility failed to establish a process for prompt resolution of patient grievances for 3 of 3 abuse allegations (patients #6, #8 and #9), and failed to provide care in a safe setting for 4 of 4 patient's (patient's #1, #3, #4 and #5).

Findings include;


-The facility failed to investigate patient allegations of abuse resulting in increased risk of injury (A-0118).

-The facility failed to provide a safe environment by enforcing time and attendance policies or assessing patient's at increased risk for falls (A-0144).

The cumulative effect of which compromises the safety of all patient's served by the facility.

Based on policy and record review and interview the facility failed to investigate 3 of 3 abuse allegations by discharged patients (#6, #8 and #9) resulting in increased risk of injury for all patients. Findings include:

Policy:

"Observation Procedures," dated 12/10/12, states:

1." The Behavior Center of Michigan will provide a means of observation procedures initiated by the attending physician or nurse who may also initiate a 1:1 or close observation (CO)status."
1. 1:1- Close Observation is defined as "staff no more than an arms-length away."
2. Close Observation (CO) requires staff/patient observations "minimally every 15 minutes."
2. The physician will; "Evaluate the patient and write an order on the physician order form for the observational procedure required indicating the specific behaviors to be observed."
3. "The physician will write the order to continue or discontinue the observation status on the clinical justification for 1:1 supervision form. They will include their assessment, interventions attempted in order to discontinue, and the patient's current response."
4. "The physician will sign, date, and time the clinical justification for 1:1 supervision form."
5. "The RN will sign, date, and time the clinical justification for 1:1 supervision form for continuation or discontinuation of observation status."
6. The policy does not define "continuous monitoring" precautions.

Record review:

1. On 11/11/12 at 10:00 am Nurse #2 noted: "Patient (#7) pacing in the hallway...tearful...confused and actively hallucinating. 'I think they are going to hurt me!'...difficult to redirect. Requires staff assist to locate his room, paranoid, holds his hands up if staff walks near him...monitored every 15 minutes checks."
2. On 11/11/12 at 10:10 am Nurse #2 noted: "Patient (#7) entered his room and grabbed his roommate's arms and pushed him into the wall...Patient (#7) stated 'I thought he was going to hurt me!' Staff continuous monitoring." (No order or form for 1:1 supervision was documented.)
3. On 11/11/12 at 11:15 am Nurse #2 noted: "Patient (#7) kicked a peer (patient #6) in dayroom...1:1 staff monitoring implemented."
4. On 11/11/12 patient #6 filed a written complaint, alleging abuse, due to being assaulted (having hair pulled and being kicked in the stomach) by patient #7 and recommended "more staff to ensure safety."
5. On 11/11/12 patients #8 and #9 filed complaints of not feeling safe due to the above events.
6. On 11/12/12 an "Acknowledgement Intervention Letter" from Recipient Rights Officer #2 to patient #6 stated: "On 11/12/12 I met with you on the 2nd floor...You (patient #6) stated that you were moved to another unit and are no longer in fear of the patient that kicked you." Patients #8 and #9 also received "Acknowledgement" letters, indicating that they had been moved or discharged.
7. On 11/12/12, the second floor census listed all complainants (patients #6, #8 and #9) and the assailant (patient #7) on the daily roster.
8. The "Acknowledgement Intervention Letter" to patient #6 states: "The staff was on the unit monitoring patient (#7) when this particular incident occurred and responded when they heard the incident."
9. There was no documentation of an investigation into staffing and staff actions to protect patients from patient #7's physical assaults on 11/11/12. The patient's observation status at the time of the second assault of the morning, at 11:15 am, was not investigated.
10. The above was confirmed by Recipient Rights Officer #1 on 2/14/13.

Based on document review, medical record review and interview it was revealed that the facility failed to enforce time and attendance requirements for Mental Health Technicians resulting in a delay in responding to a patient assault (for patient #1) and failed to assess and respond to 2 discharged patients (#4 and #5) and 1 current patient (# 3) with changes in mobility status (see details listed by patient # below), resulting in increased risk of patient injuries. Findings include:

**Mental Health Technician (MHT) Position Description, dated 4/1/11, states:
"(MHT) remains in patient areas whenever possible...Notifies supervising Nurse (i.e. Charge Nurse, Staff Nurse or LPN) prior to leaving unit."

**Charge Nurse Position Description, dated 4/10/12, states:
"Follows Center expectations regarding Time and Attendance and enforces such for all shift nursing staff."

Patient #1 was physically assaulted by patient #2 on 1/27/13. Patient #1 was transferred to an acute care hospital where he died, according to a statement by the Director of Nursing on 2/13/13.

On 2/13/13 review of the Recipient Rights Officer's timeline of events on 1/27/13 revealed:

1. From 2:32 am - 2:49 am, Mental Health Technician (MHT) #2 was off the unit without documentation of an approved break.
2. At 2:46 am MHT #1 and Nurse #1 discovered that patient #2 had physically assaulted patient #1.
3. At 2:47 am MHT #1 and Nurse #1 ran out of the patient's room, leaving patient's #1 and #2 alone and unsupervised.
4. At 2:48 am, 1 minute and 5 seconds after leaving patient #1 alone with patient #2, MHT's #1 and #3 looked in on the two patients for 35 seconds.
5. At 2:48 am, the patients were left alone and unsupervised in the room again and MHT #1 left the unit to look for MHT #2.
6. At 2:49 am MHTs #2 and #3 and Nurse #1 entered the patient's room.

On 2/14/13 review of Recipient Rights Officer's "Interview Notes" regarding the 1/27/13 incident revealed:

1. On 1/29/13 at 8 am Nurse #1 was interviewed and stated that MHT #2 did not have permission to be off the unit at the time of the above incident and that MHT #2; "never asks for permission to get off the unit."
2. On 1/28/13 at 1 pm, MHT #1 stated that she witnessed patient #2 hitting patient #1 repeatedly with his fist. After yelling at patient #2 to "get off him" patient #2 started to run towards her. At that point MHT #1 and Nurse #1 ran to the Nurses's stations, leaving the patients alone together.
3. When asked why she (MHT #1) did not use CPI (Crisis Prevention Intervention) techniques to handle patient #2, MHT #1 stated: "she (MHT #1) felt that (Nurse #1) and her cannot handle him (patient #2) alone. She (MHT #1) then ran downstairs to get (MHT #2) to help."

Interviews:

1. On 2/13/12 from 5-5:30 pm Recipient Rights Officer (RRO) #1 verified the video timeline observations (exact times) noted in the timeline above. These times match a printed timeline document written by RRO #1.
2. On 2/14/13 RRO #1 verified the content of the "Interview Notes" listed above.
3. On 2/14/3 the Director of Nursing (DON) verified that MHT #2 received education and a personnel file note regarding being off-unit without permission at the time of the 1/27/13 incident.
4. On 2/14/13 at approximately 2 pm the Director of Nursing (DON) was asked if she was aware of on-going problems with MHT #2 leaving the unit without permission from the supervising Nurse. The DON stated that she was unaware of the problem.

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Also; Patients #3, #4 and #5 had changes in mobility status that were not addressed per facility policies on fall prevention and observation status. Morse Scale documentation did not match narrative documentation of gait and cognitive deficits in patient's clinical records. Details on the discrepancies in documentation and Morse Scale omissions are listed (by patient #) below:


Policies:

**"Fall Prevention and Intervention," dated 1/2/13 states:

IV. "All patients...are assessed for fall risk at the time of initial nursing assessment using Morse Fall Scale."
V. 4. "Reassessment for fall risk occurs once daily, and when there is significant change in the patient's condition, level of care changes, or when the patient falls."

**"Observation Procedures," dated 12/10/12, states:

3. "The physician will write the order to continue or discontinue the observation status on the clinical justification for 1:1 supervision form. They will include their assessment, interventions attempted in order to discontinue, and the patient's current response."

Patient #4:

Review of patient #4's clinical record on 2/14/12 revealed:

1. On 1/19/13 a 9:25 am a physician's order, states: "Place patient on 1:1 monitoring by staff for severe confusion and fall precautions."
2. On 1/19/13 at 10 am the patient's Morse Fall Scale states: "Fell in shower today." An order for steri-strips was noted later in the day.
3. On 1/20/13 at 1 pm Nurse #1 documented: "Patient remains confused, responding to internal stimuli...1:1 monitoring by staff for safety due to severe confusion continues."
4. On 1/20/13 at 2 pm a physician's order states: "d/c (discontinue) 1:1."
5. There was no documentation by the physician indicating an assessment or justification for discontinuing 1:1 supervision and only 1 hour before Nurse #1 documented "severe confusion."
6. There was no change in patient #4's Morse Fall Scale ratings after the fall on 1/19/13. On both days, patient #4 was documented as having no gait or mental status deficits.
7. On 1/20/13 patient #4's score was incorrectly tabulated, placing the patient in the "low risk" score range. This was incorrect because the items on the Morse Scale did not accurately reflect narrative documentation of gait and cognitive deficits noted in the patient's clinical record.
8. The above findings were verified by the Director of Nursing on 2/14/13. The DON stated that it is expected that falls and impaired mental status will be accurate documented on the Morse fall scale and that that was not done.

Patient #3

Observations and review of patient #3's clinical record and interviews on 2/13/13 revealed:

1. On 2/12/13 at 8:35 am Nurse #4 completed the patient's Morse Fall Scale, indicating no mental status deficits.
2. On 2/12/13 at 8:40 am Social Worker #1 assessed the patient's mental status, stating: "The patient is very confused at this time...He also states that he even has difficulty remembering his name."
3. On 2/13/13 at 2:05 pm Nurse #3 documented: "Patient visible on unit unsteady on his feet."
4. On 2/13/13 at approximately 2:30 pm, during an interview, Nurse #3 stated that patient #1 was "more unsteady today." The nurse stated that this did not require physician notification or completion of a new fall risk assessment. Nurse #3 stated that it is "nursing judgement" to decide if a patient needs a wheelchair or walker and that she left a wheelchair in the patient's room. The DON stated that Nurse #3 accurately stated facility policy regarding use of assistive devices.
5. On 2/13/13 at approximately 2:40 pm patient #3 was observed in bed, stating that he needed to use the bathroom. A wheelchair was observed near the patient's bed.
6. The Director of Nursing (DON) called Mental Health Technician #4 to assist patient #3 in transferring from bed to wheelchair. The patient was shaky and required assistance to stand. The wheelchair slid backward when patient #3 sat down but the patient did not fall.
7. On 2/13/13 at approximately 2:45 pm MHT #5 stated that patient #3 had been more unsteady since the prior day.
8. On 2/13/13 at approximately 2:45 pm the DON told MHT #5 to provide 1:1 supervision to patient #3.
9. The above observations were verified by the DON on 2/13/13. The DON stated that it is expected that falls and impaired mental status will be accurate documented on the Morse fall scale and that a new Morse Scale would be completed by the nurse when an assistive device is given to a patient. The DON verified that this was not done.


Patient #5:

Review of patient #5's clinical record on 2/13/13 revealed:

1. On 2/8/13 patient #5 was found on the bathroom floor and stated that he fell.
2. On 2/9/13 patient #5's Morse Fall Scale indicated "no history of falls" in calculating the fall risk score.
3. The above findings were verified by the DON on 2/13/13. The DON stated that it is expected that falls and impaired mental status will be accurate documented on the Morse fall scale and that this was not done.