HospitalInspections.org

Based on record review, policy review, observation and interview, it was determined the facility failed to establish a clearly explained procedure for filing a patient grievance (A121), to provide written notice of a decision following grievance investigations (A123), protect and promote the rights of patients to formulate advance directives (A132), to ensure the patient's right to personal privacy when placed in seclusion (A 143), to ensure the patient's right to receive care in a safe setting (A144), to ensure applied restraints were in accordance with a physician order (A168), to ensure orders for restraints were not written as a standing order or as needed (PRN) order (A169), to ensure orders for seclusion to be a maximum of 2 hours for children and adolescents 9 to 17 years of age (A171), and to ensure that each patient is seen face to face within one hour after being placed into seclusion (A178).

Based on observation, interview and record review, the facility failed to establish a clearly explained and appropriate procedure for filing patient grievance. Findings include:

On 8/30/10, the grievance policy and related materials were reviewed. The grievance process as posted and policy does not identify specific steps and time frames for response by the facility. A brochure titled "Patient Rights & Responsibilities" was provided for review. Item #18 states: "The patient may utilize the MCHS patient advocate, MGHS privacy officer for resolution or may choose to bypass the MGHS system and contact the state agency." The brochure does not specify how the facility will communicate the results of grievance investigations nor specify steps in the process or timeframes for a response.

According to policy #100-040, " Patients have the opportunity to voice grievances ... " ; "a complainant has the right to appeal the matter to the Patient Advocate/Privacy Officer or Assistant Administrator if the complainant is not satisfied with the investigation or resolution of the complaint." The policy does not specify how the facility will communicate the results of grievance investigations nor how to contact the Patient Advocate/Privacy Officer or Assistant Administrator.

On 8/29/10 from 1000-1100, observations on inpatient psychiatric units for children and adults revealed no postings of contact information for filing a grievance or complaint with the hospital or State of Michigan Complaint Hotline. These findings were confirmed by the Children's Psychiatric Clinical Director.

On 8/30/10 at 1030 the Director of Quality Assurance stated that patients might receive notice of their rights from the Admissions Department, at the time of admission, or up the the floor that admits them. She confirmed that the facility does not document providing patients with information on how to file a grievance so there is no way to know if patients actually received the information and further confirmed that there was no posting in the main lobby informing patients or representatives of the process for filing a grievance or complaint.

On 8/30/10 at approximately 1400, the Director of Risk Management stated that grievances could be filed only after the patient had been discharged (which would not afford patients the right to file a grievance).

Based on interview and record review the facility failed to provide written notice of a grievance investigations for two of two patients (#14, #15). Findings include:

On 8/30/10 at approximately 1400, grievance records of patients #14 and #15 were reviewed with the Director of Risk Management. The records did not clearly indicate whether the investigations were on-going or complete. The Director also confirmed that patients #14 and #15 had not received written notices informing them that the grievances were being investigated or that the investigations had been completed.

The Director stated that the facility does not have a policy that specifies steps and timeframes for the facility's response to patient grievances.

Based on records reviewed, document/policy review and interview, the facility failed to recognize the content of an advance directive that the patient requested be invoked should the patient have little or no chance for recovery. Findings include:

The facility failed to implement the instruction specified on the advance directive formulated by the patient on 5/12/07.

The facility's policy entitled; "Advance Directives and Do Not Resuscitate Orders"(policy No. 100-136) states: "#2. If a patient lacks decision making capacity, the instructions written in a patient's advance directive are to be followed...."(sic). On page 4 the policy clarifies regarding "Patients who lack decision making capacity", that; "Patients previously competent, who have made an Advanced Directive for Health care about their DNR status in the event they are no longer capable of participating in such (a) decision, shall have their decision followed."

MR #1: The patient was admitted on 8/29/2010 at 0645 hours in direct transfer from another acute care facility to the intensive care unit. Diagnoses included; hyponatremia and seizures. During the clinical record review at 0940 hours on 8/29/2010, the Advance Directive accompanying the patient from the sending facility was signed and dated by the patient on 5/12/2007. The document also had witness signatures by a physician, a registered nurse, and the person's name identified on the current clinical record (history and physical) as the patient's significant other. The Advance Directive specified in answer to the question regarding "Life Sustaining Medications; Should medications be administered to the patient in emergency respiratory or cardiac conditions(?)" The answer marked by the patient was "No." Review of the sending hospitals emergency department and ambulance service documents indicate the patient had received a dopamine drip while in their ER and also while en route by ambulance personnel for low blood pressure (67/41). Upon arriving at the facility the dopamine drip was turned off but standing orders continued to be in place to initiate a neosynephrine drip to maintain a mean arterial pressure of (greater than or equal to) 65 mmHg.

During an interview conducted with the Director of Nursing, the record and policy were reviewed. The DON reviewed the policy and stated the Advance Directive contained in the medical record "...should have been flagged and acknowledged by the physician."

Based on observation and interview, the facility failed to ensure the patient's right to personal privacy when placed in seclusion. Findings include:

On 8/29/2010 at approximately 1255, the nurses station in the Emergency Department was observed to have video monitoring screens mounted on the back wall. The screens were clearly visible to anyone standing at the nurse ' s station. Staff #2 stated that the screens were used to monitor patients in seclusion rooms on the unit and confirmed that video monitor screens for the ED seclusion room face towards the nursing station and can be viewed by other patients and the general public.

On 8/29/2010 at approximately 1310, the VP and Staff #10 verified the video monitor for the seclusion room in the Adult Behavioral Unit could be viewed by visitors, patients and the general public.

Based on observation and interview, the facility failed to ensure that patients requiring restraint or seclusion when they pose a risk to harm themselves or others would be placed in a safe setting. Findings include:

On 8/29/2010 at approximately 1250, Staff #2 verified that there are blind spots in which a patient placed into seclusion in the ED can not be visualized by staff.

On 8/29/2010 at approximately 0900, VP verified that there are blind spots in which a patient placed in seclusion in the Adult Behavioral Unit can not be visualized.

Based on records reviewed and interview the facility failed to ensure orders for restraints were signed by the physician for 4 of 4 [MR#'s 6,7,8 and 9] restraint records reviewed. Findings include:

#6: During an interview with the facility Director of Nursing (#6) on 8/30/10 at 1020 hours it was confirmed that there was no documented evidence of a physicians order for restraints placed for the protection of the endotracheal tube and IV access. It was also confirmed that it is the facility's expectation that restraints placed in ER have a physicians order.

#7: The patient was in restraints at 0800 hours on 8/25/10. The restraints were discontinued on 8/26/10 at 1200 hours. The "Restraint Records" dated 8/26/10 at 0100 hours was initiated 12 hours after the restraints were applied and failed to have the physician's portion of the order completed including the physician's signature.

#8: There was no physician's order for restraint in the medical record on 8/25/2010 while the patient was in bilateral wrist restraints at 2000. This was verified in the 5th floor conference room with VP and Surgical Unit Clinical director on 8/30/2010 at approximately 1050.

#9: There was no physician's order for restraint in the medical record on 8/22/2010 and 8/24/2010. The patient was in restraint on these dates as verified by Staff #23 and VP while at the IMC nursing station on 8/30/2010 at approximately 1000.

Based on records reviewed and interview, it was determined that the facility permitted a restraint order to be written on an as needed basis (PRN). Findings include:

Review of the medical record for pt. #13 documents a physician order stating "Restrain if Necessary." This was verified with the VP on 8/29/2010 at approximately 1500 in the conference room.

Based on records reviewed and interview the facility failed to ensure orders for seclusion to be a maximum of 2 hours for children and adolescents 9 to 17 years of age. Findings include:

The medical record for pt. #16 who is 10 years old, contains a physician's order for seclusion up to 3 hours. This finding was verified with the VP on 8/29/2010 at approximately 1500 in the conference room.

Based on policy review, record reviewed and interview the facility failed to ensure that each patient is seen face to face within one hour after being placed into seclusion for 2 of 2 patients (#17 and #18). Findings include:

Policy No. 750-011B was reviewed on 8/29/2010. The policy describes restraint and seclusion practices for behavioral health service inpatients. The policy includes the expectation that a secluded patient will be personally examined within one hour of the seclusion.

The physician order sheet for the seclusion of pt. #17 was reviewed and shows that the patient was placed into seclusion on 6/28/2010 at 0917 by verbal order. The order sheet entries for "Signature of Physician, Date and Time" were blank. There was no evidence that the patient was seen face to face within 1 hour after being secluded. During interview with the VP in the conference room on 8/29/2010 at approximately 1500, this finding was verified.

The physician order sheet for the seclusion of pt. #18 was reviewed and shows that the patient was placed into seclusion on 4/2/2010 at 1520. The order sheet entries for "Signature of Physician, Date and Time" were blank. There was no evidence that the patient was seen face to face within 1 hour after being secluded. This finding was verified with the VP in the conference room on 8/29/2010 at approximately 1500.