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Based on observation, interview and record review the facility failed to protect patients' rights, placing all patients at risk for loss of their rights. Findings include:

---The facility failed to ensure that 3 of 13 patients (#1, #12 and #39) were not held in violation of their civil rights and rights guaranteed by the hospital. (A-0117)
---The facility failed to provide a safe setting by failing to respond per policies to 2 of 2 Emergency Codes (for patients #44 and #45), failing to provide a bed without exposed sharp metal corners for physical restraint application on the psychiatric unit and failing to report and follow-up on 2 of 2 patients who experienced falls (#13 and #17). (A-0144)
---The facility failed to investigate, respond and analyze 1 of 1 allegations of abuse and neglect (for patient #45) and complete analysis of 1 of 1 patient falls (for patient #13). (A-0145)
---The facility failed to ensure that 1 of 6 patients (patient #17) was free of unnecessary physical restraint. (A-0154)
---The facility failed to ensure that 1 of 1 patients (#12) placed in physical restraints was monitored. (A-0175)
---The facility failed to ensure that 3 of 5 patients, (#9, #11 and #17) who were physically restrained, received 1-hour face-to-face assessments. (A-0178)

Based on medical record review, interview and policy and procedure review the facility failed to show that 3 out of 13 (#12, #31, and #39) patients received and were able to invoke their patient rights to refuse treatment prior to initiating treatment, which has the potential for providing treatment against a patient's will. Additionally, the facility failed to provide documentation that 1 current patient (#31) of 31 current inpatients and 1 of two discharged patients (#39) were admitted according to facility policies and did not violate patients' civil rights.
Findings include:
On 10/9/13 at approximately 1400 during review of patient #12's medical record it was revealed that the patient came to the emergency department (ED) on 9/28/13 via ambulance with complaints of wanting to hurt a member of the group home he came from for stealing his tobacco. According to a "Security Department Offense/Incident Report", the following events occurred at approximately 0035 on 9/28/13, "At approximately. 0035 the investigating security officer was called by the ER secretary to come to A2. I went back into the treatment are and observed an angry belligerent and profane patient #12. The suspect seemed to calm down momentarily so I returned to the security desk in the ER reception area. I then noticed patient #12 leaving hospital out the ER door, the nurse and I followed him into the circle drive and told him to put out his cigarette and get back into the hospital. Patient #12 complied and followed us back into the ED and informed us that he wanted to be transported to St. Joe's. He then stated that he wanted to go AMA (Against medical advice)..." the report continues on to explain that the doctor told security "the patient wasn't going anywhere" and to restrain the patient. The patient was placed in 4-point leather restraints and placed in the isolation room. The doctor requested a psychiatric evaluation, which was completed and the patient subsequently was admitted under voluntary circumstances. There was no physician certification or petition on the medical record for review and the patient was subsequently held against his will.
On 10/10/13 at approximately 0930 during policy and procedure review it was found in the undated policy titled, "Admission and Intake Procedure: Voluntary and Involuntary Recipients" under the section titled, "Admission to Floor-Involuntary Recipient" states, "Prior to the recipient's arrival on the unit, an RN shall verify the Recipient has the following documents: An original, valid Petition (completed and signed within the past 10 days). The initial Clinical Certification completed and signed the day of admission." The patient didn't sign the voluntary admission form until he was already held against his will in the ED and transferred for admission on the psychiatric unit.
Policy Review:
"Your Rights When Receiving Mental Health Services in Michigan," revision date 2/2013, a document provided to all patients upon admission to the psychiatric unit, states, "If you are involuntarily admitted to a psychiatric hospital or unit, you have the following rights....To be examined by two doctors or by a psychologist and a psychiatrist to determine whether you need to be admitted."
Record Review:
1. On 10/10/13 at approximately 1400 current patient #31's clinical record was reviewed. Incomplete documentation for both "Involuntary" and "Voluntary" commitment status were noted. Patient #31's record contained no documents that were completed by the admitting psychiatrist (staff AA) certifying either voluntary or involuntary status. Partial paperwork for both types of admission were noted in patient #31's record.
2. On 10/9/13 from 0900-1330 review of patient #39's clinical record revealed that the patient was admitted on an Involuntary basis and filed a complaint on 9/3/13 asking for an explanation of why he was being held. The "Clinical Certification" completed by patient #39's psychiatrist (staff AA) on 8/30/13 contained no legible entries concerning why patient #39's conduct constituted a risk to self or others, the basis for patient #39's "Involuntary" admission.
Staff N responded to #39's complaint with a "Corrective Plan" that did not clarify the psychiatrist's illegible "Clinical Certification" statement.
Interviews:
1. On 10/10/13 at approximately 1400 staff N confirmed that patient #31's clinical record did not contain complete documentation for either a "Voluntary or Involuntary" admission.
2. On 10/9/13 from 1300-13:30 staff N, who responded to patient #39's complaint and wrote the "Corrective Plan" stated that she was unable to read the admitting psychiatrist's (staff AA's) "Clinical Certification" documentation on patient #39's "Involuntary Admission Certification" and that she did not obtain clarification or verify that someone read staff AA's Certification to patient #39.

Based on observation, document review, and interview the facility failed to ensure a safe setting relating to falls, code blues, and rapid responses for four of four patients who experienced unsafe events (#13, #17, #44, and #45) and those patients in the psychiatric unit subject to use of an unsafe bed with sharp metal edges. Additionally, the facility failed to report, monitor, and analyze unsafe events and failed to develop and implement interventions in order to mitigate future unsafe events. Findings include:
On 10/10/2013 at approximately 1010 during medical record review of patient #45 a document labeled "code blue event" dated 7/22/2013 at 1815, was reviewed. The document labeled "code sheet" revealed one vital sign recording with a "blood pressure of 212/120 and a heart rate of 140." Subsequent nursing interventions listed in "nursing documentation" stated "a jaw thrust and cardiac monitoring." On 7/22/2013 at 1816 a "heart rate of 78" was the only additional information documented either in the nursing documentation area or the code sheet.
On 10/10/2013 at approximately 1100 an interview with nursing manager, staff J was conducted. When asked what the expectation would be in reference to a code blue situation and nursing actions in regards to vital sign documentation and intervention it was stated "an additional set of vital signs should be documented after the initial set of vital signs were obtained along with interventions". When asked if the code sheet showed that an "additional set of vital signs were obtained or additional interventions" were listed the nursing manager (staff J) stated "No. And that is one of our critical care nurses who documented the code".
On 10/10/2013 at approximately 1115 during medical record review of patient #44 a "Rapid Response" document dated 7/25/2013 at 0145 was reviewed. Rapid response documentation shows an initial set of vital signs were obtained at 0148 with an "unpalpable blood pressure, heart rate 210, respiratory rate 16, blood sugar (test result of) 206, and a saturated pulse oxygen of 98 %." The next sets of vital signs documented were at 0215 with a "blood pressure of 73/44, heart rate 105, respiratory rate 17, and a saturated pulse oxygen of 92 %."
On 10/10/2013 at approximately 1120 an interview was conducted with the clinical nurse educator staff W where it was asked what the expectation was for monitoring and documentation for a rapid response. Staff W stated "this should have turned into a code blue". When asked what the expectation was for the frequency of vital sign monitoring when a blood pressure was not "palpable", Staff W responded "another set of vital signs should have been obtained when the blood pressure was not palpable".
On 10/10/2012 at approximately 1125 a review of the "Code Blue (CPR)" policy with a revision date of 11/01/2008 occurred. According to the policy under "responsibilities of the registered nurse: (patient's nurse or first RN to arrive)" #4 stated "take blood pressure initially and as needed". Staff W was asked if the blood pressure for patient #44 was monitored appropriately and the response was "no".

On 10/8/13 at 1400 the Restraint and Seclusion room on the Psychiatric Unit was toured. A metal bed was bolted to the floor. It had four sharp metal corners and metal bars at shin height running along the sides. A light-weight foam mattress was unsecured on top of the metal frame. The mattress could be moved about with one hand. On 10/8/13 at 1400 Staff J verified the above observations. Staff J was asked if patients had been injured during restraint application. Staff J stated that "the bed was new and has not been used for physical restraint application as yet."

On 10/8/13 at approximately 1600 during medical record review of patient #17's closed record, documentation of a fall on 9/28/13 at 1005 was found. Nursing documentation was not recorded until 10/8/13 at 1821. An occurrence report was never located for this incident and no follow-up investigation was completed for performance improvement purposes.
Interview of staff J on 10/9/13 at approximately 1600 confirmed "that's right, the occurrence report was never completed".
On 10/9/13 at approximately 1645 a review of Policy # ADM-0-1 titled "Occurrence Report" revised 9/13/12 states "I. Policy.- Patient occurrences are addressed immediately, documented and assessed using the appropriate reporting form before the end of shift by the person discovering the occurrence....V. Procedure.-...4. Notify the director of quality or hospital administrator if a patient is injured or his medical condition deteriorates as a result of the event. The director of quality will coordinate with clinical and medical staff regarding appropriate notification of the event to patient and/or family. 5. For behavioral medicine patients, the recipient rights advisor must be notified within 24 hours of the event. 6. Staff: fax a copy of the occurrence report to the director of quality by the end of the shift in which the occurrence was identified."
On 10/9/13 at approximately 1400 during observation on 4 South (the behavior health unit) staff J was asked if any current patient had fallen during their stay, to which they replied "patient #13". The medical record of patient #13 was reviewed. Documentation of a fall was found on 9/26/13 at 1805. Staff J was asked if the occurrence form and the quality follow up investigation had been completed as stated in the policy. Staff J stated "I think so." The occurrence form for the above mentioned fall could not be located. Staff C the director of quality could not find the completed form and stated "without the form being sent, a follow up (investigation/analysis) is not done".
On 10/10/13 at approximately 0900 the occurrence report for patient #13 was located. No quality management review was completed. This was confirmed with staff C on 10/10/13 at approximately 0930.

Based on interview and record review, the facility failed to fully investigate, respond and analyze 1 of 1 allegations of patient abuse and neglect (for patient #45) resulting in increased risk of harm for all patients. Findings include:
Posting:
During a tour of the Psychiatric Unit on 10/8/13 at approximately 1400 a posted notice titled
"Requirements for Reporting Abuse and Neglect," dated 09/2012, was observed. It states:
"A police report must be filed if you suspect a recipient or vulnerable adult has been abused or neglected."
Policy Review:
"Abuse and Neglect," dated 3/26/13
1. Defines Neglect Class I as :
"Acts of commission or omission by an employee...that results in noncompliance with a standard of care or treatment required by law, rules, policies, guidelines, written or oral directives, procedures, or individual plan of service and that caused or contributed to serious physical harm to a Recipient."
2. Defines a Vulnerable Adult as:
"Those individuals who are unable to protect themselves from abuse, neglect or exploitation because of a mental or physical impairment."
3. States, "If criminal abuse or neglect is suspected by a staff member: An oral report to the appropriate law enforcement agency must take place immediately."
"Occurrence Reporting," dated 9/13/12, states:
2. Documentation-Occurrence Report Form:
b. "The supervisor, manager, or House Director is responsible for ensuring completion of the documentation on the form by the end of the shift during which the event occurred. He/she will also ensure appropriate investigation of the event."
Record Review:
1. On 10/9/13 from 0900-1630 record review revealed that two "Occurrence Report" forms were initiated for patient #45. The first "Occurrence Report" dated 7/21/13, concerned an incident where patient #45 threw a trash can that hit another patient. The section for documenting "what steps have been taken to prevent reoccurrence?" states, "MD in to assess pt (patient) hit. Pt that thru garbage can placed in seclusion." No steps to prevent recurrence were documented. The "Quality Management Review" section of the form was completely blank.
2. The second "Occurrence Report" for patient #45, dated 7/24/13, states, "Pt. (patient #45) attacked staff member. During altercation Pt's OS (patient's left eye) was injured - Swelling, ecchymosis & bleeding noted." There was no documentation of initiating an investigation on the date of the incident. The "Quality Management Review" section of the form was completely blank.
3. On 10/9/13 from 0900-1630 record review revealed a Radiology report for patient #45, dated 7/24/13 at 9:27 PM, stating: "Left orbital floor blowout fracture is demonstrated, but no significant herniation of intraorbital contents is observed. This is accompanied by a mild to moderate degree of left periorbital soft tissue swelling. There is also suggestion of depression and fracture of the left lamina papyracea or medial orbital wall."
4. On 10/9/13 from 0900-1630 a "Doctor's Statement" of injuries, dated 7/24/13, completed by MD #1, describes injuries sustained by the staff member who physically restrained patient #45 (staff Y). It states: "Rt. (right) hand minor contusion. No deformity, swelling or decreased ROM Range Of Motion) minimal soft tissue tenderness-hypothenar region."
5. On 10/9/13 from 0900-1630 record review revealed an "Accident/Incident Report" completed by staff Y stating that staff Y: "pushed the pt. (patient) into his bed and lowered him to the floor."
6. On 10/9/13 from 1530-1630 review of the Office of Recipient Rights' "Investigative Findings" report revealed a statement by staff Y that he: "pushed (patient #45) away from him" and the patient "fell backwards, he hit the wall, fell toward the bed and hit the floor." The report states: "(Staff Y) was really scared of what (patient #45) could have done to him especially in the time frame he had to wait for backup to come to his aide."
7. On 10/9/13 from 1530-1630 review of the Office of Recipient Rights' "Investigative Findings" report revealed a statement by staff LA, present in the hallway at the time of the 7/24/13 incident, stating, "(Staff LA) expressed she began to yell and trot up and down the hallway calling for assistance."
8. On 10/9/13 from 1530-1630 review of the Office of Recipient Rights' "Investigative Findings" report revealed a statement by staff LA, stating that she witnessed patient #45 fall toward the bed and then fall to the floor and "that's when she went to the nurse's station to get more staff because no one had responded to (staff Y's) call out or her previous request (for help)."
9. The "investigation notes" section did not contain any dates or times when efforts were made to interview patient #45 as part of the investigation.
10. No photographs of the patient (#45) or staff (Y) injuries, sustained during restraint application on 7/24/13 were available. Video of staff activity in the hallway outside of patient 45's room was recorded but no longer available for review.
11. Patient #45 was transferred to another hospital on 7/25/13.
Interviews:
1. On 10/9/13 from 1530-1630 the Occurrence Reports for patient #45 dated 7/21/13 and 7/24/13 were reviewed with management nurses, staff J and staff C. Both nurses verified that "Quality Management Reviews" of these incidents were not completed. Nurse C stated that "it should have been completed for both occurrences."
2. On 10/10/13 at approximately 1000 the author of the "Investigative Findings" report (staff N) was interviewed. Staff N was asked whether neglect was investigated due to allegations by staff Y and LA, that there was a delay in obtaining staff assistance during the 7/24/13 incident. Staff N responded, "no."
3. On 10/10/13 at approximately 1000 staff N stated that "no photographs of the injuries sustained by patient #45 and staff Y were taken, to her knowledge."
4. On 10/10/13 at approximately 1000 staff N was asked if the video of the hallway was reviewed to determine how long it took staff to respond to staff Y's and LA's calls for help during this incident. Staff N stated that she did not review the video but that nurse J viewed it and reported "there was nothing interesting on it." Staff N had no documentation of this video review.
5. On 10/10/13 at 1015 nurse J was asked for documentation of video review of the hallway outside the patient #45's room during the 7/24/13 incident. Nurse J stated that she alone reviewed the video but didn't write any notes regarding the review. Nurse J was asked how long it took staff to respond to calls for help by staff Y and LA, visible on the video. Nurse J stated, "I didn't time it." Nurse J stated that the video had not been saved.
6. On 10/10/13 at approximately 10:30 am a posting observed on the Psychiatric Unit titled "Requirements for Reporting Abuse and Neglect" was reviewed with staff N. Staff N stated that it is facility policy to follow these requirements but that this (above) incident was not reported to any law enforcement agency. Staff N was unable to explain why it had not been reported.
7. On 10/10/13 at approximately 10:30 am staff N verified that there were no notes specifying dates and times of attempts to obtain patient #45 statement regarding the incident. The "Investigative Findings" report contained a general statement that attempts were made to interview patient #45.
8. On 10/10/13 at approximately 1300 MD #1, author of the "Doctor's Statement" (above) describing staff Y's hand injury on 7/24/13, was interviewed. MD #1 verified the content of the "Doctor's Statement" (above).

Based on record review and interview the facility failed to ensure that patients are free from restraint in 1 of 6 restrained patient records reviewed (#17). This has the potential to affect all patients seen at this facility who may require the use of restraint to ensure patient safety. Findings include:
On 10/8/13 at approximately 1600 during medical record review of patient #17 a telephone order for "2-point restraints for up to 4 hours" was written on 9/28/13 at 1010. This was signed and dated 9/28/13 but not timed, there were no further restraint orders. The record for patient #17 lacked face to face assessment by the physician, within one hour of the restraint order.
The "restraint/seclusion flow sheet" was initiated 9/28/13 at 1025 and continued through 9/28/13 at 2140, there was no documentation of alternative measures, and no documentation of "15 minute releases every 2 hours." The patient was transported to computerized tomography (CT) and returned to the floor 10/28/13 at 2052. No further restraint documentation is found, the patient was transferred to another facility 2/29/13 at 0025.
The treatment plan dated 9/27/13 does not include a plan for the use of any restraints.
Interview of staff C and staff J on 10/10/13 at approximately 0900 confirmed that "there is no further documentation (for restraint use), the record is complete".
On 10/10/13 at approximately 0930 a review of the Policy and procedure titled "Restraint/Seclusion-Behavioral" #BMD-R-5" dated 5/16/13 revealed:
"Procedure...........
6. Subsequent re-evaluation of the Recipient/patient must be performed with timed documentation within the age-specific time frame. The face-to-face evaluation must be performed by a physician. (Attachment D- form titled 'Behavioral Medicine Restraint Order/Documentation' states ' Phone order must be confirmed by the physician in person within 1 hour' and space provided for 'Physician Face to Face Assessment'
7. Continued use of restraint/seclusion is authorized for renewal periods of 4 hours for adults up to a total of 8 hours, and ordered by the physician based on the examination of the Recipient/patient. This must be a written order. Verbal or telephone orders are not permitted. ........
10. Restraints shall be removed every 2 hours for not less than 15 minutes unless medically contraindicated......
11. Intervention surrounding each episode of restraint/seclusion is provided in the Recipient/patient's medical record in order to provide clinical justification for use and clinical oversight. This documentation includes but may not be limited to: A. Alternatives considered/utilized. B. Relevant orders for use and face-to-face evaluation by a physician.....
12. The use of restraint/seclusion must be: a. In accordance with a written modification to the Recipient/patients plan of care....".

Based on medical record review and policy and procedure review the facility failed to ensure that appropriate documentation and observations for restraint monitoring were completed for 1 out of 1 (#12) patient's. Which has the potential for patient harm.
Findings include:
On 10/9/13 at approximately 1330 during medical record review of patient #12, it was found that the patient was in 4-point leather restraints and in an isolation room for being "belligerent, angry and non compliant" in the ED on 9/28/13 at approximately 0030. On the document titled, "Restraint Order/Documentation", it was documented that the patient was in "4-point leather restraints with an agitated behavior". Further review of restraint documentation it was found on the form titled, "Restraint Flowsheet-Medical/Surgical", there was no justification documentation for restraints being used, the classification of restraints according to policy should have been for the "Violent Restraints/Seclusion". The patient was in restraints and isolation for 2 hours and there was a single documented monitor of the patient with comments of, "Pt. very belligerent and threatening."
On 10/10/13 at approximately 1000 during policy and procedure review it was found in the policy titled, "Restraint/Seclusion-Behavioral", states under the section titled, Procedure, #8, "Continuous in-person observation and monitoring will occur while the Recipient/patient is in restraint/seclusion, with supportive documentation every 15 minutes during restrain/seclusion episode" and #15, "Restraint may not be used simultaneously with seclusion unless the Recipient/patient is continually monitored face-to-face by an assigned staff member...".

Based on medical record review, interview and policy and procedure review the facility failed to ensure that 3 out of 5 (#9, #11, and #17) patients in restraints/seclusion, received a face-to-face assessment by a physician within one hour of initiation of restraints/seclusion. Which has the potential for patient harm.
Findings include:
On 10/9/13 at approximately 1300 during medical record review of patient #9 it was revealed the patient was in restraints and seclusion for violent/self-destructive behavior and failed to receive the required one hour face-to-face assessment by a physician.
On 10/9/13 at approximately 1315 during medical record review of patient #11 it was revealed that the patient was in restraints and seclusion for violent/self-destructive behavior and failed to receive the required one hour face-to-face assessment by a physician.
On 10/10/13 at approximately 1000 during policy and procedure review it was found in the undated policy titled, "Restraint/Seclusion-Behavioral" it states under the section, Procedure, #5, "The physician must provide a face-to-face evaluation of the Recipient/patient within one hour of restrain/seclusion initiation...".

On 10/8/13 at approximately 1600 during medical record review for patient #17 it was found that the patient was restrained beginning 9/28/13 at 1010. No documentation of a follow up face-to-face by a physician was found. These finding were confirmed on 10/10/13 at approximately 0900 by staff C and J, stated "There is no other documentation (for a face-to-face assessment by the physician)".