HospitalInspections.org

Based on record review, policy review and interview, it was determined the facility failed to protect and promote the rights of patients as evidenced by:
A0117- failure to inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights
A0119- failure to provide grievance and complaint information to patients.
A0144- failure to monitor patients exhibiting behavioral and acute medical symptoms to ensure care was provided in a safe setting.
A0145-failure to ensure the patient was free from all forms of abuse or harassment.

Findings include;

-The facility failed to ensure that Medicare patients were not provided with "An Important Message from Medicare" or have signed hospital specific consent forms. (see A-117).

-The facility failed to provide 1 of 1 patients who filed a grievance alleging staff abuse with information on how to file future grievances of staff abuse and to provide information on where to obtain complaint forms. (see A-119).

-The facility failed to monitor and follow policies to provide a safe environment for patients, resulting in hospital transfer for emergency medical treatment. (see A-144).

-The facility failed to investigate a patient allegation of staff abuse in a thorough and timely manner. (see A-145).

Based on medical record and policy review and interview it was determined that the facility failed to provide patient consent forms, including "An Important Message from Medicare" (IM) to 3 of 6 current patients( #10, #12 and #13 ) or their guardians which could deprive them of the opportunity to exercise their rights. Findings include:

Policy 222 "Admission to the Hospital" revised 2/28/11 states:
16. The Admission Coordinator provides the following forms and obtains required signatures:
WRPH-318- An Important Message from Medicare"
"Notification of Patient Rights"
WRPH-292-Advance Directives Organ/Tissue Inquiry

Policy 224 "Advance Medical/Psychiatric Directives" revised 2/17/10 states:
A. On admission, the hospital Patient Affairs/Nursing staff person processing the admission shall inquire concerning whether the patient has an Advance Directive. The results of such inquiry shall be documented on form WRPH-292.

On 10/2/12 from 2-4:30 pm, record review revealed that the guardians for 2 Medicare patients (#10 and #12) were not provided with "An Important Message from Medicare." In addition, 2 patients with court appointed guardians (#10 and #13) did not have signed consent forms in their records indicating receipt of "Notification of Patient Rights" and WRPH-292-"Advance Directives Organ/Tissue Inquiry."
Patient #10's guardian had not signed consents for "Notification of Patient Rights" or Advance Directives (WRPH-292).
Patient #13's guardian had not signed consents for "Notification of Patient Rights" or Advance Directives (WRPH-292).

The above findings were confirmed by Unit Manager #1 during record review on 10/2/12 from 2-4:30 pm.

Based on record and policy review, observation and interview, the facility failed to provide 1 of 1 patients who filed a grievance alleging staff abuse (#14) with information on how to file future grievances of staff abuse and to provide patients with information on where to obtain complaint forms. Findings include:

Policy:
#222, "Admission to the Hospital" revised 11/28/12 states: "The Admission Coordinator .... gives and explains to the patient the following legal and WRPH (Walter Reuther Psychiatric Hospital) documents: Your Rights" booklet."
"Your Rights when receiving mental health services in Michigan," states: "If you have been abused or neglected...you should report it right away to a staff person and to the Office of Recipient Rights...You may file a complaint by calling or visiting the Rights Office, or by completing the recipient rights complaint form and returning it to the Rights Office."

Record Review:
On 8/4/23 from 10:00 am - 3 pm, review of patient #14's record revealed:
1. Review of complaint and incident logs revealed that patient #14 made one complaint of staff abuse, on 8/11/12, since admission on 5/9/12.
2. An 8/11/12 Incident Report states that patient #14 asserted that Resident Care Attendant (RCA) #2; ".... used pain and excessive force" in managing the patient's behavioral and stated, "..... ain't no f***ing cameras in here now. It's your word against mine!" during this incident.
3. On 8/11/2 RCA #2 documented a physical altercation with patient #14.
4. On 8/15/12 Recipient Rights Advisor #2 documented receipt of patient #14's abuse allegation and initiated an investigation.
5. On 8/15/12 patient #14's IPOS (Individual Plan of Service) was revised by her Treatment Team. The patient's signature was not listed among meeting participants. IPOS problem #1 states: "she (patient #14) accuses of using excessive forced causing staff suspension or firing." The long term goal was to, "Stop making false allegations against the staff." The interventions stated, "She will be encouraged not to make false allegations against the staff but to bring her concerns to staff in a calm and positive manner."
6. The patient's Treatment Team concluded that the patient's allegation of staff abuse was false before Recipient Rights Advisor #2 had completed an investigation. There were no facility policies delegating this authority to the Treatment Team.
7. On 8/29/12 Recipient Rights Advisor #2 wrote an e-mail to Administrative staff, including the Directors of Nursing and Human Resources, stating that there was insufficient evidence to substantiate an abuse finding against RCA #2 or RCA #3 and recommended that RCA #2 not be assigned to patient #14.
8. There were no revisions to patient #14's IPOS in regard to #6, following RRA #2's finding of "Insufficient Evidence", to conclude whether patient #14 had been abused.

Staff Interview:
1. On 8/4/12 at approximately 12 noon the Recipient Rights Advisor #2 stated that there was no video evidence of the 8/11/12 incident available for review because the incident occurred in an area that doesn't have cameras. RRA #2 stated that with only 1 witness, RCA #3, and no video evidence, there was insufficient evidence to determine whether RCA #2 used excessive force in managing patient #14.

Observations & Interview:
1. During a tour of the facility on 10/2/12 from 10:30-3:30, it was noted that Recipient Rights complaint boxes had no complaint forms nearby, or information specifying where to obtain a complaint form. The findings were confirmed by Unit Manager #1.
2. On 10/2/12 at approximately 3:30 pm, Unit Manager #1 stated that the facility cannot leave complaint forms out because of behavior problems of some patients who may ingest paper. Unit Manager #1 also stated that directions for obtaining complaint forms could be posted on or near the complaint boxes, which were clearly labeled as complaint boxes.

Based on document and policy review, medical record review and interview it was determined that the facility failed to provide a safe setting for two patients (#14 and #15), per policies resulting in physical harm. Findings include:

Patient #14:

Policy Review:
Policy SOP 221, "Levels of Supervision/Precautions" revised 6/4/12, states:
1:1 supervision means "One staff is assigned to one patient with no other patient care assignment. The assigned staff person will remain within arm's length of the patient at all times unless otherwise ordered...Staff will take every precaution to ensure safety of the patient/others and to seek timely evaluation when there is a change in the patient's condition that warrants reassessment of the patient's needs."

Policy SOP 201, "Incident Reporting" revised 2/1/12, states:
B. All unusual incidents shall be reported on Incident Report form (DCH-0044)
Unusual Incident is defined as "An occurrence that is a deviation from the routine care of a patient, disrupts or adversely affects the course of treatment or care of an individual...
Self abuse, neglect and accidents requiring greater than 1st Aid are listed as unusual incidents that must be reported on a DCH-0044 form.
18. The RN Manager "completes the section of the form indicating the program or administrative action taken, including any instruction to staff given to remedy and/or prevent recurrence of the incident."
21. The Treatment Team "reviews Incident Reports...and considers changes in the treatment plan to prevent the recurrence of the incident."
23. The Central Nursing Office Supervisor "forwards all incident reports to the Office of Recipient Rights."
N. The Hospital Director/Designee and Chief of Clinical Affairs shall review incident reports as scheduled and assure that:
4. Actions required to prevent recurrence were taken and documented on the Incident Report form, as necessary."

Policy SOP 203 "Abuse and Neglect" revised 7/23/12, states:
G. "All allegations of patient abuse and neglect shall be investigated per the Michigan Mental Health Code, Civil Service Rules, and the Department of Community Health guidelines."
The policy does not require compliance with CMS Conditions of Participation.

A.15. "Hospital Director/Designee instructs CNO (Chief Nursing Officer) for the Removal of staff suspected of abuse/neglect immediately from the patient's care until either the ORR (Office of Recipient Rights) investigation is completed or there is notification from ORR that the allegation will not be substantiated."

Record Review:
On 10/3/12 from 11:00 am-4 pm, review of patient #14's record revealed the following:
1. On 6/18/12 Nurse #1 e-mailed the Director of Nursing (DON) and Office of Recipient Rights (ORR) Recipient Rights Advisor (RRA) #1 to report that that on 6/17/12, while on 1:1 supervision, patient #14 self-inflicted 12-15 lacerations on each arm and several lacerations on the left leg. The incident occurred while the patient was on 1:1 supervision in bed and the implement was identified as a piece of glass.
2. Review of the Incident Report, dated 6/17/12, noted the extent of injuries as "serious physical harm" and resulted in patient #14's transfer to a hospital emergency department for treatment.
3. On 6/17/12 at 8 pm RCA #1, responsible for 1:1 supervision during the incident, completed the Incident Report, stating: "I noticed that the patient was getting restless under the cover. I lifted her cover and saw some blood, tried to stop her, she became aggressive and told me not to touch her. Writer called for help. The RN and other staff came."
4. On 10/4/12 at approximately 1 pm, video tape of the above incident, showing the hallway outside of patient #14's room during the time of the incident, was viewed with the Compliance Risk Manager. It revealed the following, as verified by the Compliance Risk Manager:
---Patient #14's arms did not appear to be bloody prior to entering the bedroom with RCA #1 the evening of 6/17/12.
---Patient #14 was in her bedroom with RCA #1 for approximately 45 minutes before RCA #1 appeared in the patient's doorway. RCA #1 stood in the patient's doorway, for a total of a few minutes, apparently requesting help. (Audio tape was not available.) At first, no staff are visible in the hallway. Eventually RCA #1 communicated with a staff member wearing purple scrubs. That staff member left the hallway. In a few minutes time additional staff come to patient #14's room.
5. The Office of Recipient Rights (ORR) did not acknowledge receipt of this complaint until 6/21/12 (Complaint Acknowledgement letter.) The ORR investigation of possible neglect did not address video evidence that the 1:1 staff assigned to patient #14 did not maintain arm's length distance from the patient during and immediately after the incident, as required in the 1:1 supervision policy. The investigation report stated: "There was a lack of evidence to show (staff name) failed to comply with the 1:1 policy." The ORR's investigation did not address video evidence showing a delay in staff response to RCA #1's request for assistance. The ORR's 8/20/12 report, states that RCA #1: "immediately called for help, however, staff did not respond. She then ran to the door and repeatedly called for help."
6. There was no documented response by the facility to video evidence and RCA #1's complaint of staff delay in responding to the call for assistance.
7. Incident reports were also documented on 8/11/12, 8/12/12, 8/19/12, 8/20/12, 9/1/12, 9/15/12 and 9/17/12. Of these 6 incidents, 3 were cutting related, 4 foreign body ingestion related, and 1 self strangulation attempt. Despite keeping the patient on 1:1 status the facility failed to provide a safe care setting for the patient.

Staff Interviews:
1. On 10/4/12 at approximately 1:30 pm review of the Incident Report (for the above incident) revealed that the Supervisor assigned to review the Incident Report (Nurse #2) did not identify any program or administration actions taken to remedy or prevent recurrence of the incident. The Supervisor stated "staff acted appropriately." No recommendations to prevent episodes of serious self-harm in the future were provided. These findings were confirmed by the Compliance Risk Manager during this review.
2. On 10/4/12 at approximately 1:30 pm the Compliance Risk Manager stated that she is unaware of any communication methods available to staff when they are alone with a patient and need emergency assistance.
3. On 10/4/12 at approximately 1:30 pm the Compliance Risk Manager stated that Incident reports dated 8/12/12 and 8/20/12 concerned patient #14's self injury and a strangulation attempt while being supervised 1:1 by staff and in bed. No suggestions for preventing recurrence were noted on either report.
4. On 10/4/12 at approximately 11:00 am review of patient #14's IPOS (Individual Plan of Service) with Unit Manager #1 revealed that a new intervention was added on 8/22/12, stating: "that assigned 1:1 staff will ensure that the patient's hands and arms are above the covers while lying in bed...due to several episodes of self abuse while lying in bed covered up with covers." Unit Manager #1 was asked why an intervention to address the patient's self-harming while in bed since 6/17/12 was not added until 8/22/12, despite repeated occurrences. Unit Manager #1 stated that she did not know.

Patient #15

Policy Review:
Policy SOP 208, "Acute Change in Medical Condition & Medical Emergency" revised 4/30/12, states:
that the hospital "recognizes and responds to changes in a patient's condition, provides emergency treatment and referral when appropriate."
An acute change in medical condition is "sudden onset of new symptoms or findings or a perception of change by the staff, the patient...such as: weakness in face, arms or legs, difficulty walking or speaking, change in mental status, any noticeable change of concern in how the person looks or feels." The policy states that any staff member that notices an acute change in a patient's medical condition shall request assistance from the RN when the patient is on the unit.

Policy SOP 201, "Incident Reporting" revised 2/1/12, states:
B. All unusual incidents shall be reported on Incident Report form (DCH-0044)
Unusual Incident is defined as "An occurrence that is a deviation from the routine care of a patient, disrupts or adversely affects the course of treatment or care of an individual...
Self abuse, neglect and accidents requiring greater than 1st Aid are listed as unusual incidents that must be reported on a DCH-0044 form."
18. The RN Manager, ".... completes the section of the form indicating the program or administrative action taken, including any instruction to staff given to remedy and/or prevent recurrence of the incident."
21. The Treatment Team "reviews Incident Reports...and considers changes in the treatment plan to prevent the recurrence of the incident."
23. The Central Nursing Office Supervisor "forwards all incident reports to the Office of Recipient Rights."
N. The Hospital Director/Designee and Chief of Clinical Affairs shall review incident reports as scheduled and assure that:
4. Actions required to prevent recurrence were taken and documented on the Incident Report form, as necessary.

Policy SOP 203 "Abuse and Neglect" revised 7/23/12, states:
G. "All allegations of patient abuse and neglect shall be investigated per the Michigan Mental Health Code, Civil Service Rules, and the Department of Community Health guidelines."
The policy does not require compliance with CMS Conditions of Participation.

Record Review:
On 10/3/12 at approximately 4 pm review of patient #15's medical record revealed the following, confirmed by Unit Manager #1:
1. Patient sustained multiple falls on 9/19/12. He was placed on 1:1 supervision at 8:30 pm. The Fall Risk Assessment Scale completed 9/19/12 noted a mental status of, "oriented to own ability."
2. On 9/20/12 at 5:30 am Resident Care Attendant (RCA) #2 stated: "Pt (patient) had a hard time getting in and out of bed during linen change. Pt was disoriented and for the most part unable to get to chair. Pt's right side arm and leg are weak. Pt. was also unable to change clothes himself."
3. On 9/20/12 at 9:45 pm a nursing note (signature unreadable) states: "Pt. required a lot of assistance to complete any given task he required staff to assist during shower he would not stand. Pt. also would not wheel his w/c (wheelchair) Pt. states: "I'm too weak."
4. On 9/21/12 at 10:30 am patient #15 was evaluated by an MD for right sided weakness. Right hemiparesis was noted and the patient was transferred to a hospital where a "large left-sided subdural hematoma" was found.
5. An Incident Report noting the delay between documented observations of an acute change in condition and examination by a physician, resulting in transfer to an acute care hospital, was not done.

Staff Interviews:
l. On 10/4/12 at approximately 2 pm patient #15's clinical record was reviewed with the Director of Quality Improvement and Utilization Review (Dir.QI&UR). The Dir. QI&UR was unable to explain why staff documentation of a change in patient #15's medical condition, beginning at 5:30 am on 9/20/12 did not result in evaluation by a physician until 10:30 am on 9/21/12. The Dir. QI&UR stated that she could not explain this delay and that facility policy requires prompt physician evaluation of the symptoms reported in the 9/20/12 progress note.
2. The Dir. QI&UR also verified that there was no Incident Report documenting the delay between documentation of acute changes and physician examination of the patient.
3. The Dir. QI&UR stated that she was unaware of any further Quality Assurance investigation into this incident.

Based on record and policy review and interview, the facility failed to investigate 1 of 1 patient's allegation of staff abuse ( patient #14's) in a through and timely manner. Findings include:

Policy SOP 201, "Incident Reporting" revised 2/1/12, states:
9. The RN "ensures all information on the incident report is complete and correct."
10. The RN "assesses patient for any potential injury."
11. The RN "writes no injury is apparent or documents a detailed description of minor injuries including the nature of the injury, precise location, size, color, depth, etc. of the injury and indicates no treatment needed or first aid with a description of treatment given."
23. The Central Nursing Office Supervisor "forwards all incident reports to the Office of Recipient Rights."

Policy SOP 203 "Abuse and Neglect" revised 7/23/12, states:
G. "All allegations of patient abuse and neglect shall be investigated per the Michigan Mental Health Code, Civil Service Rules, and the Department of Community Health guidelines."
The policy does not require compliance with CMS Conditions of Participation.

A.15. "Hospital Director/Designee instructs CNO (Chief Nursing Officer) for the Removal of staff suspected of abuse/neglect immediately from the patient's care until either the ORR (Office of Recipient Rights) investigation is completed or there is notification from ORR that the allegation will not be substantiated."

Record Review:
1. On 8/11/12 RCA #2 completed an Incident Report completed at 9:15 pm described patient #14's attempts at self-injury and the patient's behavior. There was no mention of patient #14 standing on the window sill. RCA #2 made no statement regarding laying hands on the patient except to say that a NAPPI (Non-Abusive Physical and Psychological Intervention) technique was used when the patient "swung" on her.
2. The section of the above Incident Report to be completed when physical injury to the recipient (patient) is apparent, states only: "No injuries noted or 1" and it is not timed. There was no description of the "1." The "description of treatment" and "extent of injury" sections were left blank.
3. On 8/11/12 at 9:30 pm an Incident Report was filed on behalf of patient #14, alleging that RCA #2 "used pain and excessive force" while managing her. Patient #14 alleged that RCA #2 "put a (unreadable) in her stomach and yanked her down from a window ledge while stating "ain't no f***ing cameras in here now."
4. The section of the above report noted "no apparent injury." It was unclear why an Incident Report completed 15 minutes earlier noted "or 1" injury in the same section. There was no description of the specific allegations, stating how the patient was yanked or assessment of the body parts allegedly hurt.
5. The Incident Report alleging staff abuse was states that the ORR (Office of Recipient Rights) was notified on 8/11/12.
6. The Office of Recipient Rights (ORR) did not acknowledge receipt of the abuse complaint until 8/15/12 (Complaint Acknowledgement Letter). The complaint states that RCA #2 "dragged (the patient) out of the bathroom and kneed her in the stomach."
7. RRA #2 sent an e-mail to administrative staff stating that the ORR's investigation was completed on 8/29/12 and that abuse could not be substantiated.
8. A Status Report regarding this investigation, written by RRA #2, states that the investigation is being completed and anticipated a 9/19/12 date of completion.

Staff Interviews:
1. The above record review findings were confirmed by RRA (Recipient Rights Advisor) #2 on 10/4/12 at 12 noon.
2. On 10/4/12 at approximately 12 noon RRA #2 stated that she was unable to locate an assessment or description of the patient's alleged injuries obtained during the incident with RCA #2.
3. On 10/4/12 at approximately 12 noon, RRA #2 stated that the investigation into the 8/11/12 abuse allegation was not initiated until 8/15/12.
4. On 10/4/12 at approximately 12 noon RRA #2 stated that there is no specific time requirement conducting interviews or completion of abuse/neglect investigations, except that the report must be completed within 90 days.

Based on document and policy review, medical record review and interview it was determined that the facility failed to analyze patient's adverse events and implement prevention measures for 2 of 2 patients (#14 and #15) who required emergency medical treatment. Findings include:

Patient #14:

Policy Review:
Policy SOP 221, "Levels of Supervision/Precautions" revised 6/4/12, states:
1:1 supervision means "One staff is assigned to one patient with no other patient care assignment. The assigned staff person will remain within arm's length of the patient at all times unless otherwise ordered...Staff will take every precaution to ensure safety of the patient/others and to seek timely evaluation when there is a change in the patient's condition that warrants reassessment of the patient's needs."

Policy SOP 201, "Incident Reporting" revised 2/1/12, states:
B. All unusual incidents shall be reported on Incident Report form (DCH-0044)
Unusual Incident is defined as "An occurrence that is a deviation from the routine care of a patient, disrupts or adversely affects the course of treatment or care of an individual...
Self abuse, neglect and accidents requiring greater than 1st Aid are listed as unusual incidents that must be reported on a DCH-0044 form.
18. The RN Manager "completes the section of the form indicating the program or administrative action taken, including any instruction to staff given to remedy and/or prevent recurrence of the incident."
21. The Treatment Team "reviews Incident Reports...and considers changes in the treatment plan to prevent the recurrence of the incident."
23. The Central Nursing Office Supervisor "forwards all incident reports to the Office of Recipient Rights."
N. The Hospital Director/Designee and Chief of Clinical Affairs shall review incident reports as scheduled and assure that:
4. Actions required to prevent recurrence were taken and documented on the Incident Report form, as necessary.

Policy SOP 203 "Abuse and Neglect" revised 7/23/12, states:
G. "All allegations of patient abuse and neglect shall be investigated per the Michigan Mental Health Code, Civil Service Rules, and the Department of Community Health guidelines."
The policy does not require compliance with CMS Conditions of Participation.

A.15. "Hospital Director/Designee instructs CNO (Chief Nursing Officer) for the Removal of staff suspected of abuse/neglect immediately from the patient's care until either the ORR (Office of Recipient Rights) investigation is completed or there is notification from ORR that the allegation will not be substantiated."

Record Review:
On 10/3/12 from 11:00 am-4 pm, review of patient #14's record revealed the following:
1. On 6/18/12 Nurse #1 e-mailed the Director of Nursing (DON) and Office of Recipient Rights (ORR) Recipient Rights Advisor (RRA) #1 to report that that on 6/17/12, while on 1:1 supervision, patient #14 self-inflicted 12-15 lacerations on each arm and several lacerations on the left leg. The incident occurred while the patient was on 1:1 supervision in bed and the implement was identified as a piece of glass.
2. Review of the Incident Report, dated 6/17/12, noted the extent of injuries as "serious physical harm" and resulted in patient #14's transfer to a hospital emergency department for treatment.
3. On 6/17/12 at 8 pm RCA #1, responsible for 1:1 supervision during the incident, completed the Incident Report, stating: "I noticed that the patient was getting restless under the cover. I lifted her cover and saw some blood, tried to stop her, she became aggressive and told me not to touch her. Writer called for help. The RN and other staff came."
4. On 10/4/12 at approximately 1 pm, video tape of the above incident, showing the hallway outside of patient #14's room during the incident, was viewed with the Compliance Risk Manager. It revealed the following as verified by the Compliance Risk Manager:
---Patient #14's arms did not appear to be bloody prior to entering the bedroom with RCA #1 the evening of 6/17/12.
---Patient #14 was in her bedroom with RCA #1 for approximately 45 minutes before RCA #1 appeared in the patient's doorway. RCA #1 stood in the patient's doorway, for a total of a few minutes, apparently requesting help. (Audio tape was not available.) At first, no staff are visible in the hallway. Eventually RCA #1 communicated with a staff member wearing purple scrubs. That staff member left the hallway. In a few minutes time additional staff come to patient #14's room.
---RCA #1 was not within arm's length of the patient when standing in the patient's doorway to seek help.
---After additional staff came to patient #14's bedroom, the patient exited the room and walked away from staff, including RCA #1. Patient #14 then entered the Day Room, with bloody wounds and no staff within arm's reach. RCA #1 was visibile down the hallway when patient #14 entered the Day Room.
5. The Office of Recipient Rights (ORR) did not acknowledge receipt of this complaint until 6/21/12 (Complaint Acknowledgement letter). The ORR investigation of possible neglect did not address video evidence that the 1:1 staff assigned to patient #14 did not maintain arm's length distance from the patient during the incident, as required in the 1:1 supervision policy. The investigation report stated: "There was a lack of evidence to show (patient's name) failed to comply with the 1:1 policy." The ORR's investigation did not address video evidence showing a delay in response to RCA #1's request for assistance. The ORR's 8/20/12 report report, states that RCA #1: "immediately called for help, however, staff did not respond. She then ran to the door and repeatedly called for help."
6. There was no documented response by the facility reports reviewed in response to the staff's delay in responding to RCA #1's calls for assistance.

Staff Interviews:
1. On 10/4/12 at approximately 1:30 pm review of the Incident Report (for the above incident) revealed that the Supervisor assigned to review the Incident Report (Nurse #2) did not identify any program or administration actions taken to remedy or prevent recurrence of the incident. The Supervisor stated "staff acted appropriately." No recommendations to prevent episodes of serious self-harm in the future were provided. These findings were confirmed by the Compliance Risk Manager during this review.
2. On 10/4/12 at approximately 1:30 pm the Compliance Risk Manager stated that she is unaware of any communication methods available to staff when they are alone with a patient and need emergency assistance.
3. On 10/4/12 at approximately 1:30 pm the Compliance Risk Manager stated that Incident reports dated 8/12/12 and 8/20/12 concerned patient #14's self injury and a strangulation attempt while being supervised by staff in bed. No suggestions for preventing recurrence were noted on either report.
4. On 10/4/12 at approximately 11:00 am review of patient #14's IPOS (Individual Plan of Service) with Unit Manager #1 revealed that a new intervention was added on 8/22/12, stating: "that assigned 1:1 staff will ensure that the patient's hands and arms are above the covers while lying in bed...due to several episodes of self abuse while lying in bed covered up with covers." Unit Manager #1 was asked why an intervention to address the patient's self-harming while in bed since 6/17/12 was not added until 8/22/12, despite repeated occurrences. Unit Manager #1 stated that she did not know.

Patient #15

Policy Review:
Policy SOP 208, "Acute Change in Medical Condition & Medical Emergency" revised 4/30/12, states:
that the hospital "recognizes and responds to changes in a patient's condition, provides emergency treatment and referral when appropriate."
An acute change in medical condition is "sudden onset of new symptoms or findings or a perception of change by the staff, the patient...such as: weakness in face, arms or legs, difficulty walking or speaking, change in mental status, any noticeable change of concern in how the person looks or feels." The policy states that any staff member that notices an acute change in a patient's medical condition shall request assistance from the RN when the patient is on the unit.

Policy SOP 201, "Incident Reporting" revised 2/1/12, states:
B. All unusual incidents shall be reported on Incident Report form (DCH-0044)
Unusual Incident is defined as "An occurrence that is a deviation from the routine care of a patient, disrupts or adversely affects the course of treatment or care of an individual...
Self abuse, neglect and accidents requiring greater than 1st Aid are listed as unusual incidents that must be reported on a DCH-0044 form.
18. The RN Manager "completes the section of the form indicating the program or administrative action taken, including any instruction to staff given to remedy and/or prevent recurrence of the incident."
21. The Treatment Team "reviews Incident Reports...and considers changes in the treatment plan to prevent the recurrence of the incident."
23. The Central Nursing Office Supervisor "forwards all incident reports to the Office of Recipient Rights."
N. The Hospital Director/Designee and Chief of Clinical Affairs shall review incident reports as scheduled and assure that:
4. Actions required to prevent recurrence were taken and documented on the Incident Report form, as necessary.

Policy SOP 203 "Abuse and Neglect" revised 7/23/12, states:
G. "All allegations of patient abuse and neglect shall be investigated per the Michigan Mental Health Code, Civil Service Rules, and the Department of Community Health guidelines."
The policy does not require compliance with CMS Conditions of Participation.

Record Review:
On 10/3/12 at approximately 4 pm review of patient #15's medical record revealed the following, confirmed by Unit Manager #1:
1. Patient sustained multiple falls on 9/19/12. He was placed on 1:1 supervision at 8:30 pm. The Fall Risk Assessment Scale completed 9/19/12 noted a mental status of "oriented to own ability."
2. On 9/20/12 at 5:30 am Resident Care Attendant (RCA) #2 stated: "Pt (patient) had a hard time getting in and out of bed during linen change. Pt was disoriented and for the most part unable to get to chair. Pt's right side arm and leg are weak. Pt. was also unable to change clothes himself."
3. On 9/20/12 at 9:45 pm a nursing note (signature unreadable) states: "Pt. required a lot of assistance to complete any given task he required staff to assist during shower he would not stand. Pt. also would not wheel his w/c (wheelchair) Pt. states: "I'm too weak."
4. On 9/21/12 at 10:30 am patient #15 was evaluated by an MD for right sided weakness. Right hemiparesis was noted and the patient was transferred to a hospital where a "large left-sided subdural hematoma" was found.
5. An Incident Report noting the delay between documented observations of an acute change in condition and examination by a physician, resulting in transfer to an acute care hospital, was not done.

Staff Interviews:
l. On 10/4/12 at approximately 2 pm patient #15's clinical record was reviewed with the Director of Quality Improvement and Utilization Review (Dir.QI&UR). The Dir. QI&UR was unable to explain why staff documentation of a change in patient #15's medical condition, beginning at 5:30 am on 9/20/12 did not result in evaluation by a physician until 10:30 am on 9/21/12. The Dir. QI&UR stated that she could not explain this delay and that facility policy requires prompt physician evaluation of the symptoms reported in the 9/20/12 progress note.
2. The Dir. QI&UR also verified that there was no Incident Report documenting the delay between documentation of acute changes and physician examination of the patient.
3. The Dir. QI&UR stated that she was unaware of any further Quality Assurance investigation into this incident.