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Based on interview, and record review, the facility failed to follow its grievance policies and procedures resulting in incomplete investigation of grievances for two patients (P-35 and 36) of 4 grievances reviewed, lack of accurate and timely follow up, and potential for negative outcomes. Findings include:

On 11/14/24 at 1323 during interview with facility's Director of Risk and Compliance, Staff B, he stated that former Patient Advocate, Staff KK, left on 10/24/24 and facility is currently in a process of hiring for this position. When asked who was responsible for grievance process (maintaining the complaint and grievances log, conducting investigations of grievances and following up with patients/responsible parties), Staff B stated it was Recipient Rights officer, Staff V's, responsibility.

On 11/20/24 at 1130 grievances were reviewed for P-35 and P-36. Grievance file for P-35 contained 2 follow up response letters regarding grievance submitted by the patient during her stay at the facility. Letters were signed by a Patient advocate, Staff KK. One letter addressed results of the facility investigation regarding physical altercation with the other patient. Allegations were substantiated. Letter stated that "Interviews were conducted with you and the other peer". No documentation was found in a file supporting the findings, no record of the interviews with the patients of witnesses. This complaint was not logged in a Complaint log provided by facility. Second letter addressed allegation of verbal abuse by staff. The documentation attached in a file had an interview record with P-35 and a staff member who witnessed and reported a verbal abuse towards the patient. Response letter stated: "The allegations were unable to be substantiated".

Review of the grievance file for P-36 revealed a response letter sent to the patient. Letter was not dated. Further, letter indicated that allegation was "that you (P-36) hit a peer in a face". The allegation was substantiated. The facility's complaint log was reviewed and revealed that P-36 filed 2 grievances with facility on 9/23/24. One for "boundaries- patient/patient", with resolution: "After a full investigation it was found that the patient did violate the patient's boundaries". And a second one for "patient care- staff", with resolution: "After a full investigation it was found that staff was appropriate towards the patient". There was no documentation in a grievance file provided by facility supporting that investigation regarding the allegation of inappropriate behavior by staff was completed and a follow up resolution letter was sent to the patient regarding her grievance.

Chief Operating Officer, Staff DD, was interviewed on 11/20/24 at 1145 and confirmed the above findings.

Facility's policy "Complaint and Grievances Procedures", effective 07/2024, was reviewed on 11/20/24 and revealed:
"Purpose. To provide standard operating procedures for addressing customer care complaints, customer service complaints, and CMS complaints or grievances regarding services rendered to patients and to reinforce the obligation of respective staff to listen and respond to patient concerns and when necessary forward complaints or grievances to the appropriate person for resolution.

Procedure. 7. On average, a written response will be provided within 7 business days to the patient who is the subject of the grievance or the patient's legal representative regarding the grievance in a language and manner that is easily understood. The written response must contain the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. 11. A log will be kept documenting all grievances, the date of the grievance, name of the grievant, how the grievance was received, medical record number of the patient, responsible party, date of resolution and outcome".

Based on interview and record review, the facility failed to ensure that patient rights were exercised for one (P-23) of 36 patients reviewed for patient rights, resulting in the unmet exercise of patient rights. Findings include:

Review of facility handout document "Your Rights When Receiving Mental Health Services in Michigan," states under "Civil Rights," "Your civil rights are protected even though you are receiving mental health services. You have the right to an education, the right to register and to vote. (Mental Health Code Section 704; Administrative Rule 330.7009)."

An interview was conducted with Recipient Rights Advisor (Staff V) on 11/14/24 at 1335. Staff V was questioned how patients would participate in the presidential election voting process. Staff V stated that patients can file for an "Absentee" ballot, up until the Friday (11/01/24) prior to the election. Staff V was next queried who was responsible for ensuring patients rights to vote. Staff V stated that the responsibility was his. Staff V stated, "I went through and canvassed the units for two weeks prior to the election." Staff V was questioned if he had provided voting information to P-23. Staff V stated that he spoke with P-23 the day before the election (11/04/23) about her inpatient complaints, but not about voting. Staff V was next asked if he ' d spoke with P-23 prior to 11/04/24. Staff V stated, "I did not, I didn ' t know she was in the hospital." Staff V was next questioned if he had any documentation of P-23 being informed of her voting rights? Staff V stated, "No. I should have documented."

Record review of P-23's chart revealed the patient was admitted to the facility on 10/30/2024, the Wednesday before the absentee ballot deadline.

Based on interview, and record review, the facility failed to provide comprehensive discharge information to patient's representative (guardian) for one patient (P-31) of 4 patients reviewed, resulting in patient's guardian not being included in a final step of patient discharge process, lacking full information needed to post-discharge patient care, and inability to exercise the right to make informed decisions with potential for negative outcomes for the patient. Findings include:

During phone interview with P-31's legal guardian on 11/19/24 at 1715, he stated that P-31 was discharged from the facility on 4/17/24 and arrived home with incomplete discharge paperwork in hand. He added that he is P-31's responsible party and details of discharge were not discussed with him prior to patient leaving the facility. Guardian also expressed concern that 2 new medications were prescribed to the patient, and he had no prescription sent to the pharmacy. He added that he had to call facility after patient was discharged and ask for the prescriptions.

On 11/20/24 at 0930 interview with Director Clinical Services, Staff D, was conducted. Staff D was asked to explain discharge process and the role and involvement of the legal guardian when patient unable to make his/her own decisions. Staff D explained that discharge process begins on admission and responsible party has to be involved in all decisions regarding care if patient unable to make his/her own decisions. When asked what would be included in the process of the discharge instructions review, Staff D stated that social worker need to speak with the guardian or patient's representative and document this in the notes. Also, there should be a documentation that the responsible party agreed to a discharge plan and signing off by phone. This part should be included in the discharge paperwork which will be send with the patient. Further, Staff D was asked if newly prescribed medications would be sent to a pharmacy of choice prior to the patient's discharge. Staff D said "yes", all new medication prescriptions will be automatically sent to a pharmacy before patient leaves the facility.

Review of the P-31's record on 11/19/24 revealed that patient was a 35-year-old male admitted to facility on 4/12/24 at 1050 with diagnoses of Major depressive disorder with psychosis. Patient also had a history of Dravet syndrome (is an epilepsy syndrome that begins in infancy or early childhood and can include a spectrum of symptoms ranging from mild to severe), and developmental disorder. P-31 had a court appointed legal guardian.

Further record review revealed a discharge summary note completed by social worker and dated 4/16/24 1405: "Case manager met with patient for discharge planning and informed of aftercare appointment. Further review of the provided discharge documentation revealed a discharge form not signed by the patient or legal guardian. No notes were found with documentation that discharge information was discussed with legal guardian and he agreed with the terms of patient's discharge.

Review of the provider's orders indicated two new to the patient medications that were added during his stay in a facility. Both medications: Escitalopram (an antidepressant belonging to a group of drugs called selective serotonin reuptake inhibitors) 10 mg oral once a day, and Quetiapine (Seroquel- atypical antipsychotic medication) 50 mg oral once a day were part of the discharge documentation under medications to continue to take. No record indicated that patient's legal guardian was aware that both new medications needed to be continued after discharge. Prescription history provided by facility revealed that both medications were entered in a system and automatically sent to pharmacy on 4/17/24 at 1439. P-31 left facility on 4/17/24 at 1124.

Facility policy "Discharge Planning" effective 07/2024, was reviewed on 11/20/24 and revealed:
"It is the policy that discharge planning for any level of care within facility will begin upon the patient's admission to the unit/program. Therapists, in conjunction with the treatment team, will identify initial
discharge plans and address barriers to discharge at the earliest opportunity. Aftercare treatment and residential needs will be incorporated into the discharge planning process. Patients will have in hand a completed discharge instruction sheet when they leave the unit program. Staff will obtain all necessary release of information forms for the communication with aftercare treatment teams. Throughout the discharge planning process therapists will keep in close communication with all appropriate parties to ensure a smooth transition for the patient upon discharge and document process in medical record.
Procedures. D. Therapists: 10. Document discharge on progress note. E. RN: 3. Review medication to ensure that all prescriptions and/or medications are ready, i.e. sent to pharmacy, back from pharmacy, correct, etc. 5. Go over final discharge instructions with patient and/or family/guardian. 6. Complete medical portions of discharge sheet and review with patient/family/guardian as appropriate for their signature. 7. Complete Discharge note".

Based on observation, interview, and record review, the facility failed to ensure that
that dietary staff adhered to the safety practices and facility's policies for food handling and storage affecting all patients, and failed to ensure individual patient nutritional needs were met in accordance with practitioner' orders for dietary consult for one patient (P-2), resulting in the potential for negative outcomes for all patients in a facility that likely being served and consumed undated and/or expired food, food served in unsanitary manner and potential for food-born illnesses. Findings include:

See Specific Tags:

A-619 Failure to ensure that dietary staff adhered to the safety practices and facility's policies for food handling and storage

A-629 Failure to ensure that special nutritional needs of the patients are met

Based on observation, interview, and record review, the facility failed to ensure that established policies and procedures for labeling and storing produce, preparing and serving food are maintained and followed by dietary staff resulting in all patients in a facility potentially being served and consumed undated and/or expired food and potential for a food-born illnesses. Findings include:

On 11/19/24 from 1110 to approximately 1135 the kitchen tour was conducted with facility's Infection Preventionist and Nurse Educator, Staff CC, and Director of Dietary Services, Staff S. Dry storage room was inspected and revealed clear storage bin with cookies in individual packages with no expiration dates on the packets. Further, clear plastic bin was observed with pop tarts in individual packages with no expiration dates on the packets. Staff S was asked if these snacks were to be distributed for patients' consumption. Staff S confirmed that the snacks were for the patients. Staff CC and Staff S were asked how kitchen staff knows that these snacks were not expired. Staff CC said they should be dated after the original box with expiration date was opened and snacks were transferred to the clear bins for storage.

Next, the produce refrigerator was inspected. There were the following clear bags found without expiration dates on them: chocolate cookies, pretzel sticks, omelettes, and 6 bags of cubed chicken. There were 2 long bricks of semi-hard yellow cheese that were opened, and the top was wrapped with a clear plastic wrap. Upon picking them up from the shelf, the wrap fell of, and cheese was exposed to the air and touch. There was a clear plastic bag with shredded cheese inside, unlabeled, undated and open. Cheese was falling out when bag was touched. Two bags of shredded lettuce were observed on the top shelf in clear bags with no expiration dates on them.

Further, the freezer was inspected. Multiple debris were found on the floor under the shelves. There was a meat product in a clear package laying directly on the floor under the shelf.

Next, the food preparation area of the kitchen was observed. There were 16 clear bags with pita bread lying on the counter. No expiration date was found on the bags. Kitchen staff was preparing lunch for delivery to the units. Kitchen staff was observed wearing gloves, touching different kitchen surfaces, and packing food with the same gloves. Multiple fruit cups in plastic factory packages were observed to be placed in Styrofoam containers that contained fries and chicken sandwiches. Total of 7 boxes were found with plastic cups inside. When asked if this was a usual practice, kitchen staff said that the other option would be to put the cups separately on the trays.

On 11/19/24 at 1140 Unit P2 kitchenette was inspected with Staff CC. A food cart was found with 20 ready to serve Styrofoam containers with lunch. Staff CC inspected all containers and found chicken fingers with fries in them along with fruit cups in plastic factory packages. Staff CC was queried if factory packaged food usually served in a same containers as freshly prepared food. Staff CC stated that it should not be placed inside with the prepared meal.

Facility's Food storage policy, dated 07/2024, was reviewed on 11/19/24 and revealed:

"Purpose. To ensure that food and supplies used by the Dietary department will be stored in a clean and safe environment, consistent with all applicable regulations for storage.
Procedure. 1. Frozen and refrigerated items will be labeled, dated with date received, and stored in the appropriate freezer and refrigeration units immediately after delivery.
a. All items will be placed on shelving units off the floor.
d. All food items sorted after opening or preparation will be covered, labeled, and dated with both the date opened and the date to be discarded. All opened perishable food items will be discarded within 72 hours of opening.
f. Any food that is refrigerated and undated is discarded immediately.
i. Any prepackaged items, or individually packaged items, will be labeled with the manufacturer's expiration date when removed from the original packaging".

Based on interview and record review, the facility failed to provide a nutritional consultation for 1 (#2) of 3 patients reviewed for special diet requirements, resulting in the potential for less than optimal outcomes. Findings include:

Medical record review revealed that patient #2 was a 17-year-old female admitted to the female pediatric behavioral health unit on 7/9/24 through 7/12/24 for diagnoses of anorexia nervosa (eating disorder), suicidal ideation, and celiac disease (an immune reaction to eating gluten-- a protein found in foods containing wheat, barley or rye). The patient's medical record documented allergies to wheat, Penicillin, and Imitrex.

On 11/13/24 at approximately 1200, review of patient #2's medical record with the Director of Quality (Staff C) revealed that the initial nursing assessment on 7/10/24 at approximately 0215 triggered a nutritional assessment/consult to be done. The Director of Quality stated that the facility policy allowed the nutritional consult to be done within 72 hours when triggered by nursing.

Medical record review also revealed that on 7/10/24 at 0700 the psychiatrist ordered a dietitian consult due to allergy to wheat and celiac disease. Then again on 7/10/24 at 0900, the psychiatrist ordered the dietitian consult "now" due to patient's BMI 16.6 (body mass index - low) and patient has an eating disorder.

On 11/19/24 at approximately 0930, interview with the Registered Dietitian (Staff U) and Chief Nursing Officer (Staff E) revealed that the registered dietitian (RD) had up to 72 hours to complete the nutritional assessment. The RD was not always on site but could be called in if needed. It was not determined why the RD did not respond to the physician "now" order for consultation. The RD confirmed that if she was made aware of the "now" order, she would have seen the patient that day for a nutritional consult on 7/10/24. The patient was discharged on 7/12/24 without a nutritional consult.

Review of the dietary/nutrition policies and procedures provided by the facility revealed that they did not address nutritional consults or diets/meals that were ordered "now." This was verified by the Director Risk/Compliance (Staff B) on 11/21/24 at approximately 1200.