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Based on observation, interview and document review the facility failed to protect the rights of current and discharged patients, placing all current patients at risk for loss of their rights.

Findings include:
---the facility failed to prevent and report abuse (See A-145)

--- the facility failed to obtain a signed physician order within 24 hours of a seclusion/restraint verbal order. (See A-168)

--- the facility failed to conduct a 1 hour face to face evaluation according to policy. (See A-179)

Based on interview and document review the facility failed to prevent and report allegations/incidents of abuse to the appropriate agencies in accordance with State and Federal Laws for 1 of 1 (patient #28) patient placing all current patients at risk for loss of their rights. Findings include:

On 08/25/2015 at 1000 during record review for patient #28 it was noted that on 03/13/2015 the patient was in an altercation with staff R. Staff R "punched patient (#28) in the nose" the patient was sent to the Emergency room for care and was returned with a report of being uninjured.

Further review of documents provided by the recipients rights officer on 08/25/2015 at 1400 included eyewitness statements and documentation of review of the video footage for the incident on 03/13/2015 reviewed by risk management, staff A and the recipient rights officer, staff S. Staff R was terminated after the incident was investigated and subsequently, substantiated.

Staff S was interviewed on 8/26/2015 at 1400 and was asked if the allegation of abuse had been reported to Adult Protective Services or to the Department of Licensing and Regulations? He stated, "I did not report it but let me ask staff A to see if he did." Staff A was subsequently asked if he had reported it and stated, "We called the police and they did not want to press charges so we did not pursue it any farther."

On 8/27/2015 at 0900 during review of the document titled, "Identifying and Reporting Abuse and Neglect" #100.05 effective date 8/2004 on page 8 of 9, "C....4. If an employee....has reasonable cause to suspect abuse....a verbal report must immediately be made to Department of Human Services-Protective Services in the county in which the violation is alleged to have occurred, pursuant to their definitions of abuse......"

Based on document review and interview, the facility failed to obtain a physician's signed order within 24 hours of initiation for behavioral restraints for 1 of 5 (#27) patients who reported abuse from a total sample of 30 patients resulting in the potential for loss of patients rights for the entire 64 current patients. Findings include:

On 08/24/2015 at 1130 during tour of the adult in-patient unit the chart for patient #27, a current patient was reviewed, her name was found on the restraint log dated 08/10/2015. Two orders for restraint were found on the chart; #1 dated 08/09/2015 at 0115 for "4 point mechanical"-telephone order/read back signed by RN, and #2 dated 08/10/2015 at 0315 for "3 point soft restraint" telephone order/read back signed by RN. Both orders were unsigned by a prescriber and did not have the name of the provider anywhere on the order who actually gave the telephone order.

On 08/25/2015 at 1100 staff A was asked to confirm date and times of the unsigned orders. He stated, "order #1 was a misdated order as the midnight RN forgot to change his date after midnight, but that both order #1 & #2 were unsigned by a physician well after the 24 hour expectation."

On 08/26/2015 at 0900 during review of the policy titled, "Seclusion and Restraint" #1972.00 effective date 6/1994 it stated on page 7 of 18, "lll. E. The physician, to order Restraint or Seclusion must verify the telephone order by signing the order within 24 hours of the order."

Based on interview and record review, the facility failed to conduct a one hour face to face evaluation of a patient in restraints, according to facility policy for 4 of 5 patients (Patients #1, #11, #16, and #27) reviewed for restraints, from a total sample of 30 patients, resulting in the absence of a thorough assessment of patients #1, #11, #16, and #27 while they were in restraints, which has the potential for unnecessary restraints, and the potential for unknown injuries. Findings include:

Patient #16:
Review of Patient #16's medical record on 8/25/15 at 1000, revealed he was admitted to the facility on 3/19/15 with a diagnosis of autistic spectrum disorder.

Review of Patient #16's facility "Seclusion Restraint Form" revealed he was placed in restraints on 3/26/15 at 0123, for hitting, kicking, spitting, spitting at staff, and throwing objects and was assessed by Registered Nurse (RN) "P" at 0225. RN "P" documented on the Seclusion Restraint Form that Patient #16's current medical/physical condition was, "calm, cooperative, VSS (vital signs stable).

Review of facility policy titled, "Seclusion and Restraint" (dated 4/23/15) revealed section XII "When restraint or seclusion is ordered the patient will be seen face-to-face within 1 hour after the initiation of the intervention by a physician to evaluate the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint or seclusion." Section A. "if a physician is unavailable, a registered nurse who has completed the hospital's training may conduct the initial required face to face evaluation of a restrained or secluded patient..." Section XVIII of the policy indicated "When restraint or seclusion is used, there must be documentation in the patient's medical record of the following: (i) The 1-hour face-to-face medical and behavioral evaluation completed by the physician when restrain or seclusion is used to manage violent or self-destructive behavior."

The facility "Seclusion and Restraint In-Service" (revision date 3/13) indicated in section #21 "(i) the RN is responsible for documentation in the patient's medical record the 1 hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior."

In an interview on 8/25/15 at 1600, Risk Manager "A" stated Registered Nurses were to follow the facility Restraint and Seclusion policy regarding the 1 hour face-to-face assessment of patients in restraints. Risk Manager "A" stated he was the staff member who had educated the Registered Nurses on how to complete the 1 hour face-to-face assessments of patients in restraints, and that he was not a Registered Nurse. Risk Manager "A" stated he was a Recreational Therapist.


27781

Patient 11
A review of restraint logs was conducted during the initial tour of the older adult unit on 08/24/2015 at approximately 1030 which indicated written documentation that noted a 77 year old female was placed in four point restraints on 04/08/2015 from 1340 until 1540.
A clinical record review on 08/24/15 at 1340 revealed that the 77 year old patient (#11) was admitted into the facility on 04/07/2015 with a diagnosis of dementia, adjustment disorder, and neurocognitive disorder.
According to the undated CPI (Crisis Prevention Intervention) Postvention Model Debriefing Worksheet for Patient #11, the following narrative of the event was documented, "Patient stole papers out of nursing office when staff attempted to retrieve papers, patient began getting agitated and hit staff x 2 (twice). RN and LPN (licensed practical nurse) noticed and a PRN (as needed) IM (intra-muscular injection) was drawn. When staff attempted to give PRN patient continued to try and hit and kick staff...Patient was then placed in 2 person CPI hold and escorted to quiet room. Once there patient continued to hit, spit and kick staff. Patient was then placed in 4 point restraints."
The Medication Administration Record revealed that Ativan 0.5 mg (anti-anxiety) was administered to Patient #11 at 1320 and again at 1440.
Review of the Seclusion/Restraint form dated 04/08/2015 revealed that a one hour face to face assessment was conducted by a Registered Nurse (RN) at 1400 (20 minutes after Patient #11 was placed in the restraints). The RN documented that at the time of the assessment, the patient was sitting upright in restraints, conversing with staff, no relevant thought process pertaining to situation, calm and confused ..." The RN failed to address the medical and behavioral condition of Patient #11 during the one hour face to face.
It was unclear why a restrictive intervention was used on an elderly, demented, confused patient, or why a second injection of Ativan was administered at 1440 when the nurse documented that the patient was "calm" at 1400, and why the use of restraints continued for an additional one hour and forty minutes after the assessing RN documented that the patient was calm.
An interview was conducted with the Director of Clinical Services and RN Supervisor (Q) on 08/25/15 at approximately 0955 who verified the findings but was unable to explain the reason a thorough assessment was not completed for the patient, or why the restraints were not released once the RN assessed that the patient was calm.


30988

Patient #1

On 08/24/2015 at 1100 during tour of the adult in-patient unit patient #1 was found on the "Seclusion and Restraint Log." The medical record was reviewed for documentation for the subsequent "seclusion." The patient was placed in seclusion on 08/24/2015 at 0105, the telephone order was obtained 08/24/2015 at 0120, the document titled "Seclusion/Restraint Form" was reviewed for the 1 hour face to face, it was completed by an RN on 8/24/2015 at 0200. The question "What is the patient's current medical/physical condition?" was answered "NONE".

Patient #27

On 08/24/2015 at 1120 during further review of the "Seclusion and Restraint Log" patient #27 was placed in 4 point and soft restraint on 08/10/2015. The medical record was reviewed for documentation for the subsequent "Restraint." The patient was placed in 4-point mechanical restraints on 08/10/2015 at 0115 the order was obtained by telephone at 0115, the document titled, "Seclusion/Restraint Form" was reviewed for the 1 hour face to face, it was completed by an RN on 08/10/2015 at 0150. The question "What is the patient's current medical/physical condition?" was answered "VSS (vital signs stable). No injuries."
A second order for 3 point soft restraint was ordered by telephone 08/10/2015 at 0315, the document titled "Seclusion/Restraint Form" was reviewed for the 1 hour face to face, it was completed by an RN on 08/10/2015 at 0320. The question "What is the patient's current medical/physical condition?" was answered "No s/s (signs and symptoms) of distress noted. VS (vital signs) 129/87, P (pulse) 96, RR (respiratory rate) 18."

Based on document review and interview, the facility failed to have Medical Staff Bylaws that documented time frame requirements for completion of the medical history and physical, resulting in potential for untimely patient assessment. Findings include:

On 8/18/15 at approximately 1100, review of the facility document titled, "Medical Staff Bylaws" dated 2015 revealed that there was no documentation for time frame requirements that addressed the patient history and physical requirements. Interview with the Medical Director on 08/25/2015 at approximately 0945 and with the Facility Administrator, on 08/26/2015 at approximately 0900, verified that the requirement for the patient history and physical was not documented in the Medical Staff Bylaws.

Based on document review and interview, the facility failed to ensure nursing staff maintained an updated plan of care (POC) for 1 out of 4 partial hospitalization program patients reviewed (#23) resulting in the potential for ineffective care.

Findings include:

On 8/24/15 at 1115 review of patient #23's medical record revealed the patient had been admitted to the program on 8/10/15 and an initial treatment plan was developed on the day of admission. Review of treatment plan updates dated 8/17/15 and 8/24/15 revealed a lack of nursing documentation in the "Nursing" section, the box designated "Present at Team Conference" was not checked, and the signature line was blank. On 8/24/15 at 1130 staff L was queried as to the lack of nursing documentation for the treatment plan updates. Staff L replied, "I was there, I wasn't able to jot it down."

On 8/26/15 at 0925 review of the document titled, "Individualized Plan Of Service (IPOS)/Treatment Planning" dated 10/2013 revealed on page 2 "3) Treatment Plan Review/Team Conference - The IPOS for each patient shall be reviewed and updated each week ...The patient...should be present at this meeting along with the attending physician, RN (registered nurse)..."

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include:

See the individually and below cited K-tags dated August 26, 2015.
Building 1
K-0039
K-0049
K-0060

Building 2
K-0048

Building 3
K-0029
K-0048
K-0147

Based on observation and interview, the facility failed to ensure that supplies are maintained at an acceptable level of safety and quality resulting in the potential for poor patient outcomes. Findings include:

On 08/25/2015 at 0900 during observation of the medication pass on the adult in-patient unit the high and low control solution vials for the glucose meter were opened and undated, the space provided by the manufacturer for the date opened was unmarked. The package insert to check for manufacture recommendations for the safety of the controls after opening was not readily available.

On 08/25/2015 at 0910 Staff A and J were asked if they knew how long the controls were safe to use after opening and if they knew when the control vials were opened responded, "No" to both questions.

Based on observation and interview, the facility failed to provide and maintain a sanitary environment resulting in the potential for transmission of infectious agents among all residents receiving services in the facility. Findings include:
See specific findings in A-749

Based on observation and interview, the facility failed to maintain a clean and sanitary environment by 1) ensuring that the facility kitchen was free from dirt, grease and grime during food preparation 2) by ensuring staff wore hair coverings in the food preparation area, and 3) by ensuring that an under-sink cabinet in the medication room was not used as a storage area for clean patient care supplies, 4) maintaining dust free environment resulting in the potential for cross contamination and patient harm. Findings include:
During the initial tour of the older adult unit, on August 24, 2015 at 1040, an observation was made in the medication room which revealed that an under sink cabinet was being used for storage. The cabinet contained several boxes of patient care supplies including a large cardboard box containing colostomy supplies, lotion skin cleanser, a full box of sterile bulb tip Yankauer and various other patient care supplies.
The Director of Patient Care was present and instructed registered nurse (F) to remove the items from underneath the sink. Registered nurse (F) failed to explain why the under sink cabinet was being used for storage of clean patient supplies.


30988


On 08/24/2015 at 1500 during an initial tour of the cafeteria/kitchen and nutrition area for the adult in-patient unit it was found that there was an accumulation of dust, debris, accumulated grease and sticky tape residue on the food-preparation equipment (meat slicer), wall clock, walls, food storage shelving, food serving counters, cooking hood and floors.

Staff A was interviewed during the tour and stated, "the floors are mopped daily, kitchen equipment is supposed to be wiped down daily, and the cooking hood is scheduled to be cleaned every 3 months, it is scheduled for next week. Our kitchen manager is new and is making a big difference."


28042

On 8/25/15 at 1015, an observation was made in the main kitchen of Dietary Manager (DM) "T" in the food preparation area without a hair net, or hair covering over her hair. During the same observation, Housekeeper "U" was observed in the walk in cooler with no hair cover on. The surveyor asked DM "T" what the facility hair net policy stated. DM "K" stated, "Every employee must wear a hair net at all times, and all hair must be covered when in the kitchen."

Risk Manager "A" was in the kitchen at the time of the observation and also stated hair nets were to be worn by anyone who entered the kitchen.

According to the facility policy titled, "Sanitation of Food Handling Personnel" (undated), provided to the surveyor by Risk Manager "A", Section 3. a. indicated, "Proper attire for food handlers includes a proper hair covering...".

According to the 2009 Michigan Modified Food Code "2-402.11 (A)...Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food."


25992


On 8/25/2015 at 1000 during an initial tour of the facility, a large accumulation of dust was observed on the return and exhaust grills in all medication rooms as well as the laundry room.