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UNIVERSITY OF MICHIGAN HEALTH-SPARROW LANSING
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on observation, interview and record review, the facility failed to provide a safe environment for 1 (P-2) of 10 patients when hygiene care was not provided during the period of time in which the patient was hospitalized in the Emergency Department resulting in the potential for the loss of emotional and physical well being. Findings include:
On 05/07/2024 at 1045 a tour of the Emergency Department (ED) revealed a busy 69-bed unit with 4 trauma bays, which is a Level 1 Trauma Center. Observations of the triage process, provider in triage area and patient care area including bedside care, medication administration and patient interviews were completed during the tour. At the time of the tour the ED was "holding" 40 patients awaiting bed placement in the facility, while continuing to care for new ED arrival patients.
On 5/7/2024 at 1142 an interview was conducted with ED Patient Care Tech (Staff P). Staff P revealed patients in the unit are rounded on the half hour to hourly and are monitored to make sure they are clean and dry, call lights are within reach, meal trays are provided. When queried whether they document hygiene interventions in the medical record, Staff P responded, "we try to".
On 5/7/2024 at 1150 an interview with P-6 revealed she had been in the ED approximately 16 hours. P-6 stated the care "has been very good, despite how busy they have been". When queried whether she has received a timely response to her call light, request for food, medication and hygiene assistance during her stay in the ED, P-6 stated "yes".
On 5/8/2024 at 1530 during review of policy "RISK-Investigation of Patient Reports of Abuse & Neglectful Behavior Occurring within the Inpatient Setting", dated 4/25/2023, under Section 3.0 Definitions: Neglect "The absence of the minimal services or resources required to meet basic needs. Neglect includes withholding or inadequately providing medical care and, consistent with the usual care, treatment, or services, food and hydration...clothing, or good hygiene."
On 5/7/2024 at 1446 record review of P-2's chart revealed no documented entries for hygiene care from 1/22/2024 through the time of discharge of 1/25/2024.
On 5/7/2024 at 1515 an interview with the ED Director (Staff G) and ED Manager (Staff H) was conducted. Staff G and Staff H revealed it is an expectation that patients being "held" in the ED awaiting bed placement should be provided adequate assistance with hygiene during their stay and these interventions should be documented in the medical record. Staff H confirmed there were no entries of hygiene interventions throughout P-2's admission.