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Based on record review, interview and policy review, the facility failed to inform 4 (#21, #22, #23, #24)of 22 current patients and 6 (#14, #15, #17, 18, #19, #20) of 8 former patient of their discharge appeal rights as stated in "An Important Message from Medicare." Findings include:

On 4/12/10 at 1610, the Client Representative/Patient Affairs Director was queried regarding whether patients are asked to sign a copy of "An Important Letter from Medicare" at admission. She responded that the letter is part of an admissions packet but that patients do not sign-off on a copy of the form. The Client Representative/Patient Affairs Director stated that she didn't know if patients were given the form again, once a discharge date had been determined.

On 4/13/10 at 0820, the Director of Social Services was asked whether "An Important Message from Medicare" was given to patients to sign prior to discharge, once a discharge date was identified. She responded that it was not facility practice to do so.

On 4/ 14/10 at approximately 1530, review of patient #14's medical record revealed that "An Important Message from Medicare" had not been signed by the patient within 48 hours of admission nor prior to discharge once a date had been determined.

Review of additional medicare closed records #15, #17, #18, #19 #20 revealed that the "An Important Message from Medicare" was not documented and signed by the patient or patient representative.

Based on medical record review, in 1 of 1 applicable cases involving a patient who was diagnosed with a terminal conditions, the hospital failed to ensure that it adhered to Public Act 258 of 1974, Section 330.1712 when it did not honor the patient's request to be placed on and maintained on "Do Not Resuscitate" (DNR) status. Findings include:

<1> On 10/12/09 patient # 12, a 53 year old African American male, while hospitalized at the Michigan Department of Community Health's (Department) Center for Forensic Psychiatry, completed and had notarized and witnessed a memorandum to "whom it may concern" regarding "Advanced Medical Directive/Living Will". Review of the 10/12/09 memorandum revealed that this document in part noted that:

a) I have been diagnosed with having third stage lung carcinoma. This medical condition may likely terminate my life.

b) In the event that my medical condition may require emergency medical treatment , I wish to advise any and all medical personnel that if I stop breathing, I do not wish to be revived by any means. If my heart stops beating, I do not wish to be revived by any means. I do not not want to participate in any way with experimental medical techniques or pharmacological drugs that might temporarily prolong my breathing or heartbeat.

c) Provided for the disposition of his personnel property.

d) He wished to be buried in Flint, Michigan and not to be cremated.

<2> While the patient's 10/12/09 memorandum's subject line references "Advance Medical Directive/Living Will", the memorandum is not a durable power of attorney nor designates a patient advocate as provided by Michigan statute at Michigan Compiled Laws 770.5506. In essence, the 10/12/09 memorandum is the patient's last will and testament regarding the disposition of his assets, remains, and his living will regarding desired medical care. Under Michigan statute, a living will is not enforceable but may considered by a provider in ordering medical care for the patient.

<3> When admitted to Walter Reuther Psychiatric Hospital on 11/20/19, he was initially placed on a DNR status based on the provisions of his 10/12/09 "Advance Medical Directive/Living Will". On 11/25/09 the patient's DNR status was changed to full code status based on the Department's 7/22/93 Administrative Directive (#01-C-1116(1)/AD-08) that stated that under Michigan law a "durable power of attorney" completed while a patient was hospitalized was not valid as it was questionable that a person residing in a mental health facility could legally sign such a document as Michigan statute required that a person completing a durable power of attorney and designating a patient advocate must be of "sound mind". As previously noted, the patient's 10/12/09 memorandum was not a "durable power of attorney".

<4> Review of the patient's treatment plan dated 11/25/09 revealed that "Today the patient also expressed to change his DNR that was done while he was at the Forensic Center. The patient stated that he will consider CPR, but not artifical ventilation. The psychiatrist explained that as the patient is in a psychiatric hospital we need to maintain a full code in case the patient's medical status deteriorates." While the 11/25/09 treatment plan note references that the "patient will consider CPR", the note does not specify that the patient agreed to a full code procedure. There is no basis in Michigan law requiring that a patient residing in a psychiatric hospital MUST be maintained on a full code status. The Department's 7/22/93 Administrative Directive (#01-C-1116(1)/AD-08) does not provide any guidance regarding end of life care wishes of a patient when a patient has not completed a valid durable power of attorney and designated a patient advocate.

<5> Review of 3/25/10 Mortality Review Team-Review of Death report revealed:

a) In December 2009 the patient was admitted two times to Oakwood-Annapolis Hospital for pneumonia, thought secondary to obstruction from the tumor mass. CT scan showed large masses on the right lung and mediastinum involving the right upper lobe pulmonary artery; thickening of cecum and ascending colon, and mass in the bladder and prostrate.

b) After consultation from Oncologist, the patient accepted the diagnosis of lung cancer and requested treatment for the same. The patient was referred to VA Hospital Oncology in Detroit where patient was a registered veteran.

c) In January 2010, he developed dysphagia confirmed by modified barium swallow most likely from enlarged paratracheal modes from metastatic lung cancer. Modified texture diet was started. Nutritional supplements were also provided.

d) In February 2010 VA Hospital oncologist recommended re-staging evaluation of the patient prior to initiating (chemotherapy) therapy. The patient continued to complain of poor appetite, generalized malaise and weight loss despite nutritional supplementation.

e) On March 2, 2010, at 5:20 AM, the patient was found unresponsive by staff in his bed. Medical Emergency was called at that time and CPR initiated, following ACLS protocol. Pulse and blood pressure were absent and AED monitor showed Asystole. The patient was pronounced dead by the On-Duty Physician at 6:04 AM.

f) Case of death was Non-Small Carcinoma of the Right Lung with Metastasis, Stage III-B. No autopsy was performed.

Based on interview, record review, and observation, the facility failed to ensure that pharmacy medications were secured in the pharmacy resulting in the potential harm to 37 of 232 patients. Findings include:

During a tour of the Pharmacy on 4/13/10 at 1000 an open window into one of two pharmacy rooms. The window measured approximately 39 inches wide by 28 inches tall and was 40 inches from the floor. Medication, including a vial of Lorazepam, a controlled drug, was stored in this room. The Pharmacy Director stated that there was always a pharmacy staff member present in this room when the window was open.

On 4/13/10 at approximately 1400 the pharmacy window was observed to be open with nobody in the room. The Pharmacy Director was called and verified that the room was unattended with the window open.

On 4/15/10 at 1400 the pharmacy window was observed open with nobody present in the room. This finding was confirmed by employee #25.

On 4/15/10 at approximately 1410, the Administrative Secretary verified that 37 patients had the ability to walk by the pharmacy, either because they had grounds privileges with access to the floor or because they ate meals in a to dining room down the hall from the pharmacy.

Facility policy #324 states that "The pharmacy is only accessible to Pharmacy staff."

Based on observation and interview, the facility failed to keep outdated drugs unavailable for use. Findings include:

During inspection of the Pharmacy, on 4/12/10 at approximately 10:00, it was noted that a container of Cortef 10 mg with multiple tablets had expired on 11/09. Interview with the Pharmacy Director at that time verified that the medication should have been taken off the pharmacy shelf to make unavailable use.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on April 12-14, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated April 14, 2010, for Life Safety Code.