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Based on record review, policy review, observation and interview, it was determined the facility failed to protect and promote the rights of patients as evidenced by:
- failure to provide patients with notice of rights (A-0116)
- failure to establish a process for prompt resolution of patient grievances (A-0118)
- the governing body's failure to approve and be responsible for an effective grievance process (A-0119)
- failure to provide patients with written notice of grievance decisions (A-0123)
- failure to investigate and report allegations of staff abuse (A-0145)

Based on interview and record review the facility failed to provide 1 of 1 patients (patient #3) with a personal letter containing information on complaint rights from the Centers for Medicare & Medicaid, in response to a complaint MI00047667. Findings include:

The Michigan Department of Community Health booklet, "Your Rights When Receiving Mental Health Services in Michigan," provided to patients at admission, states:
"You have the right to receive and send mail without anyone else opening or reading it."

On 10/31/11 at 1220 hours the Director of Performance Improvement and Risk Management (DPI/RM) was asked to explain why the original copy of a letter addressed to patient #3, dated 10/5/11, was mixed in with facility Incident Reports provided for review. The DPI/RM stated that the letter arrived after patient #3's discharge and that the patient may have had no forwarding address. The DPI/RM was unable to provided documentation of any attempt to forward the letter to patient #3. Review of patient #3's clinical record revealed that the facility had an address for patient #3 at the time of discharge. These finding were confirmed by the DPI/RM.

Based on observation, interview, record and policy review the facility failed to establish a process for prompt resolution of patient grievances. Findings include:

Policy Review:

1. On 10/31/11 at 0930 hours the booklet entitled "Your Rights When Receiving Mental Health Services in Michigan" was noted to be on display in wall holders in the lobby. Section VI describes the Complaint and Appeals Process for recipients of mental health services. It directs recipients who believe that any right listed in the booklet has been violated to call the Rights Office or complete a recipient rights complaint form and return it to the office.
2. None of the information provided in the New Patient Intake Packet explained the use of a Grievance form.
3. The facility 's "Complaint and Appeal Process, " Policy RR-1-001/ADM-1-009 contains no instructions for handing patient complaints that are written on a Patient Grievance Form.


Observations:

1. On 10/31/11 from approximately 0950-1045 hours observations were made on all units of the facility. A form titled Recipient Rights Complaint Form was observe red on units along side another form, titled " Patient Grievance Form. "There was no posting explaining when one form or another should be used. On the "Patient Grievance Form", it states: " Please use this form for complaints that your unit staff may help you with. Once you have completed this form, please give it to a supervisor or manager. "
2. On 10/31/11 from 0950-1045 hours these observations were witnessed by the Director of Nursing.

Interviews:

1. On 10/31/11 at approximately 1500 hours the faculty ' s Recipient Rights Advisor (RRA) was asked if she had copies of any patient Grievance forms submitted by patients. The RRA stated that she had received some of these forms, from Unit Managers or in the Recipient Rights Complaint box but had not retained copies of any of the forms or responded in writing to any of these written grievances.
2. On 11/1/11 at approximately 0900 Adult Unit Manager (Unit Manager #1) was asked whether she had received any completed grievance complaint forms. The Unit Manager stated that she had but had not retained copies of any of the forms and had passes some along to the RRA.
3. On 11/1/11 at approximately 0900 the DON was unable to locate a staff member or location with knowledge of any patient grievance forms being retained on either unit.
4. On 11/1/11 at approximately 0910 the Unit Manager on the Child/Adolescent Unit (Unit Manager #2) was asked whether she had received completed grievance forms from patients. The Unit Manager stated that she had but had not retained any of the forms or responded to patients in writing. Unit Manager #2 stated that most of the forms contained requests to change Psychiatrists. She stated that she did not pass these forms along to the Recipient Rights Advisor.
5. The above interviews were witness by the Director of Nursing and Director of Performance Improvement and Risk Management.

Based on interview, policy review and review of governing body minutes, the facility's governing body failed to approve and be responsible for an effective grievance process. Findings include:

On 11/1/11 at approximately 1100 hour the Director of Performance Improvement/Risk Management was asked to provide documentation of the governing body's review of patient grievances or delegation of this duty to a grievance committee. Board Meeting Minutes dated 4/19/11 contained general information regarding whether the number of complaints was up or down but no specifics on responses to individual grievances. The Director of PI/RM was unable to provide this documentation prior to survey exit on 11/1/11 at approximately 1700 hours.

Based on record review and interview, the facility failed to inform 2 complainants (for patients #9 and #2) who filed grievances with written responses of its decision. Findings include:

1. Patient #9 filed a written complaint dated 6/23/11, requesting a change in physician and complaining about the physician's behavior. On 6/28/11, the RRA provided a written response to patient #9 but did not address her request for a change in physician..

2. On 11/1/11 at approximately 1530 hours documentation of a verbal complaint made by patient #2's parent on 1/20/11 was discussed with the Director of PI/RM. Patient #2 was a minor and the complainant (a parent) alleged that another child had been touching her daughter inappropriately. A Physician's note, documenting a meeting with patient #2 and "parent," dated 1/20/11, noted "allegations of peer being inappropriate towards her." There was no documentation of any investigation or written response to the complainant. These findings were confirmed by the Director of PI/RM.

Based on record review and interviews, the facility failed to investigate and respond in a timely manner to 1 of 1 (patient #4) physical abuse allegations. Findings include:

Policy Review:

"Identifying and Reporting Abuse and Neglect," RR-1-006, III. Reporting Procedures:

"All complaints involving abuse or neglect shall be forwarded to the hospital Recipient Rights Advisor for investigation."
A. Employee:
1. Upon witnessing or being informed of the abuse or neglect of a recipient in the hospital, must immediately report the incident to their supervisor and the Recipient Rights Advisor.
2. Documents all information concerning the incident on a Risk Identification Report form.
3. Completes a Recipient Rights Complaint form, or assists a recipient or complainant ....in filling out a complaint form.


Patient record review and interviews:

I. On 10/31/11, record review revealed a note by Social Worker #1, dated 10/17/11, stating that patient #4 reported to her that MHA #1 "socked me in the face" 6 days ago. On 11/1/11 at approximately 1420, Social Worker #1 confirmed this and noted that she provided the note to her supervisor, the Director of Social Work, on 10/18/11.
2. On 10/31/11 from 1130-1500 hours documentation of patient #4's complaint was reviewed with the Recipient Rights Advisor (RRA). The RRA stated that she was first informed of the allegation of staff abuse by patient #4 on 10/24/11 and that an investigation into the complaint had not been initiated until that date, in response to a complaint from a community agency.
3. On 11/1/11 at approximately 1430 Nurse #1, who was present on the night of the alleged abuse, stated that he recalled the patient's abuse allegation and noted some swelling of patient #4's right cheek following the alleged incident but did not document it.
4. In an undated note, Nurse #2 acknowledges receiving a complaint from patient #4's mother, stating that the patient was punched.
5. On 11/1/11 at approximately 1500 hours the Director of Performance Improvement/Risk Management verified that neither an Incident or Risk Identification report form nor a Recipient Rights Complaint form was completed by facility staff.