HospitalInspections.org

Based on observation, interview and record review the facility failed to establish a process for prompt resolution of patient grievances and to provide 2 of 4 current patients (#7 and #2) with prompt resolution of written grievances, resulting in increased risk of all patients being denied grievance rights. Findings include:

Observations:
On 10/20/14 from 0945-1350 all five units were toured. All units were locked units. Each unit had one complaint box and one version of a complaint form; for filing complaints with the State Office of Recipient Rights (ORR). These observations were confirmed by staff C and staff D.

Interviews:
1. On 10/20/14 at approximately 1350 Nurse K was asked how patient's can file written complaints. Nurse K stated that patients can put complaints in the Recipient Rights complaint box. Nurse K stated that Recipient Rights complaint forms are available on the unit.
2. On 10/20/14 at 1400 staff G stated that the only complaint form and box (for complaint form submission) is for filing complaints regarding possible violations of State (Michigan Mental Health Code) rights. Staff G stated that she has responsibility for removing patient complaints from unit complaint boxes and reviewing them for compliance with patient rights under the Michigan Mental Health Code. Staff G was asked how written complaints are reviewed to determine whether a complaint should be treated as a Centers for Medicare and Medicaid Service (CMS) grievance. Staff G stated that staff I reviews complaints for compliance CMS requirements.
3. On 10/20/14 at 1410 staff I stated that only complaints that are not being investigated for State regulatory compliance are reviewed for compliance with Federal (CMS) requirements.

Record Review:
1. On 10/20/14 at approximately 1415 patient #7's written complaint was reviewed with staff G.

Patient #7 filed two written complaints, dated 6/8/14 and 6/10/14. Both complaints were stamped as received by the Office of Recipient Rights (ORR) on 6/13/14. Both complaints state that the patient is only getting about 3 hours of sleep at night due to noisy roommates. The complainant states that lack of sleep triggers the patient's manic episodes and that staff have not responded to requests for a room change and medication for sleep. On 6/27/14, two weeks after receipt of these complaints, staff G documented meeting with patient #7 to follow-up on the complaints. Patient #7 stated that the roommates were still noisy and that staff had not been helpful; telling the patient "she had to live with it." On 7/9/14 staff G wrote a letter to patient #7. The letter states: '"ORR notified your treatment team of your concerns and request to have your room assignment changed." The letter concludes; "there was no violation of the right to receive services in a safe, sanitary and humane treatment environment."

On 7/10/14 staff G wrote a memo to members of patient #7's Treatment Team, requesting that the team address the patient's concerns. On 7/11/14 staff J responded with a list of things that patient #7 has been told to do to address insomnia and reasons for not addressing the complaint. The response letter makes no mention of an attempt to investigate whether the patient's room is noisy at night, whether the patient sleeps at night or any interventions on the patient's behalf. Staff G confirmed these finding during record review.

2. On 10/20/14 at approximately 1430 patient #2's written complaint was reviewed with staff G.

Patient #2's complaint was stamped as received on 7/23/14. The complaint states that the patient wants to see a dentist, is having a problem with her eyes and that other patients are taking her things. On 8/4/14, 12 days later, staff G met the patient to follow-up on the complaint. Staff G documented asking patient #2 if she had pain and the patient responding, "I can feel it." On 8/20/14, over 2 weeks after meeting with the patient, staff G sent an e-mail to the patient's Treatment Team listing the patient's 7/23/14 complaints. On 8/21/14, almost one month after receipt of the written complaint, patient #2 met with the Treatment Team to discuss the complaint issues.

On 9/3/14 patient #2 was seen for a dental consultation. The dentist found recurrent decay in a tooth and recommended that the patient return for a filling. That had not occurred yet.

Interview:
On 10/20/14 at approximately 1430 staff G was asked why there were delays in responding to patient #2's complaints. Staff G was unable to provide further information.

Based on observation and interview the hospital failed to establish a clearly explained procedure for submission of patient's written and verbal grievances to the hospital, resulting in increased risk of all patients being denied their grievance rights. Findings include:

Observations:
On 10/20/14 from 0945-1350 all five units were toured. All units were locked units. Each unit had one complaint box and one version of a complaint form; for filing complaints with the State Office of Recipient Rights. These observations were confirmed by staff C and staff D.

Interviews:
1. On 10/20/14 at approximately 1350 Nurse K was asked how patient's can file written complaints. Nurse K stated that patients can put complaints in the Recipient Rights complaint box. Nurse K stated that Recipient Rights complaint forms are available on the unit.
2. On 10/20/14 at 1400 staff G stated that the only complaint form and box (for complaint form submission) is for filing complaints regarding possible violations of State (Michigan Mental Health Code) rights. Staff G stated that she has responsibility for removing patient complaints from unit complaint boxes and reviewing them for compliance with patient rights under the Michigan Mental Health Code. Staff G was asked how written complaints are reviewed to determine whether a complaint should be treated as a CMS grievance. Staff G stated that staff I reviews complaints for compliance to CMS requirements.
3. On 10/20/14 at 1410 staff I stated that only complaints that are not being investigated for State regulatory compliance are reviewed for compliance with Federal (CMS) requirements.

Based on interview and record review 2 of 4 current patients with abuse allegations (#5 and #6) did not receive timely, through investigations, resulting in increased risk of abuse for all patients. Findings include:

Policy Review:
Conducted on 10/21/14 at 1700.
Abuse and Neglect, 8/29/14, states:
"All allegations of patient abuse and neglect shall be investigated per Centers for Medicare and Medicaid Conditions of Participation, the Michigan Mental Health Code..."
Complaint Investigation, Reports and Remediation, dated 8/11/08, states:
"ORR (Office of Recipient Rights) shall initiate investigation of apparent or suspected rights violations in a timely and efficient manner. Investigation shall be initiated immediately in cases involving alleged abuse, neglect..."

Record Review & Interview:
1. On 10/21/14 at 0910 patient #5's complaint of being sexually harassed by other patients and feeling unsafe was reviewed with staff H. The complaint was dated 4/19/14 and stamped as received by the Office of Recipient Rights on 5/13/14. A 6/10/14 letter from staff H to patient #5 states that the patient's complaint was not classified as an abuse allegation. The letter states that the facility's action was to meet with the Treatment Teams of the patients who were allegedly harassing the patient. There was no documentation of an interview with the patient to clarify the sexual harassment allegations or ask whether the harassment had stopped. Staff #5 confirmed these findings during record review.
2. On 10/21/14 at 0915 an Incident Report stating that patient #6 complained that staff were hitting the patient was reviewed with staff H. Staff H confirmed that the the abuse allegation was not listed on the Office of Recipient Rights' log of patient complaints. Staff H was unable to find any documentation of the allegation being investigated.
3. On 10/21/14 at approximately 1130 staff H provided a brief note (by staff H) documenting an interview with patient #6, dated 10/7/14. The note states that patient #6 alleged that staff hit and spit at her. The note does not state whether the patient was asked to specify when and where the alleged abuse occurred or whether there were any witnesses. No other investigative review documents were provided.
4. The findings In #2 and #3 were confirmed by staff H during record reviews at the times listed above.