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Based on medical record review, interview, and document review, the hospital failed to ensure that the medical records maintained by the hospital permitted determination of the degree and intensity of the treatment provided to individuals who were furnished services in the hospital as evidenced by: failure to ensure that psychiatric admission evaluations included a medical history (B-0112), failure to ensure that psychiatric admission evaluations established the patient's memory functioning and/or orientation (B-0116), failed to ensure that written treatment plans included specific treatment modalities utilized (B-0122), failed to ensure that written treatment plans included the responsibilities of each member of the treatment team (B-0123), failed to ensure that treatment received by patients were documented in such a way to assure that all active therapeutic effects were included (B-0125), and failed to ensure that progress notes were recorded by the patient's physician responsible for the care of the patient (B-0126).

Based on medical record review and interview, the hospital failed to ensure that completed psychiatric evaluations in 10 of 10 active sampled patients (Patient #1, #2, #3, #4, #5, #6, #12, #13, #14, and #15) included a medical history. Failure to perform and document a patient's medical history compromises the identification of pathology that may contribute to the current mental illness, or of co-occurring illness requiring attention during hospitalization. Findings include:

(1) Medical record review conducted on 10/25/2010 and 10/26/2010 revealed that:

(a) The psychiatric evaluation of patient #1 completed on 7/29/10 did not document the patient's medical history. The patient was admitted to the hospital on 7/29/10.

(b) The psychiatric evaluation of patient #2 completed on 4/13/10 did not document the patient's medical history. The patient was admitted to the hospital on 4/13/10.

(c) The psychiatric evaluation of patient #3 completed on 10/16/2010 did not document the patient's medical history. The patient was admitted to the hospital on 10/15/2010.

(d) The psychiatric evaluation of patient #4 completed on 10/10/2009 did not document the patient's medical history. The patient was admitted to the hospital on 10/09/2009.

(e) The psychiatric evaluation of patient #5 completed on 7/26/2010 did not document the patient's medical history. The patient was admitted to the hospital on 7/26/2010.

(f) The psychiatric evaluation of patient #6 completed on 05/13/2010 did not document the patient's medical history. The patient was admitted to the hospital on 05/13/2010.

(g) The psychiatric evaluation of patient #12 completed on 10/08/2010 did not document the patient's medical history. The patient was admitted to the hospital on 10/08/2010.

(h) The psychiatric evaluation of patient #13 completed on 07/15/2010 did not document the patient's medical history. The patient was admitted to the hospital on 7/15/2010.

(i) The psychiatric evaluation of patient #14 completed on 4/19/2010 did not document the patient's medical history. The patient was admitted to the hospital on 4/19/2010.

(j) The psychiatric evaluation of patient #15 completed on 05/15/2010 did not document the patient's medical history. The patient was admitted to the hospital on 5/14/2010.

(2) The acting Medical Director, interviewed on 10/26/2010 at 1400 hours, reviewed the above 10 psychiatric evaluations with the physician surveyor. The acting Medical Director acknowledged that the reviewed psychiatric evaluations did not document the patient's medical history.

Based on medical record review and interview, the hospital failed to ensure that completed psychiatric evaluations included an evaluation of the orientation of the patient in 2 out of 10 sampled patients (Patient #4, and #12), and failed to include supportive information for the psychiatrist's conclusions regarding memory functioning in 7 out of 10 active sampled patients (Patient #1, #2, #3, #5, #12, #13, and #14). These failures to document specific testing compromise the identification of pathology which may be pertinent to the current mental illness and compromises future comparative re-examination to assess patient's response to treatment interventions. Findings include:

(1) Medical review conducted on 10/25/2010 and 10/26/2010 revealed that in the following 2 cases the completed psychiatric evaluation did not include adequate documentation of the patient's orientation:

(a) The psychiatric evaluation of patient #4 completed on 10/10/2009 only stated "Oriented times: x. " There was no supportive information documented. The patient was admitted to the hospital on 10/09/09.

(b) The psychiatric evaluation of patient #12 completed on 10/08/2010 did not document the patient's orientation. The patient was admitted to the hospital on 10/08/2010.

(2) Medical record review conducted on 10/25/10 and 10/26/10 revealed that in the following 7 cases completed psychiatric evaluations did not include adequate documentation of the patient's memory functioning:

(a) The psychiatric evaluation of patient #1 completed on 7/29/2010 stated "Adequate for immediate, recent, remote events." There was no supportive information documented. The patient was admitted to the hospital on 07/29/2010.

(b) The psychiatric evaluation of patient #2 completed on 4/13/2010, regarding memory stated only "89067" [sic] without any supportive information. The patient was admitted to the hospital on 4/13/2010.

(c) The psychiatric evaluation of patient #3 completed on 10/16/2010 stated, "Patient was able to remember data from the past," without any supportive information. The patient was admitted to the hospital on 10/15/2010.

(d) The psychiatric evaluation of patient #5 completed on 7/26/2010 stated, "Patient had difficulty remembering data from the past," without any supportive information. The patient was admitted to the hospital on 7/26/2010.

(e) The psychiatric evaluation of patient #12 completed on 10/08/2010 stated, "Unable to repeat five digits backward." No information regarding other areas of memory functioning was documented. The patient was admitted to the hospital on 10/08/2010.

(f) The psychiatric evaluation of patient #13 completed on 7/15/2010 stated "Memory intact for six digits" without any supportive information. The patient was admitted to the hospital on 7/15/2010.

(g) The psychiatric evaluation of patient #14 completed on 4/19/2010 stated "Patient able to remember dates from the past" without any supportive information. The patient was admitted to the hospital on 4/19/2010

(3) The acting Medical Director, interviewed on 10/26/2010 at 1400 hours, reviewed the above 7 psychiatric evaluations with the physician surveyor. The acting Medical Director acknowledged that the psychiatric evaluations either did not document supportive information justifying the psychiatrist's conclusions regarding memory functioning and orientation, or were missing essential elements of the psychiatric evaluation such as an orientation.

Based on medical record review, in 5 of 10 sampled active patients (Patient #1, #3, #4, #5, and #15, ) the hospital failed to ensure that patients' written plan of service include the specific utilized treatment modalities. Findings include:

(1) The 10/25/2010 review of patient #4's Individual Plan of Service (IPOS) revealed that the patient's IPOS did not state the specific treatment modalities that were to be utilized to enable the patient to attain both the stated long term and short term goals.

Under Long Term Goal #1, the patient's IPOS stated: "He will become competent to stand trial by 12/09/2010." Short Term Objectives stated: 1) "He will attend Incompetent to Stand Trial class as scheduled for two months and be able to state his charge accurately by 11/09/2010." b) "He will join at least two social groups per week for one month by 11/09/2010." c) "He will continue to work a job as scheduled for two months by 11/09/2010." d) "He will demonstrate appropriate boundaries in his interactions with others during activities 40 minutes weekly by 11/09/2010."

The patient's IPOS also did not address any medical issues for this patient. Record review revealed that the patient did not have any chronic medical conditions requiring treatment but he did receive medication for ADHD which puts him at risk for an adverse drug reaction.
During the 10/25/2010 review of the patient's medical record, the above findings were confirmed with staff E.




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(2) The 10/26/10 review of patient #1's Individual Plan of Service (IPOS) conducted at approximately 0850 hours revealed that the patient's IPOS did not include the specific treatment modalities that were to be promulgated to enable the patient to attain stated short term goals.

For short term objective a), to "communicate an understanding of the impact of Not Guilty by Reason of Insanity (NGRI) status within the hospital and community setting; complete a Letter of Responsible for the NGRI committee and complete contract drafts by 12/05/10" no modalities to achieve these goals were specified.

For short term objective b), to "develop a relapse prevention plan, identifying warning signs/symptoms, and how he will respond..." no interdisciplinary team member specified any activities to achieve these goals.

The 10/26/10 review of patient #2's IPOS conducted at approximately 0900 hours revealed that the patient's IPOS did not include the specific treatment modalities to be utilized to enable the patient to attain stated short term goals. For short term objective a), to "maintain 15-20 minutes of reality-based interactions per therapy contract by 10/18/10, there was no information on the modalities being used to achieve that goal nor how progress is monitored.

On 10/27/2010 at 1100 hours, the above findings were reviewed with the Acting Director of Nursing, Medical Director and Hospital Director.




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(3) The 10/25/2010 review of patient #15 Individual Plan of Service (IPOS) revealed that the IPOS stated that problem #3 was that the patient had medical problems that included hypertension, diabetes, gastroesophageal reflux disease, cardiomyopathy, and mitral regurgitation. Short term objectives for these medical problems was "he will cooperate with all ordered tests, exams, meds, and treatment for medical conditions daily." The patient's IPOS did not identify the specific treatment interventions and modalities that were to be used to treat the patient's hypertension, diabetes, gastroesophageal reflux disease, cardiomyopathy, and mitral regurgitation.





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(4) The 10/26/2010 review of the patient #5 Individual Plan of Service failed to address whether the patient required translator services during therapy sessions.

Medical record review conducted on 10/26/2010 and 10/27/2010 revealed that that patient #5, a 47 year old Cuban male educated as a physician in Cuba, was admitted to Kalamazoo Psychiatric Hospital (KPH) on 7/26/2010. The patient was admitted to KPH from the Center of Forensic Psychiatry (CFP) where he had been evaluated for competency to stand trial for a misdemeanor charge of domestic assault and interfering with a police officer. The evaluations conducted at the CFP determined that the patient was incompetent to stand trial.

The forensic evaluation report dated 9/17/2010 completed by CFP Consulting Forensic Examiner (staff AA) and sent to the District Court Judge (staff AB) at the Ingham County District Court stated that the CFP forensic evaluation of the patient was conducted with the participation of a Spanish interpreter. The report notes that the Spanish interpreter translated into Spanish the forensic examiner's questions and translated back into English the patient's responses.

The KPH nursing assessment completed on 7/26/2010 notes that "language" is a patient weakness.

On 10/26/2010 the charge nurse (staff V) for the Holder nursing unit where patient #5 resided was interviewed regarding patient's condition. The nurse stated that the patient is able to speak in "broken English". The nurse acknowledged that translation services are not used in communicating with the patient.

The patient's Admission Psychological Assessment dated 8/5/2010 was reviewed on 10/26/2010. Review revealed that the summary of the patient's cognitive functioning stated that "...the language barrier makes assessment difficult." The psychological report also states that "At the time of his admission, it is thought that he only speaks Spanish....He is not willing to cooperate with an interview at the time he was approached. Staff had indicated that his English was very poor."

The psychologist (staff AC) who completed the Admission Psychological Assessment dated 8/5/2010 was interviewed on 10/26/2010 at 1700 hours. The psychologist acknowledged that his Admission Psychological Assessment report was based on review of clinical information received from the CFP and assessments completed at KPH and that he did not complete a formal assessment of the patient's ability to understand English.

On 10/26/2010 at 0905 hours to 0940 hours the patient was observed in a Psycho Social Rehabilitation (PSR) group. The patient did not respond to questions. The patient did not appear to understand the questions. On 10/27/2010 from 0845 hours to 0910 hours the patient was again observed in a PSR group. Patient did not engaged in the group.

The patient was interviewed on the Holder unit on 10/26/2010 at 1430 hours. The patient did not respond to the surveyor's questions and did not appear to understand the questions posed by the surveyor.

The patient was again interviewed on the Holder unit on 10/26/2010 at 1800 hours with the assistance of KPH staff person U who is a native Spanish speaker. The patient communicated easily in Spanish with the staff person U. The patient's affect noticeably brightened when staff person U began speaking to the patient in Spanish. The patient was able to describe the events that lead to his domestic assault charges and his encounter with the police when they came to arrest him. The patient stated that he does not have a person or staff to speak with him in Spanish on a regular or even daily basis. The patient stated that he fills out paper work for court every three months but does not understand the concept of "competency". The patient told staff person U that he is done with charges regarding his assault and is awaiting discharge from the hospital. Review of the patient's IPOS reveals that long term goal #1 is for the patient's mental illness to remit allowing a recommendation of competency by 2/2011 which would allow the patient to stand trial for the pending charges.

The 10/26/2010 review of the patient's Individual Plan of Service (i.e. treatment plan) reveals that no mention is made of the patient's English proficiency or need for a Spanish interpreter in therapy groups and PSR groups.

Based on medical record review and interview, the hospital failed to ensure that a patient's written plan of care included the responsibilities of each member of the treatment team in 5 of 10 sampled patients (Patient #1, #2, #3, #5, and #15). Findings include:

(1) The 10/26/10 review of patient #1 and #2 Individual Plans of Service (IPOS) conducted at 0900 hours with the Edwards Unit Nurse Manager (staff O) revealed that neither patients' IPOS stated who was responsible for monitoring the patient's progress toward attaining long-term goals. Short-term objectives did not specify staff responsibilities for assisting the patient in achieving goals or monitoring progress.


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(2) The 10/25/2010 review of the individual plan of service (IPOS) for patient #3 conducted at 1600 hours revealed that IPOS did not state who was responsible for 2 of the 4 short term objectives documented and did not state who was responsible for determining if the patient had reached the one long term goal. These findings were discussed and confirmed by staff E during review of patient #3's IPOS.


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(3) The 10/25/2010 review of patient #15 Individual Plan of Service (IPOS) revealed that the IPOS stated that problem #3 was that the patient had medical problems that included hypertension, diabetes, gastroesophageal reflux disease, cardiomyopathy, and mitral regurgitation. Short term objectives for these medical problems was "he will cooperate with all ordered tests, exams, meds, and treatment for medical conditions daily." The patient's IPOS did not specify which physician was going to treat the identified medical problems and monitor the patient's response to ordered medications and treatment.




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(4) The 10/26/2010 review of the individual plan of service (IPOS) for patient #5 revealed that the IPOS did not state who was responsible for determining if the patient had achieved his 2 long term goals and 4 short term objectives.

Based on observation, interview, record review, and policy review the facility failed to assure active treatment for 10 of 19 patients (#3, #5, #6, #16, #17, #18, #19, #20, #21 and #23). Findings include:

(1) The hospital failed to ensure that provisions were made for patient's to participate in Psycho Social Rehabilitation groups who could not leave their nursing unit in 6 of 10 sampled active patients (Patient #3, #18, #19, #20, #21, and #23).

During observations from 10/25/2010 through 10/26/2010 of patient #3, #18 and #23 residing on the MH Roll unit it was observed that during the scheduled time for Psycho Social Rehabilitation (PSR) class the three patients were all restricted to the unit. The observations of all 3 patients were conducted during both the morning and afternoon scheduled class times. There were also several other patients who chose not to attend class and remained back on the unit.

During the first observation on 10/25/2010 at 0900 hours, patient #3 was observed to be sitting at a table working on a puzzle with his assigned 1:1 staff sitting with him. During the observation, there was no active treatment being provided for the patient. At 1315 hours during the afternoon PSR class, the patient was observed sitting at a table with his assigned 1:1 staff and another staff and two peers. The television was on in the area and the patient had a picture in front of him that could be colored but he was not doing that. He sat quiet most of the time and would occasionally say something to the 1:1 staff. No active treatment was noted to be going on.

During these same times as above patients #18 and #23 were also observed in the dayroom during PSR class, both patient #18 and #23 sat quietly in chairs. There was no active treatment going on for either client. Review of 4 schedules for attendance of PSR class reveal that patient #18 remained on the unit with no documentation of active treatment being carried out during these times. The patient also refused to go to PSR class on 6 other occasions that documentation was provided for. Again there is no documentation in the patient's record of an alternative active treatment class being provided for this patient during these times.

Patient #23 remained on the unit 10 of 10 times that documentation was provided for. During observation by this surveyor and review of documentation provided revealed no evidence of active treatment being provided for this patient.


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On 10/27/2010 from 0900-1030 hours, patients #19, #20, and #21 were observed on the Schrier Unit.

At 0900 hours patient #19 was observed asking a Resident Care Aide (RCA) (staff Z) if he could attend a PSR (Psycho-Social Rehabilitation) class. The RCA denied the patient's request. At 0905 hours the Nurse Manager (staff S) stated that the patient was not able to attend PSR groups because the interdisciplinary team member responsible for the patient's PSR referral (staff T) had not completed the referral. Documentation dated 10/22/10 indicated that the patient was appropriate for referral and would be encouraged to attend PSR classes. A facility-wide list of class schedules revealed that there were no classes scheduled for this patient. Staff S stated that there was no activity option available to patient #19 on the unit at that time except for television or video games.

Further review of patient #19's record revealed an Interdisciplinary Treatment Note by staff T, a Psychologist, dated 10/22/2010, stating: (Patient) "Has not begun attending groups at PSR. He will be signed up for groups early next week, as PSR facilitator is away from the office, not to return for another week or so." These findings were confirmed by the Nurse Manager (staff S) at 1000 hours.

From 0900 to 1030 hours, patient #20 was observed in the dayroom watching a violent scene on the television. The Nurse Manager (staff S) was asked what programming this patient had scheduled. The Nurse Manager stated that she was unaware of the scheduled programming for this patient. Record review revealed that patient #20 was scheduled for PSR class at that time. Review of 11 PSR attendance records revealed that the patient had missed 11 of 11 classes in October 2010. The Nurse Manager stated that the patient did not attend PSR classes on 10/26/10. The PSR Attendance Record and nursing Progress Notes for 10/26/10 provided no explanation as to why the patient did not attend.

From 0900 to 1030 hours, patient #21 was observed in the dayroom watching a violent scene on the television. The Nurse Manager (staff S) was asked what programming this patient had scheduled. The Nurse Manager was unable to produce any documentation regarding the program schedule for this patient. Record review revealed that this patient was scheduled for PSR class at that time. Review of 11 PSR attendance records revealed that the patient had missed 8 of 11 classes in October 2010.


(2) The hospital failed to ensure that a restrained patient was released from restraints at the earliest possible opportunity in 3 of 4 sampled patients (#16, #17, #18). Failure to release patients from restraint at the earliest possible opportunity jeopardizes patients' rights to receive treatment in the least restrictive manner possible, including the right to be free from restraint except to prevent immediate harm to self or others.

The review of the medical records for 3 of 4 patients (#16, #17, #18) revealed documentation that patients were maintained in restraints even though they were calm. During record review on 10/26/2010, patient #16 's Seclusion/Restraint Progress Note, written by the RN, revealed that restraints were applied on 10/22/2010 at 1915 hours. Seclusion/Restraint Notes written by the resident care aides (RCAs) on 10/22/2010 from 1915-2145 hours, revealed no documentation of aggressive behavior. Documentation by the RN at 2015 hours revealed that patient #16 remained in restraints but did not document any aggressive behavior. At 2145 hours documentation by the RN revealed no statements regarding the patient's behavior. RN documentation at 2145 hours revealed only that restraints were discontinued, no documentation regarding the patient's behavior or response to the intervention.


On 10/26/2010 from 0800-1700 hours, review of patient #17 's medical record revealed that the patient was placed into 4 point restraints on 10/19/2010 at 1930 hours due to aggression. Seclusion/Restraint Notes by the RN and RCA staff revealed no episodes of aggressive behavior from 1930-2055 hours, when he was released from the restraints.

The 10/26/2010 review of patient #17's medical record revealed that the patient was placed into 4 point restraints on 08/02/2010 at 1330 due to aggressive behavior. Seclusion/Restraint documentation by the Nurse and RCA staff revealed no observations of aggressive behavior form 1455 until his release at 1600. The only documented behavioral observation by staff was that the patient was lying in bed rocking his head back and forth.

On 10/26/2010 at approximately 1400 hours, the above findings were confirmed by the Director of Nursing designee, employee B. The facility 's policy titled "Seclusion and Restraint,"dated 10/14/09, page 4, section S, states: "A consumer in seclusion or restraint shall be released from seclusion or restraint when the circumstances that justified its use cease to exist."


(3) The hospital failed to ensure that restraint devices were applied only pursuant to a physician's order for 2 of 5 patients that were restrained (#6, #16).

The 10/26/2010 review of patient #16's medical record revealed that he was put into 4 point restraints 08/12/2010 at 1445 hours due to aggressive behavior. A nursing Progress Note stated: "Both RN Managers came out of report and found staff members put consumer in 4 point restraints."

These findings were confirmed by the Acting Director of Nursing during an interview on 10/26/2010 at 1615 hours, following review of the Seclusion/Restraint Progress Notes regarding this incident. According to the facility's "Seclusion and Restraint" policy, dated 10/14/09, page 4, section O: "A consumer may be temporarily secluded or restrained after a face to face assessment by an RN."





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(4) The hospital failed to ensure that a patient who was not proficient in the English language was provided translator services in 1 of 1 applicable sampled patients (Patient #1).

Medical record review conducted on 10/26/2010 and 10/27/2010
revealed that patient #5, a 47 year old Cuban male educated as a physician in Cuba, was admitted to Kalamazoo Psychiatric Hospital (KPH) on 7/26/2010. The patient was admitted to KPH from the Center of Forensic Psychiatry (CFP) where he had been evaluated for competency to stand trail for a misdemeanor charge of domestic assault and interfering with a police officer. The evaluations conducted at the CFP determined that the patient was incompetent to stand trail.

The forensic evaluation report dated 9/17/2010 completed by CFP Consulting Forensic Examiner (staff AA) and sent to the District Court Judge (staff AB) at the Ingham County District Court stated that the CFP forensic evaluation of the patient was conducted with the participation of a Spanish interpreter. The report notes that the Spanish interpreter translated into Spanish the forensic examiner's questions and translated back into English the patient's responses.

The 10/26/2010 review of the patient's treatment plan reveals that no mention is made of the patient's English proficiency or need for a Spanish interpreter. The nursing assessment completed on 7/26/2010 notes that "language" is a patient weakness. On 10/26/2010 at 0905 hours to 0940 hours the patient was observed in a Psycho Social Rehabilitation group. The patient did not respond to questions. The patient did not appear to understand the questions. On 10/27/2010 from 0845 hours to 0910 hours the patient was again observed in a PSR group. Patient did not engaged in the group.

On 10/26/2010 the charge nurse (staff V) for the Holder nursing unit where patient #5 resided was interviewed regarding patient's condition. The nurse stated that the patient is able to speak in "broken English". The nurse acknowledged that translation services are not used in communicating with the patient.

The patient was interviewed on the Holder unit on 10/26/2010 at 1430 hours. The patient did not respond to the surveyor's questions and did not appear to understand the questions posed by the surveyor.

The patient was again interviewed on the Holder unit on 10/26/2010 at 1800 hours with the assistance of KPH staff person U who is a native Spanish speaker. The patient communicated easily in Spanish with the staff person U. The patient's affect noticeably brightened when staff person U began speaking to the patient in Spanish. The patient was able to describe the events that lead to his domestic assault charges and his encounter with the police when they came to arrest him. The patient stated that he does not have a person or staff to speak with him in Spanish on a regular or even daily basis. The patient stated that he fills out paper work for court every three months but does not understand the concept of "competency". The patient told staff person U that he is done with charges regarding his assault and is awaiting discharge from the hospital. Review of the patient's IPOS reveals that long term goal #1 is for the patient's mental illness to remit allowing a recommendation of competency by 2/2011 which would allow the patient to stand trial for the pending charges.

The patient's Admission Psychological Assessment dated 8/5/2010 was reviewed on 10/26/2010. Review revealed that the summary of the patient's cognitive functioning stated that "...the language barrier makes assessment difficult." The psychological report also states that "At the time of his admission, it is thought that he only speaks Spanish....He is not willing to cooperate with an interview at the time he was approached. Staff had indicated that his English was very poor."

The psychologist (staff AC) who completed the Admission Psychological Assessment dated 8/5/2010 was interviewed on 10/26/2010 at 1700 hours. The psychologist acknowledged that his Admission Psychological Assessment report was based on review of clinical information received from the CFP and assessments completed at KPH and that he did not complete a formal assessment of the patient's ability to understand English.

Based on medical record review, the hospital failed to ensure that physician progress notes were recorded by the doctor of medicine or osteopathy responsible for the care of the patient in 1 of 10 active sampled patients (Patient #6). Findings include:

10/26/2010 review of patient #6 medical record revealed that:
(1) The patient, a 21 year old female admitted to the hospital on 5/13/2010, had an extensive history of ingestion of foreign objects.
On 6/6/2010 the patient reported to unit nursing staff that she had swallowed multiple spoons. On 6/7/2010 the patient was admitted to Bronson Hospital for extraction of swallowed spoon handles. As the spoon handles could not be removed by endoscopy nor did the spoon handles pass naturally, the spoon handles were removed by gastrostomy and the tip of one spoon handle was removed by a hole in the jejunum. Her abdominal incision was stapled and after she stabilized, she was returned back to Kalamazoo Psychiatric Hospital on 6/16/2010.
(2) There were no physician progress notes or treatment notes regarding the patient's medical or psychiatric condition for the following dates during the period of May 18, 2010 to October 24, 2010: 5/18, 5/19, 5/21, 5/22, 5/23, 5/25, 5/25, 5/25, 5/26, 5/30, 5/31, 6/1, 6/2, 6/3, 6/4, 6/5, (patient was at Bronson Hospital from 6/7 to 6/16) 6/26, 6/27, 7/10, 7/11, 712, 7/13, 7/14, 7/22, 7/24, 7/25, 7/26, 7/28, 7/29, 7/31, 8/1, 8/2, 8/3, 8/7, 8/8, 8/9, 8/10, 8/11, 8/12, 8/13, 8/14, 8/16, 8/17, 8/18, 19, 8/21, 8/22, 8/23, 8/25, 8/28, 8/29, 9/1, 9/4, 9/5, 9/6, 9/8, 9/9, 9/10, 9/11, 9/12, 9/14, 9/15/, 9/19, 9/20, 9/24, 9/29, 10/2, 10/3, 10/5, 10/9, 1010, 1012, 1014, 10/14, 10/15, 10/21, 10/22, 10/23, and 10/24.

Based on medical review, document review, and interview, the former Medical Director (retirement effective 9/30/2010) and current Acting Medical Director (appointment effective 10/1/2010) failed to adequately monitor and evaluate the quality and appropriateness of services and treatment provided by the hospital's medical staff. Findings include:

(1) Medical record review conducted on 10/25/2010 and 10/26/2010 revealed that in 10 of 10 active sampled patients (patient #1, #2, #3, #4, #5, #6, #12, #13, #14, and #15) psychiatric physician documentation of completed psychiatric evaluations did not include documentation of the patient's medical history.

(a) The psychiatric evaluation of patient #1 completed on 7/29/10 did not document the patient's medical history. The patient was admitted to the hospital on 7/29/10.

(b) The psychiatric evaluation of patient #2 completed on 4/13/10 did not document the patient's medical history. The patient was admitted to the hospital on 4/13/10.

(c) The psychiatric evaluation of patient #3 completed on 10/16/2010 did not document the patient's medical history. The patient was admitted to the hospital on 10/15/2010.

(d) The psychiatric evaluation of patient #4 completed on 10/10/2009 did not document the patient's medical history. The patient was admitted to the hospital on 10/09/2009.

(e) The psychiatric evaluation of patient #5 completed on 7/26/2010 did not document the patient's medical history. The patient was admitted to the hospital on 7/26/2010.

(f) The psychiatric evaluation of patient #6 completed on 05/13/2010 did not document the patient's medical history. The patient was admitted to the hospital on 05/13/2010.

(g) The psychiatric evaluation of patient #12 completed on 10/08/2010 did not document the patient's medical history. The patient was admitted to the hospital on 10/08/2010.

(h) The psychiatric evaluation of patient #13 completed on 07/15/2010 did not document the patient's medical history. The patient was admitted to the hospital on 7/15/2010.

(i) The psychiatric evaluation of patient #14 completed on 4/19/2010 did not document the patient's medical history. The patient was admitted to the hospital on 4/19/2010.

(j) The psychiatric evaluation of patient #15 completed on 05/15/2010 did not document the patient's medical history. The patient was admitted to the hospital on 5/14/2010.
(2) Medical record review conducted on 10/25/2010 and 10/26/2010 revealed that completed psychiatric evaluations did not include an adequate evaluation of the orientation of the patient in 2 out of 10 sampled patients (Patient #4, and #12), and failed to include supportive information for the conclusions regarding memory functioning in 7 out of 10 active sampled patients (Patient #1, #2, #3, #5, #12, #13, and #14).
(a) The psychiatric evaluation of patient #4 completed on 10/10/2009 only stated "Oriented times: x. " There was no supportive information documented. The patient was admitted to the hospital on 10/09/09.

(b) The psychiatric evaluation of patient #12 completed on 10/08/2010 did not document the patient's orientation. The patient was admitted to the hospital on 10/08/2010.

(c) The psychiatric evaluation of patient #1 completed on 7/29/2010 stated "Adequate for immediate, recent, remote events." There was no supportive information documented. The patient was admitted to the hospital on 07/29/2010.

(d) The psychiatric evaluation of patient #2 completed on 4/13/2010, regarding memory stated only "89067" [sic] without any supportive information. The patient was admitted to the hospital on 4/13/2010.

(e) The psychiatric evaluation of patient #3 completed on 10/16/2010 stated, "Patient was able to remember data from the past," without any supportive information. The patient was admitted to the hospital on 10/15/2010.

(f) The psychiatric evaluation of patient #5 completed on 7/26/2010 stated, "Patient had difficulty remembering data from the past," without any supportive information. The patient was admitted to the hospital on 7/26/2010.

(g) The psychiatric evaluation of patient #12 completed on 10/08/2010 stated, "Unable to repeat five digits backward." No information regarding other areas of memory functioning was documented. The patient was admitted to the hospital on 10/08/2010.

(h) The psychiatric evaluation of patient #13 completed on 7/15/2010 stated "Memory intact for six digits" without any supportive information. The patient was admitted to the hospital on 7/15/2010.

(h) . The psychiatric evaluation of patient #14 completed on 4/19/2010 stated "Patient able to remember dates from the past" without any supportive information. The patient was admitted to the hospital on 4/19/2010
(3) The acting Medical Director, interviewed on 10/26/2010 at 1400 hours, reviewed the above 10 psychiatric evaluations with the physician surveyor. The acting Medical Director acknowledged that the content or lack of reviewed psychiatric evaluations as described above did not: (a) document: the patient's medical history, (b) document supportive information justifying the conclusions about memory functioning and orientation, and (c) were missing essential elements of the psychiatric evaluation such as an orientation.
These failures to document specific testing elements compromise the identification of pathology which may be pertinent to the current mental illness and compromise future comparative re-examinations to assess patient's response to treatment interventions.
(4) The Hospital Director and the Director of Standards/Compliance, interviewed on 10/26/10 at approximately 0945 hours, were requested to provide to the surveyor any relevant assessment conducted by the former medical director regarding the quality of psychiatric services provided to patient # 6 who had a history of ingestion of foreign objects.
On 6/6/2010 the patient reported to unit nursing staff that she had swallowed multiple spoons. On 6/7/2010 the patient was admitted to Bronson Hospital for extraction of swallowed spoon handles. As the spoon handles could not be removed by endoscopy nor did the spoon handles pass naturally, the spoon handles were removed by gastrostomy and the tip of one spoon handle was removed by a hole in the jejunum. Her abdominal incision was stapled and after she stabilized, she was returned back to Kalamazoo Psychiatric Hospital on 6/16/2010.
The hospital did not provide to the survey team members any documentation during the site visit or after the completion of the survey regarding the former medical director's monitoring or review of the quality of psychiatric services provided by patient #6's attending psychiatrist concerning the management of the patient's self-abusive behaviors.

Based on record review and interview, the Nursing Director failed to ensure that the individual plan of service (IPOS) developed by the multi-disciplinary treatment team includes the specific nursing interventions for 6 of 7 records reviewed (#1, #2, #3, #5, #6, #15). Findings include:

During review of the IPOS for patient #3 on 10/25/2010, the document revealed under "Primary Problem
#2 chronic medical conditions that the patient had been diagnosed with i.e., Hyperthyroidism, Diabetes Type II, Obesity and Gastroesophageal reflux (GERD) under "Primary Problem #2. Under the area titled Goals/Objectives/Anticipated Achievement Dates reads "Patient will be free from complications related to medical conditions." There is no documentation of specific interventions in regards to the individual diagnosis of the patient.

Findings were discussed at time of exit conference 10/27/2010 at 1100, with Acting Director of Nursing, Medical Director and Facility Director present in regards to the IPOS being a complete plan of service for each patient.



13155

The 10/26/10 review of patient # 15"s IPOS revealed that the patient's Primary Problem #3 was Medical problems that consisted of Hypertension, Diabetes Gastroesophageal Reflux Disease (GERD), Obesity, cardiomyopathy, Mitral Regurgitation and History of Neuroleptic malignant Syndrome. Under the area titled Goals/Objectives/Anticipated Achievement Dates reads Long Term Goal #3 "(Patient) will experience no complications from medical problems, by 9/10. "Short Term Objectives: a) "He will cooperate with all ordered test, exams, meds and treatment for medical conditions, daily, by 6/20/10." There is no documentation of specific interventions in regards to the individual diagnosis of the patient.

Findings were discussed at time of exit conference 10/27/2010 at 1100, with Acting Director of Nursing, Medical Director and Facility Director present in regards to the IPOS being a complete plan of service for each patient, including both psychiatric and medical conditions.




26688

The 10/26/2010 review of patient # 6 IPOS revealed that the patient's "Primary Problem #2 was "(Patient) has medical concerns including obesity, gastroesophageal reflux disease and asthma." Under the area titled Goals/Objectives/Anticipated Achievement Dates reads Long Term Goal #2 "(Patient) will will be free of medial complications, by 3/11. "Short Term Objectives: a) "She will be compliant with all test, exams, medications and orders daily, by 12/10." There is no documentation of specific interventions in regards to the individual diagnosis of the patient. Nursing Director failed to ensure that the IPOS was updated for the patient in regards to a surgical procedure that the patient required on 6/7/2010.

Findings were discussed at time of exit conference 10/27/2010 at 1100, with Acting Director of Nursing, Medical Director and Facility Director present in regards to the IPOS being a complete plan of service for each patient, including both psychiatric and medical conditions.





27065

On 10/26/2010 from 0900-1500, the IPOS (Individual Plan of Service) for patient #1 was reviewed.
-Under "Primary Problem #2 chronic medical conditions that the patient had been diagnosed with i.e., Obesity, Hyperlipidemia, Chronic back Pain and constipation.
-Under the area titled Goals/Objectives/Anticipated Achievement Dates, Long Term Goal #3 it states: "Consumer will be free of complications from medical problems, achieve and maintain optimal physical health by 1/11." Short term objectives reads: "Consumer will a) comply with ordered treatment, exams and take prescribed medication by 12/05/10. b) Comply with ordered diet, General, ongoing. c) comply with education and instruction on medication and diagnosis by 12/05/10. There was no documentation of specific interventions in regards to the individual diagnoses of the patient.

The IPOS for patient #2 was reviewed on 10/26/2010, from 0900-1500.
-Under "Primary Problem #2 chronic medical conditions that the patient had been diagnosed with i.e., Hypertension, Non-insulin dependent diabetes Mellitus, hyperlipidemia.
-Under the area titled Goals/Objectives/Anticipated Achievement Dates, Long Term Goal #2 it states:"Consumer will remain free from all medical complications, by 11/18/10." Short Term Objectives read a) "Consumer will comply with all prescribed medication, by 10/18/10". b) "Consumer will comply with all exams, consults, and lab work, by 10/18/10."
There was no documentation of specific interventions in regards to the individual diagnoses of the patient.


Findings were discussed at time of exit conference 10/27/2010 at 1100, with Acting Director of Nursing, Medical Director and Facility Director present in regards to the IPOS being a complete plan of service for each patient, including both psychiatric and medical conditions.