HospitalInspections.org

Based on observation, interview and document review, the facility failed to protect the rights of current and discharged patients, placing all 120 current patients at risk for loss of their rights.

Findings include:
---the facility failed to establish a process for prompt resolution of patient grievances and complaints about treatment. (See A-118)

--- the facility failed to ensure that all patients are free from all forms of abuse. (See A-145)

---the facility failed to ensure that all uses of restraint or seclusion are done under the order of a physician. (See A-168)

Based on interview and record review the facility failed to establish a process for prompt resolution of patient grievances, resulting in increased risk of all patients being denied their grievance rights. Findings include:
Record Review & Interview:
On 01/07/15 from 0900-0920 facility complaint and grievance logs were reviewed with staff H and R. Staff H stated that they (staff H and R) have responsibility for logging and tracking patient grievances. Review of the grievance log revealed that grievance investigations assigned to Nurse X, dating back to October 2014, had not been documented as completed. Staff H stated that Nurse X left her position and the grievance investigations assigned to her not been reassigned. There was no documentation indicating that any action had been taken to assign or investigate over 90 grievance log entries from the month of October 2014. Staff R stated that some grievances may be under investigation as complaints, by the Office of Recipient Rights. Staff H and R were asked to provide the facility's policy or procedure for responding to patient complaints and grievances and explaining how the two processes communicate. Both staff stated that they are not aware of written policies or procedures explaining how the complaint and grievance processes are related.
On 01/07/2015 at 1025 staff P stated that the Office of Recipient Rights (ORR) is responsible for reviewing patient complaints for compliance with the Michigan Mental Health Code, not for compliance with CMS Standards. Staff P was asked how the complaint and grievance investigators communicate. Staff P responded: "we have two completely separate processes." On 01/07/2015 at approximately 1420 staff C stated that it is facility practice to wait for the complaint investigation to be completed before acting on grievances.

Based on observation, interview, and document review the facility failed to protect all patients from abuse and neglect by:
--failing to prevent staff with substantiated and pending patient abuse allegations from working with patients.
--failing to investigate abuse or neglect allegations in a thorough, timely manner for 2 of 3 current patients (#11 and #12).
Resulting in increased risk of patient abuse or neglect for all 120 current patients.

On 01/07/2015 beginning at 1000, an interview with the Fire safety supervisor staff (K) began, including review of security videos. Staff K stated, "We began our review of the security videos on 10/02/2014 after the report of the injury to patient #4, a total of 33 incidents to multiple patients were observed and reported to the administration. We do not routinely monitor the electronic video surveillance tapes, we only look at them if a problem has been identified."
On 01/07/2015 at 1030 the video for 06/25/2014 was observed completely, a total of 6 staff were observed participating in confining a resident under a table with chairs, footstools, and body blocking including sitting on top of the table. The resident was reaching out through cracks in the confining furniture, the staff was then observed grabbing the residents arm and pushing it back under the table. Staff K stated, "I do not know what has happened to all of the staff involved, but I believe that 4 (staff) were put on suspension, 2 (staff) have returned to work the other 2 (staff) will be let go."

On 01/07/2015 at approximately 0930 staff L from human resources provided the training records for Non-Abusive Psychological & Physical intervention (NAPPI) for 11 staff that have been allowed to return to work as a result of the 33 incidents identified on the security videos including staff J, resident care attendant (RCA) one of the 6 involved in the incident on 06/25/2015. Staff L stated "3 (staff) have not been allowed to return to work and 2 (staff) that failed to report, have yet to be disciplined. The investigation involving the employees that failed to report patient abuse is just beginning, those employees have been allowed to work pending results of the investigation."

On 01/07/2015 at 1145 review of the document titled, "Employee Handbook" updated 04/14/2014 on pages 18,19,20,21,&22 it stated:
"Section ll-Recipient Rights/Mental Health code violations........7. Recipient abuse l; and/or failure to report abuse l......1st violation: Dismissal.
8. Recipient abuse ll; and or failure to report abuse ll.........1st violation reassignment and or demotion and/or 5-day suspension......2nd violation reassignment and/or demotion and/or 5-day suspension to dismissal.......3rd violation dismissal..............9. Recipient abuse lll; and/or failure to report abuse lll........1st violation; reassignment and/or demotion and/or written reprimand to 5-day suspension........2nd violation; reassignment and/or demotion and/or 5-day suspension to dismissal.....3rd violation; dismissal.........10. Recipient neglect 1; and/or failure to report neglect l......1st violation; dismissal......11. Recipient neglect ll; and/or failure to report neglect ll......1st violation; Reassignment and/or demotion and/or 5-day suspension......2nd violation; reassignment and/or demotion and/or 5-day suspension to dismissal......3rd violation; dismissal.....................
.....Overall Note...Penalties should be based on the severity of the incident. Discipline will normally be progressive........"

"Attachment A Definitions
Abuse class l ....non-accidental act.......serious physical harm to a recipient.
Abuse class ll...non-accidental act....unreasonable force....
Neglect class l...commission or omission....non-compliance with standard of care.......failure to report apparent or suspected abuse class l...."


27065

Policy Review:
On 01/06/2015 at 1700, review of a booklet provided to all patients upon admission titled, Your Rights When Receiving Mental Health Services in Michigan, dated 06/13, was conducted. The booklet stated: "When receiving mental health services you have the right not to be physically, sexually, or otherwise abused and the right not to be neglected."
Discharged Patient #4: Record Review:
On 01/06/2015 from 1540-1700 facility investigation reports for patient #4's physical restraint incident and injury on 06/25/2014 were reviewed with staff F. A report of video review findings for the 06/25/2014 incident, written by staff F, dated 12/19/2014, stated that staff V and W were observed on video: "wrestling with (patient #4's) arms" and "blocking (patient #4) in under a table." The report stated that staff V: "grabs (patient #4's) left hand to push it down, then with his right forearm pushes hard into the left side of (patient #4's) neck, forcing him sharply to the left (patient #4's right) against (staff W's) hand or arm ...(Staff V) has a hold of (patient #4's) left forearm. Together they (staff V and W) force (patient #4) arm down." The report continues: "more wrestling with (patient #4's) arms ensues ..."
On 01/06/2015 review of a "Psychiatrist's Summary" by staff S, dated 10/9/2014, revealed the following statement: "The only time that he (patient #4) had been referred to the hospital was June 25, 2014, when he had injured his left arm and diagnosed to have a complete fracture of the radius and ulna of the left arm."
An investigative report by a government agency (by Y) stated that patient #4's Orthopedic Surgeon, physician Z, was interviewed on 8/18/2014. The report stated that physician Z stated that the left arm fractures that patient #4 sustained on 06/25/14 were "rare, and would take a substantial amount of force. Furthermore, such an amount of force is improbable to have been precipitated by an individual of and within themselves...(Physician Z) expressed confidence that (patient #4) would have been incapable of causing his own injury."
Interview:
On 01/06/2015 from 1540-1700, during record review, staff F confirmed the video report findings referenced above. Staff F stated that video review of staff interactions with patient #4 on 06/25/2014 and other dates resulted in substantiated patient abuse findings against multiple staff members. Staff F stated that some staff with substantiated patient abuse findings had been allowed to return to work. Staff F stated that facility Work Rules allow staff with substantiated abuse findings to resume patient care duties.
Current Patients #11 and #12: Record/Video Reviews and Interviews:
On 01/07/2015 at approximately 1110 patient #11's written complaint alleging sexual abuse by staff was reviewed. The complaint was logged (on the complaint log) as received on 11/26/2014. The only documentation of any response to the complaint was a letter from staff P, dated 12/04/2014, stating: "under most circumstances, the investigation will be completed within 90 days." Staff P confirmed that this investigation had not been completed and that there was no documentation of investigative activities. This complaint was not listed on the facility's grievance log.
On 01/07/2015 from 1030-1125 a complaint alleging that patient #12 was neglected by staff U, a Resident Care Attendant, was reviewed. A 12/15/2014 e-mail from staff Q states that this complaint was received (by staff Q) on 12/15/2014. The complaint stated that staff U got on top of patient #12 while the patient was in prone position. This complaint/grievance was listed on both the complaint and grievance logs. The complaint states that the incident occurred on 11/23/2014 at 1907 and is logged as a possible neglect. A 12/17/2014 letter from staff Q to staff U instructed staff U to attend a meeting in regard to this allegation on 12/26/2104. No documentation of video review findings or any follow-up to the 12/17/2014 meeting request letter was found in the complaint investigation file. Staff P confirmed these findings. Staff P stated that the case is still open and that the complaint investigator has 90 days to complete the investigation.
The grievance log lists Staff C, a nursing administrator, as the assigned grievance investigator. The grievance log stated: "(staff C) viewed the tape of the alleged incident with staff Q on 12-16-2014." On 01/07/2015 at approximately 1420 staff C stated that video review revealed that staff U had gotten on top of the patient, as alleged, and that the physical restraint technique used was improper. Staff Q stated that he did not document the results of video review or have any investigation notes. Staff C stated that he was unaware of any action being taken in response to this incident. Staff C stated that it is facility practice to wait for the complaint investigation to be completed before acting on grievances.

Based on interview and record review, 1 of 1 discharged patients (#4) was physically restrained and secluded without a physician's order, resulting in patient injury. Findings include:
Policy Review:
On 01/06/2015 at 1700 review of a booklet provided to all patients upon admission, titled Your Rights When Receiving Mental Health Services in Michigan, dated 06/13, was conducted. The booklet states: "Freedom of movement is a right, not a privilege ...If there are limitations on your freedom of movement, the expected length and the reasons for them must be written into your record."
On 01/06/2015 at 1710 review of a booklet provided to all patients upon admission, titled FACTS for Patients and Families, under USE OF SECLUSION OR PHYSICAL RESTRAINT stated: "Seclusion or physical restraint is used as a last resort to keep you from harming yourself or others...we may physically restrain you or place you in a locked room. A Nurse and a Psychiatrist will review and approve these methods before they are used."
Record and Video Review:
On 01/06/2015 from 1540-1700 patient #4's facility investigation reports for 06/25/2014 were reviewed with staff F. A review of video documentation of the 06/25/2014 incident, written by staff F, dated 12/19/2014, stated that staff V and W were observed on video: "wrestling with (patient #4's) arms" and "blocking (patient #4) in under a table." The report stated that staff V: "grabs (patient #4's) left hand to push it down, then with his right forearm pushes hard into the left side of (patient #4's) neck, forcing him sharply to the left (patient #4's right) against (staff W's) hand or arm ...(Staff V) has a hold of (patient #4's) left forearm. Together they (staff V and W) force (patient #4) down." The report continues: "more wrestling with (patient #4's) arms ensues ..."
On 01/07/2015 from approximately 1000-1030 video of the above (06/25/2014) incident was reviewed with staff K. A total of 6 staff were observed participating in confining patient #4 under a table with chairs, footstools, and body blocking including sitting on top of the table. The patient was observed reaching out through cracks in the confining furniture. The staff was observed grabbing the patient's hands and arms and pushing them back under the table.
On 01/06/2015 review of a "Psychiatrist's Summary" by staff S, dated 10/9/2014, revealed the following statement: "The only time that he (patient #4) had been referred to the hospital was June 25, 2014, when he had injured his left arm and diagnosed to have a complete fracture of the radius and ulna of the left arm."
Interviews:
On 01/06/2015 from 1540-1700, during record review, staff F confirmed that video evidence showed that facility staff prevented patient #4 from coming out from under the table on 06/25/2014. On 01/07/2015 at 1400 staff C confirmed that there was no physician's order for restraint or seclusion of patient #4 on 06/25/2014.