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Based on record review and interview, it was determined that the facility failed to maintain an environment that would ensure that patients receive care in a safe setting as evidenced by the following findings:

1. On 1-06-2010 at 2200 hours nurse #1 (RN #1) was suspended due to a complaint allegation that he struck patient #1 while placing the patient in a pelvic restraint on 1-06-2010 at 1800 hours. RN #1 reportedly left the unit around 2200 hours when notified of the suspension. Hospital staff failed to ensure that RN#1 could not re-enter the psychiatric unit and have further contact with patients and staff (patient starting census for the PM shift on the date of the incident was 22) as the hospital did not secure from RN#1 his hospital identification badge and unit keys and escort him from the facility. It was hospital "practice" to secure the keys and identification badge of a suspended employee at the time of the empolyee's suspension.

2. On 1-06-2010 at approximately 2350 hours RN #2 observed patient #1 in the psychiatric dinning room laying on the floor by a heater vent with his pajama bottoms on fire. Patient #1 was transfered to the Detroit Receiving Hospital's burn unit with 2nd degree burns to his legs and groin area and subsequently expired on 1-08-2010.

See tag A 144.

Based on document review and interview, the hospital failed to ensure that the grievance process included a mechanism for timely referral of Medicare beneficiaries's concerns regarding quality of care to the appropriate Utilization and Quality Control Quality Improvement Organization. Findings include:

<1> Hospital recipient rights advisor, interviewed 1-08-2010, was asked whether the Recipient rights Office advises a Medicare beneficiary of his/her right to have his/her complaint/grievance regarding a quality of care concern referred to the local Quality Improvement Organization. The rights advisor stated that no such notice is provided to a Medicare beneficiary when a complaint/grievance is received or when notice of the hospital's investigative findings or interventions are sent to the patient

<2> The hospital recipient rights advisor further stated that she was not aware of any hospital policy/procedure or directive that would require such notice to a Medicare beneficiary when a complaint is received regarding the quality of care rendered by the hospital.

<3> The hospital's "Patient Complaint and Grievance Process Policy (#P123P) was
reviewed. The policy does not reference how a Medicare patient as part of the grievance process is informed of the right to refer concerns regarding quality of care to the local Quality Improvement Organization.

Based on medical record review and interview, the hospital failed to ensure that patients residing on the hospital's psychiatric unit were receiving care in a safe setting. Findings include:

<1> Medical record review revealed that on 1-06-2010 at 1800 hours patient #1 was placed in a pelvic restraint in a geri-chair for reported aggression and agitation that did not respond to redirection. The patient was released from his pelvic restraint at 2315 hours on 1-06-2010.

<2> Hospital psychiatric program manager, hospital rights advisor, and hospital legal counsel were interviewed on 1-08-2010. The following narrative was provided:

One of the nursing staff participants in the application of the pelvic restraint to patient #1 on 1-06-2010 was nursing assistant (NA #1) staff person who was on duty on the psychiatric unit for 4 hours on a temporary basis as a float staff.

Upon returning to her home nursing unit at 1900 hours, NA#1 reported to her supervisor that nurse #1 struck the patient once with a fisted hand on the patient ' s neck after patient #1 bit him on his hand while assisting with the application of the pelvic restraint.

The unit manager called the house supervisor who in turn at approximately 2000 hours called the psychiatric program manager at home and advised her of the battery allegation. The psychiatric program manager directed the house supervisor to inform nurse #1 that he was suspended and that he should leave the hospital pending an investigation of the battery allegation. Nurse #1 left the unit when informed of his suspension.

The hospital did not secure from the suspended nurse his hospital keys or identification badge when the nurse was suspended. Hospital staff did not escort suspended nurse #1 out of the hospital to ensure that he left the hospital premises as directed.

<3> As the hospital did not secure the badge and keys of the suspended employee, it would have been possible for the suspended employee to re-enter the psychiatric unit at his own discretion. In a 1-25-2010 follow up phone conversation with the hospital CEO/President, he stated that this failure was a breach of "practice" as it was customary for the Human Resources Department to secure a suspended employee's identification badge and keys when suspended. The President/CEO confirmed that the hospital does not have an enforceable hospital policy/procedure that details the expected "practice" when an employee is suspended on weekends or weekdays after normal busines hours when the human resources departmet is closed. As nurse #1 was suspended at 2000 hours, there was no enforceable policy/procedure in place.

<4> On 1-06-2010 at 2330 hours the patient was observed in the unit dining area eating a snack consisting of cookies.

At 2345 hours the patient observed still in the dining area.

At approximately 2355 hours while walking towards the dining rooms, nurse #2 observed an orange color in the dining room. The nurse's progress note dated/timed 1-06-2010 @ 2350 hours, states "No smoke smell or call for help was noted. After several steps closer, flames and fire noted coming from the floor level near
heating unit. Upon entering door, patient (#1) was noted to be on fire, lying supine on floor, directly next to wall and heating unit. Second nurse (nurse #3) arrived and pt. was pulled away from the wall. Pt. was alert and talking, stating "I'm on fire." Blanket near pt. used to start putting out flames. No other pt. or staff was present in dining room with pt. @ time of incident..."

Review of preliminary draft progress note dictated 1-08-2010 @ 0332 hours by resident physician #1 states in part that "Upon arrival (to the psychiatric unit), we were able to either remove rest of the patient ' s clothes or cut his clothes off. It was noted the patient had circumferential burns to the bilateral feet, calves, and thighs. These are 2nd degree burns representing 18% of the right leg and 15 % of the left. There are also 2nd degree burns to the right hand secondary to patient trying to put out the fire with his hand... There are also 2nd degree burns to the entire genitalia in the low pelvic area. The patient was placed on a stretcher and secured. The patient was then transported to the ED for further treatment and transfer.

Review of Completed ED Trauma Physical Examination form revealed that patient #1 was accepted for transfer to the burn unit at Detroit Receiving Hospital on 1/7/09 at 0050 hours.

<5> At the 1-08-2010 entrance conference the Hospital CEO/President stated that:

a) Farmington Hills Police Officer #1 informed the hospital that patient #1 expired at 0247 hours on 1-08-2010 while hospitalized at Detroit Receiving Hospital's burn unit where he was transferred on the early morning of 1-07-2010.

b) In a 1-07-2010 meeting between the hospital and representatives of the Farmington Hills Fire Department (FD), the FD ' s preliminary finding was that the fire was caused by a human and that the ignition source was unidentifiable and missing.

Based on medical record review and interview, in 1 of 6 patients (patient #1) the hospital failed to ensure that the use of restraint was only used when less restrictive intervention had been determined to be ineffective to protect the patient, a staff member, or others from harm. Findings include:

<1> Medical record review reveals that on 1-06-2010 at 1800 hours the patient was placed in a pelvic restraint in a geri-chair. The patient was released from his pelvic restraint at 2315 hours. The restraint order dated/timed 1-06-2010 @ 1800 hours states that the restraint was required for "agitation/poor impulse control" and "combative/physical aggression." Diversional activities and verbal reminders were attempted alternatives to the use of restraint.

<2> The medical record does not contain a nursing progress note associated with this restraint episode that describes the circumstances requiring the use of the vest restraint.

<3> On 1-07-2010 the surveyor was advised by phone by the psychiatric program manager reporting to the Department of Community Health the alleged abuse of patient #1 that that patient #1 was restrained due to the fact that he had pushed a female peer resulting in her fall. Review of incident reports revealed that patient #7 did fall on 1-07-2010 @1735 hours due being "bumped accidentally by male peer".