HospitalInspections.org

Based on interview and record review the facility failed to protect the rights of current and discharged patients, placing all 71 current patients at risk for loss of their rights.

Findings include:

-the facility failed to ensure that patients were allowed to participate in their treatment planning decisions, resulting in loss of treatment planning rights for two current patients (#5 and #10) and one discharged patient (#1) and increased risk for loss of treatment planning rights for all patients. (See A-0131)
-the facility failed to ensure patient safety by assessing, monitoring and providing appropriate care to one patient (#1) who exhibited symptoms of a recurring infection. (See A-0144)
-the facility failed to thoroughly investigate five patient abuse allegations (for patients [#13, #14, #15, #17 and #18]) and respond to abuse allegations with actions to reduce the risk of abuse for all patients. (See A-145)
-the facility failed to ensure that patients were physically restrained by trained staff, according to facility policy, resulting in improper physical restraint of one current patient (#5) and increased risk of injury during physical restraint for all patients. (See A-0194)

Based on interview and record review, two current patients (#5 and #10) and one discharged patient (#1) were denied the right to participate in their treatment decisions and refuse care, resulting in loss of their treatment planning rights and increased risk of all patients being denied these rights. Findings include:
Patient #5:
Record Review and Interview:
On 3/4/15 from 1000-1030 patient #5's clinical record was reviewed with staff B. Patient #5, an 12 year old, was admitted to the facility on 2/18/15. Patient #5 was placed on the Journal Program according to notes dated both 2/25/15 and 2/27/15. The notes stated "CM (Case Manager) informed (Patient #5) and Mother about Journal Program and purpose." There was no mention of asking the patient or parent whether they agreed with this treatment decision or the unit restriction being imposed. Per patient #5's "Journal Program Expectations Form," dated 2/27/15, the "Objective/Reason for program:" section of the form stated, "Focus on Tx (treatment)." The "Program Specifics:" section of the program form stated, "Journal and 3 Groups...Trays...No gym/AT (Activity Therapy)." The section for "Patient can return to group:" stated, "Not until further notice." There is no section on the form for patient or family/guardian consent to the treatment modality or program restrictions

A 2/26/15 note by staff J stated that patient #5 was assigned to journaling and had responded, "this isn't going to help, I don't need to do this." A 3/1/15 "Shift Progress Note" stated that patient #5 was "in room most of shift working on journals, but (she)states it is not helping..."

The Journal Program was not added to patient #5's "Individual Treatment Plan" (ITP) and neither the patient nor a parent had signed the ITP. Facility staff signed patient #5's ITP on 2/18/15. The signature lines for patient and family were blank. On 3/4/15 at approximately 1030 staff J stated that staff should have made a note on the ITP signature page explaining why patient #5 and a family did not sign the ITP. On 3/4/15 staff B confirmed that additional ITP updates (after 2/18/15) for patient #5 could not be located.

Interview:
Patient #5 was interviewed on 3/4/15 at approximately 1045. Patient #5 stated "I hate journaling" and stated that she has been on the Journal Program for over a week. Patient #5 stated that she has repeatedly told staff that she would like to get off the Journal Program and be able to attend more groups and off-unit activities. Patient #5 stated that patients assigned to the Journal Program are not allowed to leave the unit for meals or go to the gym and may attend only 3 groups per day. Patient #5 stated that her writing assignment is extremely long. Patient #5 stated that she has been working on it for several days and still has a long way to go to complete it. Patient #5 provided a copy of the writing assignment. It consisted of 111 topics. Patient #5 stated that staff have refused to accept her work if they feel it is of insufficient length.

Patient #10:
Record Review and Interview:
On 3/4/15 from 1000-1030 patient #10's clinical record was reviewed with staff B. Patient #10, a 13-year old, was admitted to the facility on 2/22/15. Per patient #10's "Journal Program Expectations Form," dated 3/3/15, the "Objective/Reason for program:" was "Needing to process emotions on SI (suicide ideation) & relationship w/ (with) Mom." The "Program Specifics:" section of the form stated, "Journal and 3 Groups...Trays...No gym/AT (Activity Therapy)." The section for "Patient can return to group:" stated, "After sufficient processing with CM (Case Manager)." Documentation that patient #10 or a parent agreed to this treatment plan and the limitations imposed as part of the plan, was not found in patient #10's record. A 3/2/15 "Shift Progress Note" stated that patient #10 was depressed about a writing assignment and requested to change Case Managers because of the assignment.

The Journal Program was not added to patient #10 's "Individual Treatment Plan" (ITP) and neither the patient nor a parent had signed the plan. Facility ITP staff signed the plan on 2/23/15 and 3/2/15. The signature lines for patient and family on both dates were blank. On 3/4/25 at approximately 1030 staff J stated that staff should have made notes on these ITPs, explaining the signature omissions.

Interview:
Patient #10 was interviewed on 3/4/15 at approximately 1110. Patient #10 stated she was assigned to the Journal Program without consenting to participate. Patient #10 stated that she was not allowed to go to the cafeteria or gym and was not allowed to select food at meals. Patient #10 stated "the Journal program and the whole food restriction thing is too much for me. I am not allowed to pick my food at meals and I'm a picky eater." Patient #10 stated that she doesn't eat most of the meals being selected for her because they are foods that she doesn't like. Patient #10 stated that staff had assigned her 110 questions to write on for her journaling assignment.

Policies and Procedure Review:
On 3/4/15 from 1400-1600 hospital policies and procedures were reviewed. Findings include:

According to "Your Rights When Receiving Mental Health Services in Michigan," a book provided to all patients at admission, dated 4/11, "You have the right: to participate in the development of your plan of service and to involve family members, friends, advocates and professionals of your choice in the development process."
Under "Person-Centered Planning" the booklet stated "the treatment you receive will be made up of activities which you think will help you, which you assist in developing, and which meet your goals."

According to the Department procedure entitled, "Journal Program" dated November, 2014, "Journal can be assigned by anyone on the treatment team ...If it appears that a patient is not making expected progress in general and/or special programming the treatment team may place the patient on journals...Journal will take place on the unit...Criteria for a patient to return to general programming includes: completion of assignments with good effort, a positive attitude toward treatment and ability to follow unit rules and expectations." Although the "Program Guidelines" state that the patents/Guardians of patients will be notified when a patient is placed on the Journal program it does not specifically state that that they will be informed that the patient may not be allowed to leave the unit to go to the cafeteria or the gym. There is no provision for the patient or family to participate in the decision to accept or decline participation in the Journal Program.

According to "Interdisciplinary Treatment Plan for Inpatient and Partial Hospitalization Program," #PC 01, dated 04/14, "It is the policy of (hospital name) to provide each individual admitted to the hospital's inpatient or partial hospitalization program a written, individualized treatment plan...The Master Treatment plan is reviewed and updated as frequently as necessary, but at a minimum, is reviewed every seven (7) days...The Master Treatment Plan is discussed and reviewed with the patient/guardian and/or support person(s)." The policy does not state that patients or parents of minors will be involved in treatment team meetings or decisions.


27781

Patient #1
On 03/03/2015 at 1300, during a tour of the facility, the Director of Nursing (DON) mentioned that many of the adolescent patients participated in a Journaling Program. Per the DON, the youths were encouraged to journal in the milieu among their peers, and patients usually spend approximately an hour journaling daily.

The DON explained that a 'Journaling Program expectation form' would be completed for each child in the program. A Journaling expectation form was presented which revealed that activities such as gym, groups and meals (in dining area) were prohibited to individuals in the Journaling Program.

On 03/04/15 at 0930 a medical record review was conducted which revealed that patient #1 was a youth who was admitted into the facility on 05/16/13 at age 11 years. Patient #1 had an eating disorder diagnosis of anorexia nervosa, major depression disorder and a history of C-diff.
The complainant was unable to be reached by telephone, on 02/27/2014 at 0900, however the written complaint indicated that patient #1 had been forced to participate in a journaling program at the facility whereby he would sit, isolated for extended periods of time and be expected to write in a journal for several hours against his will.
On 03/04/15 at 0940 an interview was conducted with risk manager (D) who explained that patient #1 was asked to journal in a consult room, across from the nurses station so that he could continuously be monitored by nursing staff due to his self-injurious behavior and his eating disorder. It was unclear when the Journaling Program began or ended for patient #1 as there was no "Journaling expectation form" located in the medical record.
Review of progress notes for patient #1 revealed the following:
On 05/26/13 at 1500 "...Pt had been oppositional with staff ...Patient redirected from work room to journals ...was observed picking a scab on left anterior forearm ..." Patient #1 was placed on unit restrictions for 24 hours per the SIB (self-inflicted behavior) protocol. According to the "precaution check sheet" patient #1 spent a total of 4 hours and 15 minutes in the consult room journaling.
On 05/27/13 "...frequent prompting to complete journaling assignments..." The precaution check sheet revealed that patient #1 spent a total of 3 hours 15 minutes in the journaling room.
On 05/28/13 "...patient doing journaling ...15 minute checks ..." The precaution checklist indicated that the patient spent 6 hours 45 minutes in the journaling room. It was unclear why patient #1 was confined to the journaling room for extended periods of time when the 24 hour restriction should have ended on 5/27/13.
On 05/29/13 (first shift) "...Patient expressed that he wants to get off of his journaling program ..." (second shift) "...reports moods as annoyed that he is still on journals..." Patient spent 3 hours 15 minutes in the journaling room that day.
The check sheets indicated that patient #1 had short breaks in between journaling, on some days, to use the restroom or the telephone at the nursing station. Most of the hours were spent confined to a consult room. It was unclear why the patient was mandated to remain in the consult room journaling for excessive periods of time.
On 03/04/15 at 1145 Staff (D) stated that the patient was not in seclusion because he was allowed to leave the room as he pleased, however, the documentation that reflected patient #1's annoyance with the journaling program and the desire to get off of the program, indicated that the youth did not have freedom of movement. There was no documentation in the record that revealed the expected length of time that the patient was required to remain isolated in the journaling area.
Further review of progress notes revealed that on 06/01/13 the family of the patient was interviewed by a house supervisor, and the family expressed concerns about the care that had been provided to patient #1. "...parents were concerned about the time their son spent journaling this past week ...Parents stated their son informed them he was spending 6-7 hours journaling... Parents dissatisfied with the journaling program, ...writer informed parents that if they had specific concerns and questions related to the journaling program they should contact his case manager. Parents then reported they had been trying to get in contact with the patient's case manager for days and had not heard back from her ...Writer encouraged parents to continue calling nursing staff for updates ..."
On 03/04/15 at 1145 an interview was conducted with the staff (D) who explained that the case manager for patient #1, no longer worked at the facility.
There was no documentation that indicated that the parents of patient #1 was given the information needed to make informed decisions regarding the participation of their child in the Journaling Program. There was no care plan that addressed the Journaling Program or the need for it, and there was no "Journaling expectation form" in patient #1's medical record.
According to the Department procedure entitled "Journaling Program" dated November, 2014, "Journaling can be assigned by anyone on the treatment team ...Each patient will be provided with a copy of journaling program expectations ... a patient may choose to complete journals in their assigned room or in the common area ...at no time shall a patient assigned to a Journaling Program be prevented from leaving the assigned journaling work area by physical means or any form or coercion."

Based on record review, facility's policy and procedure review and staff interview the hospital failed to ensure quality care by assessing, monitoring and providing appropriate care to one of two patients (#1) who exhibited symptoms of a recurring infection from a total sample of 16 patients resulting in a failure to follow standard infection control practices. Findings include:
A record review was conducted on 03/04/15 at 0930 which revealed that patient #1 was a youth who was admitted into the facility on 05/16/13 at age 11 years. Patient #1 had an eating disorder diagnosis, and a history of Clostridium-difficile {C-Diff}(infectious diarrhea) and was on a course of antibiotics at the time of admission.
On 03/04/15 at 1130 an interview was conducted with Registered Nurse (E) who explained that "the doctor authorized for the patient to continue the antibiotic use until they were done." Review of the medication administration (MAR) record with Registered Nurse (E) revealed that patient #1 was administered Flagyl (antibiotic) on 05/16/13 and the medication was completed on 05/17/13. Staff member (D) was asked if patient #1 had any episodes of diarrhea while he was an inpatient at the facility. Staff member (D) stated that patient #1 had diarrhea and vomiting one time on 05/24/13 and it was a result of eating too fast.
Further review of the clinical record revealed the following progress notes:
On Friday, 05/24/13 "one episode of diarrhea, vomited x 3 ...ate 50% of lunch ..."
On Saturday, 05/25/13 "patient reports diarrhea at 1300 and throughout the day. Reports poor concentration ...can't focus on anything ..."
On Tuesday, 05/28/13 at 1715 (unsigned nurses note revealed) "...patient had 3 loose stools today ...IM (internal medicine physician) notified ...no new orders at this time."
On Thursday, 05/29/13 "...reported that he had diarrhea since Sunday to mother during visit ...pt did not report to staff ...placed on IM (internal medicine) board ...pt ate 15% of dinner, stated ...didn't really want to eat, don't like the food..." However, there was documentation in the record that revealed patient #1 did in fact report having episodes of diarrhea since 05/24/13, but nothing was done for the patient considering the limited food intake with the episodes of diarrhea.
On 05/31/13 (unsigned nurses note revealed) "...pt questioned if he had a bowel movement in order to obtain stool specimen for C-diff culture. Pt denied being able to go yet ...spoke with family about pt's report and inability to obtain a stool sample. Pt's family concerned that pt may be dehydrated r/t pt reporting diarrhea for many days."
Review of physician orders on 03/04/15 at 1140 revealed a verbal order dated 05/30/13 at 1215 which indicated "stool culture for C-diff ..."
Staff member (D) was asked on 03/04/13 at 1140 if the results of the C-diff stool culture was in the clinical record. Staff (D) presented a laboratory result collected on 06/01/13 at 1500 for Cryptosporidium antigen and Giardia lamblia antigen which both detects for parasites, not C-diff. Both Staff member (D) and RN (E) were again queried about the results of the C-diff they could not be found. There was no documentation in the record that indicated results of the C-diff stool culture.
Nurses notes dated 06/01/13 1745 revealed "...parents asked about stool specimen orders and collection. Parents informed one more specimen was needed and there were no results available at this time ...parents asked about vomiting and diarrhea situation and reported feelings of confusion as to why their son informed them he was sick and not staff ...parents informed that with initial episodes of vomiting and diarrhea the parents are not called, but when the issue is ongoing ...parents should be notified ..." However, there was no indication that the facility notified the family of the patient's symptoms, the family was notified by the patient.
The facilities infection control officer was reportedly not available at the time of the survey according to staff member (D), and It was unclear if patient #1 was placed in a private room on contact precautions or provided additional fluids to prevent dehydration since the patient had an eating disorder, as there was no documentation in the record to verify that it occurred.
On 03/04/15 at 1245 an interview was conducted with the DON who was unable to explain whether patient #1 was placed on contact precautions upon admission or anytime during his hospitalization, because, reportedly the facility was unable to retrieve bed information for 2013.
The facility policy entitled, "Clostridium difficile (C. diff.) revised July 2014 revealed "...Symptoms of C. difficile are diarrhea, and history of having taken antibiotics, within the last two months. Internal medicine ...identifies patients infected with C. diff bacteria."

Based on record review and interview the hospital failed to:
-thoroughly investigate 1 of 1 staff abuse allegations (for patient #17) and respond by making appropriate referrals to outside investigative agencies and thoroughly screening the accused staff member (staff G) who has contact with hospital patients discharged to the hospital's Partial Hospitalization Program.
-investigate and respond to 4 of 4 patient abuse grievances (for discharged patients #13, #14, #15, #18) with interventions to protect other patients, resulting in increase risk of abuse for all patients. Findings include:

Patient #17:
Record Review and Interview:
On 3/3/15 from approximately 1430-1630 a complaint alleging an inappropriate relationship between former patient #17 and staff G, filed with the facility in 2014, was reviewed. Staff G was patient #17's inpatient Case Manager during the patient's hospitalization from April-May 2013. Staff G, a social worker who is currently employed by the hospital, in the hospital building, working in the hospital's Partial Hospitalization Program. Patients discharged to the hospital's Partial Hospitalization Program may have contact with staff G upon discharge.

On 3/3/15 from approximately 1430-1630 review of the facility's investigation of this complaint revealed that administrator A wrote a letter, dated 9/4/14, stating that staff G admitted to "inappropriate response to a serious (series) of emails including self photos of the client."

On 3/3/15 from approximately 1430-1630, staff I was interviewed. Staff I stated that he was the assigned investigator for this complaint and the only staff member who viewed the email messages provided by the complainant. The emails between patient #17 and an email address bearing staff G's name were reviewed on 3/3/15 from approximately 1430-1630. The emails included sexually explicit photos of patient #17. Emails from an address bearing staff G's name contained an email encouraging patient #17 to send "selfies"and positive responses to the photos of patient #17. Review of the facility's investigation of this allegation revealed that the facility investigator did not ask staff G to verify his personal email address, state whether the email strings and photos provided by the complainant were the same ones he received or provide his copies of the admittedly "inappropriate emails" between himself and patient #17. Staff I confirmed these findings during review of investigation files on 3/3/15 from approximately 1430-1630

There was one note in the investigation file stating that patient #17 was not available for interview. Documentation of dates, times and phone numbers, specifying attempts to contact patient #17, was not found. Staff I confirmed these findings during review of this investigation on 3/3/15.

On 3/3/15, during the above investigation review, staff I was asked if the hospital reported this complaint to police since it involved allegations of sexually explicit emails and photos being emailed from a former patient to a mental health professional who may have encouraged the patient to send them. Staff I responded that hospital staff informed the local police department that a former patient had filed a complaint alleging that a former hospital staff member had an inappropriate relationship with another former patient who was the complainant's girlfriend. Staff I stated that police responded that they did not think that this allegation warranted police investigation. Staff I was asked if the hospital provided the police department with copies of the sexually explicit emails. Staff I stated that this was not done.

On 3/4/15 at approximately 0815 staff A was asked why this complaint was not reported to the State Agency responsible for investigating abuse allegations against licensed health care professionals. Staff A stated that since it could not be proved that emails provided by the complainant had not been altered, the facility did not have a duty to report this complaint to staff G's licensing agency.

Patients #13, #14, #15 and #18:
Record Review and Interview:
On 3/4/15 at 1350 a February 2015 Grievance Log, listing 1 open grievance (for patient #18) and 3 closed grievances (for patients #13, #14 and #15) was reviewed with staff H. The log indicated that in February 2015 patient #12 physically assaulted 4 patients (patients #13, #14, #15 and 18) without provocation.
-On 2/3/15 patient #12 "hit a male peer (patient #15) in the face with her fist." The attack was described as "unprovoked."
-On 2/8/15 at 0750 patient #12 "slapped a male peer (patient #13) on the face." The attack was described as "unprovoked."
-On 2/8/15 at 0900 patient #12 reportedly hit a male peer (patient #14) on the arm and then on the face.
-On 2/9/15 at 1405 patient #12 approached patient #18 and "slapped her face."
Facility incident reports state that staff responded to the above incidents of patient assault by redirecting patient #12 to another room, moving one of the assaulted patients to another unit and telling patient #12 that the behavior was unacceptable. On 3/4/15 at 1410 staff H stated that staff documentation that patients #13, #14 and #15 had made statements that they understood that patient #12 was mentally ill indicated that the patients were satisfied, allowing the facility to close the grievances without taking further action. The problem of patient #12 being physically aggressive toward a physician and other staff members was addressed in patient #12's treatment plan. The problem of patient #12 attacking other patients was not addressed in the patent's treatment plan between 2/3/15 and 2/915. The above findings were confirmed during record review with staff H.

Based on observation, interview and record review, the facility failed to train 1 of 2 staff members (staff C) to properly implement the facility's physical restraint protocol and provide evidence of staff C's current training in the facility protocol, resulting in 1 current patient being improperly restrained (patient #5) and increased risk of injury during physical restraint for all patients. Findings include:
Record Review and Interview:
On 3/4/15 at 0935 a video of patient #5's physical hold during transport on 2/28/15 was reviewed with staff B and staff I. In the video staff C held patient #5's left arm with the elbow raised while walking the patient down the hall to the Seclusion Room. Another staff member held patient #5's right arm, without raising the patient's elbow. Staff B and staff I were asked what the facility's training protocol was for applying physical holds during patient transport. Both responded that staff are instructed to use CPI (Nonviolent Crisis Intervention) and that current CPI certification is a requirement for all staff involved in physical restraint of patients. Both staff (B and I) confirmed that the transport technique used by staff C, on the video, is not an approved CPI technique. At 1000 staff B and staff I were asked to provide evidence of staff C's training in CPI. On 3/4/15 at approximately 1530 staff B stated that facility staff were unable to locate evidence that staff C was certified in CPI training at the time of this incident.
Policy Review:
On 3/4/15 at approximately 1600, "Seclusion/Restraint, Use of, PC 18, dated 10/14, was reviewed.
According to the policy, "Direct care staff and PAs (Physician Assistants) /NPs (Nurse Practitioners) are required to attend Crisis Prevention management training and show evidence of competency related to participating in code situation...Physicians must have a working knowledge of the facility's policy regarding the use of restraint/seclusion."