HospitalInspections.org

Based on observation, interview and document review the facility failed to protect the rights of current and discharged patients, placing all 225 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 provide patients with complaints about treatment with grievance investigations for compliance with CMS (Centers of Medicare & Medicaid) requirements (See A-118),

--- the hospital's governing body failed to establish an effective process for ensuring that patient complaints/grievances are reviewed for compliance with CMS requirements (See A-119),

--- the facility failed to ensure timely and through abuse investigations (See A-145),

--- the facility failed to ensure that the use of "Law Enforcement Restraints" (hand cuffs with a belly chain and leg restraints), are used only by Law Enforcement Officials (See A-154),

--- the facility failed to ensure that instances of physical restraint are in accordance with a Physician's order (See A 168),

--- the facility failed to ensure that staff perform the one hour face to face evaluation for patients placed in restraints (See A-178).

Based on observation, record review and interview, the facility failed to establish a process for prompt resolution of patient grievances and provide 1 of 1 patients with complaints about treatment (patient #1) with grievance investigations for compliance with CMS (Centers of Medicare & Medicaid) requirements, placing all 225 current patients at increased risk of untimely, ineffective grievance resolution. Findings include:

Observations:
On 4/29/14 from 0950-1330 all 7 facility units were toured. Complaint forms and wall mounted boxes for filing complaints with the Office of Recipient Rights (ORR) were observed on all units. Postings with information on how to contact ORR staff were observed on all units. Postings with contact information for the CMS Complaint Hotline were observed on 6 of 7 units.

Policy Review:
On 4/30/14 from 1300-1730 policy review revealed that the facility lacks policies for ensuring review of grievances for compliance with CMS Conditions of Participation, including timelines and processes for resolution of verbal and written grievances.

Patient Rights Booklet Review:
On 4/30/14 from 1300-1730 a booklet included in the patient admission packet was reviewed. The booklet, titled Your Rights When Receiving Mental Heath Services in Michigan, dated 10/03, includes the following statements:
"Michigan's Mental Health Code and other laws safeguard your rights. Staff are responsible to protect your rights when they provide services to you."
"You have the right:
"To participate in the development of your plan of service."
"To choose within certain limitations, the physician or other mental health professionals to provide services for you."
"If you are an involuntary recipient, you do not have the right to refuse treatment."

Record Review:
1. On 4/30/14 at approximately 1700 review of the facility's organizational chart revealed that Office of Recipient Rights (ORR) staff are not part of the hospital's organizational structure. ORR staff report to a State agency outside the hospital's organization hierarchy.
2. On 4/30/14 from 0800-1500 review of the facility's "Complaint Log," provided by the ORR, for the period from 4/7/14-4/16/14 revealed that 10 complaints had been investigated, 26 complaint investigations were incomplete and 14 complaints were deemed to be outside of the ORR's (state regulatory) purview. There was no documentation indicating that these complaints (received by the ORR) were reviewed for compliance with CMS grievance requirements.
3. On 4/30/14 from 0800-1700 complaints filed by patient #1, dated 3/6/14 and 3/10/14, were reviewed. These complaints alleged that the facility was forcing the patient to take harmful drugs. The 3/10/14 complaint and an undated complaint by patient #1 (date stamped as received by ORR on 3/24/14) asked for a change in the patient's treatment team. No documentation of interviews or actions to address these complaints was found.

Interviews:
1. On 4/30/14 at 1330 Recipient Rights Advisor staff G stated that the Office of Recipient Rights receives most complaints made by patients and reviews them for compliance with the Michigan Mental Health Code, not CMS requirements. Staff G stated that he was not aware of a complaint review process to ensure compliance with CMS grievance requirements. Staff G stated that patient #1's complaints (above) had not been reviewed yet.
2. On 4/30/14 from 1710-1730 the facility Director was interviewed. The Director stated: "most patient complaints come in through the Office of Recipient Rights (ORR). I get a copy of the Acknowledgement Letter (from ORR) but I don't get a copy of the complaint for review." The Director stated that she does not supervise Office of Recipient Rights staff but is responsible for the hospital's complaint/grievance process. The Director confirmed that Recipient Rights staff are charged with ensuring compliance with the Michigan Mental Health Code only, not CMS Conditions of Participation. The Director stated that there is no process for reviewing complaints received by the ORR to ensure that CMS requirements are met.

Based on interview and record review the hospital's governing body failed to establish an effective process for ensuring that patient complaints/grievances are reviewed for compliance with CMS requirements, placing all 225 current patients at increased risk of untimely, ineffective grievance resolution. Findings include:

Policy Review:
On 4/30/14 from 1300-1530 review of facility policies revealed that the facility lacks policies and procedures to ensure review of patient grievances for compliance with CMS Conditions of Participation.

Interview:
On 4/30/14 at approximately 1730 interview with staff A, the Hospital Director stated that she has authority to act as the governing body for oversight of the facility's grievance process. The Director stated that she does not have authority to direct the activities of the Office of Recipient Rights. The Director confirmed that most complaints/grievances come in through the Office of Recipient Rights and are not reviewed for compliance with CMS requirements.

Based of record review and interview the facility failed to ensure timely and through abuse investigations for 4 of 6 patients (#17, #22, #19 and #20) with abuse complaints, resulting in increased risk of abuse for all 225 current patients. Findings include:

Policy Review:
The following policy was reviewed from 1300-1730 on 4/30/14.
Abuse and Neglect: Reporting, Investigation and Review, dated 7/1/11, states:
"It is the policy of (the facility)...to assure that all incidents of abuse or neglect are reported, reviewed, and investigated in a timely manner."

Record Reviews & Interviews:
1. On 4/30/14 at 1245 RRA (Recipient Rights Advisor), staff H stated that unit complaint boxes are checked 1-2 times per week, facility-wide.
2. On 4/30/14 at approximately 1030 RRA staff H confirmed that a verbal complaint alleging suspected staff abuse of patient #22, was received by the ORR (Office of Recipient Rights) on 2/24/14. Staff H stated that the investigation had not been completed yet.
3. On 4/30/14 at approximately 1250, two complaints dated 3/4/14, alleging that staff BB had been verbally abusive to patient #17, were reviewed. Staff H stated that these complaint investigations have not been completed.
4. On 4/30/14 at 1255 a complaint alleging staff physical abuse of patient #17 was reviewed with Recipient Rights Advisor staff H. The complaint was dated 4/4/14 and stamped as received by the Office of Recipient Rights (ORR) on 4/9/14. Staff H stated that the investigation had not been completed.
5. On 4/30/14 at approximately 1255 video tape of the above incident (see #4) was reviewed with staff H. Staff H confirmed that the video appears to show that patient #17 was pulled backward by staff F, using a physical restraint technique not taught in CPI (Crisis Prevention Intervention), the hospital's approved program for physical management of patients.
6. On 4/30/14 at approximately 1325 a 4/6/14 Incident Report describing a patient to patient altercation resulting in injuries to patients #19 and #20 was reviewed with RRA staff G. Patient #20 filed a complaint (dated 4/8/14) in regard to this incident, alleging that the care environment was unsafe. Patient #19 filed a complaint regarding this incident (dated 4/10/14), alleging that while physically restrained by staff, patient #20 was able to physically assault him. Staff G stated that he had not reviewed video evidence of the incident and that these investigations had not been completed.
7. On 4/30/14 at approximally 1715 Incident Reports for the physical abuse allegations involving patients #19, #20 and #22 (above) were reviewed with the facility Director. The last section of the "Incident Report" form, for completion by "Designated Supervisor," states: "Indicate program or administrative action taken, including disciplinary action, to remedy and/or prevent recurrence of incident." The Director was asked why review of these Incidents for appropriateness of program and administrative action was completed by Security staff, not clinical staff. The Director stated that facility policy allows non-clinical staff to make these determinations.

Based on interview and policy review, the facility failed to ensure that the use of "Law Enforcement Restraints"(hand cuffs with belly chain and leg restraints), are used only by Law Enforcement Officials for 68 of the 225 patients at the facility under a Court Order of Not Guilty By Reason of Insanity (NGRI) or are considered Incompetent to Stand Trial (IST) resulting in the potential for patient harm. Findings include:

On 04/30/2014 at 1400 during an interview with staff A, it was revealed that when patients who are under a court order either NGRI or IST need to be taken off the facility's grounds for medical appointments or court proceedings are placed in "hand cuffs with belly chains and if an escape risk leg restraints are also used." When staff A was queried as to if the facility staff are considered law enforcement she stated "no, we have talked about maybe getting some of the security staff/transportation staff deputized but have not done so yet." Staff A also stated, "the restraints would only be applied just prior to transporting the patient and would be removed once the patient is back at the facility."

On 04/30/2014 at 1430 during review of the facility's policy titled "Seclusion and Restraint, Effective Date: 12/15/09, Review Date: 12/15/12, 3. POLICY, Because the use of seclusion and restraint poses an inherent risk to the physical safety and psychological well-being of the patient and staff, it is {Facility A's} policy that seclusion and restraint are used only in an emergency, when there is an imminent risk of a patient physically harming himself or herself or others, including staff."

Based on record review, interview and policy review, the facility failed to ensure that instances of physical restraint for 6 of 6 patients (#3, #4, #5, #6, #7, #8) are in accordance with a physician's order resulting in the denial of the patient's right to be free from restraint. Findings include:

On 04/29/2014 between 0930 and 1500 with staff A (Facility Director), reviews were conducted of medical records for patients that had required physical management.

Review of documentation in the medical record for patient #3 revealed that on 09/08/2013 at 1135, "patient was in physical altercation with peer, threw plate at peer." According to the documentation, the staff used "hands on" to separate patient (#3) away from the other patient. The medical record lacked a Physician's order for the physical restraint of the patient.

Review of documentation in the medical record for patient #4 revealed that on 04/21/2014 at 1230, "patient charged at staff member." Staff used "hands on" physical redirection to direct the patient away from the employee. The medical record lacked a Physician's order for the physical restraint of the patient.

Review of documentation in the medical record for patient #5 revealed that on 11/14/2011 at 1140, " patient came out of room, sat in hall and began to perform an inappropriate sexual behavior, ignored staff's redirection, staff assisted patient to quiet room using proper CPI (Crisis Prevention Intervention) techniques." The medical record lacked a Physician's order for the physical restraint of the patient.

Review of documentation in the medical record for patient #6 revealed that on 04/04/2014 at 1305, the patient attempted to elope off the unit. "Staff blocked the patient from leaving the unit, patient struggled with staff resulting in physically controlling the patient's violent aggressive behavior using CPI techniques." The medical record lacked a Physician's order for the physical restraint of the patient.

Review of the documentation in the medical record for patient #7 revealed that on 03/25/2014 at 1200, "two patients yelling at each other, patient threw plate, verbal separation tried, then used CPI techniques to hold the patient by the arms..." The medical record lacked a Physician's order for the physical restraint of the patient.

Review of documentation in the medical record for patient #8 revealed that on 03/25/2014 at 2000, "patient hit peer, staff verbally redirected, patient held..." The medical record lacked a Physician's order for the physical restraint of the patient.

During reviews of the above medical records, Staff A was present and interviewed. Staff A confirmed that all of the records lacked physician orders for the physical managements. When queried about the lack of physician orders for the physical restraint, staff A stated, "we do not get a physician's order for physical hold, it is my understanding that if the physical hold only last for a short time then we do not need an order." When queried if it would be safe to assume that staff's statements above of using "proper CPI technique" means that they are using hands on physical management to redirect a patient, staff A stated, "Yes, they are putting on hands."
On 05/09/2014 at 0900 during a follow up phone interview with staff A, revealed that no physician's order is obtained for restraints that are applied, by facility staff, to patients taken off facility property for appointments such as court proceedings or medical appointments. Staff A stated, "this would apply to 25% of our patients that were here on an Incompetent to Stand Trial (IST) order and 5% of our patients that were here on a Not Guilty by Reason of Insanity (NGRI) order at the time of the survey visit." Facility census was 225 patients at the time of survey. Staff A also stated, the use of the restraints for off site visits does not occur very often."

On 04/30/2014 at 1000 a review of the facility's policy titled, "Seclusion and Restraint,: Effective Date: 12/15/09, Review Date: 12/15/12, reads in section 5. Definitions, 5.8 Restraint: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body, or head freely...Manual restraint/manual hold-A method in which the individual is restrained by the physical force of facility staff. Note: manual restraint includes such interventions of any duration, however brief..."

Based on record review, interview and policy review the facility failed to ensure that staff perform the one hour face to face evaluation for 6 of 6 patients (#3, #4, #5, #6, #7, #8) that required physical restraint for non-redirectable behavior resulting in the potential for a loss of the patient's right to be free from restraint. Findings include:

On 04/29/2014 between 0930 and 1500 with staff A (Facility Director), reviews were conducted of medical records for patients that had required physical management.

Review of documentation in the medical record for patient #3 revealed that on 09/08/2013 at 1135, "patient was in physical altercation with peer, threw plate at peer." According to the documentation, the staff used "hands on" to separate patient (#3) away from the other patient. The medical record lacked documentation of the one hour face to face evaluation.

Review of documentation in the medical record for patient #4 revealed that on 04/21/2014 at 1230, "patient charged at staff member." Staff used "hands on" physical redirection to direct the patient away from the employee. The medical record lacked documentation of the one hour face to face evaluation.

Review of documentation in the medical record for patient #5 revealed that on 11/14/2011 at 1140, " patient came out of room, sat in hall and began to perform an inappropriate sexual behavior, ignored staff's redirection, staff assisted patient to quiet room using proper CPI (Crisis Prevention Intervention) techniques." The medical record lacked documentation of the one hour face to face evaluation.

Review of documentation in the medical record for patient #6 revealed that on 04/04/2014 at 1305, the patient attempted to elope off the unit. "Staff blocked the patient from leaving the unit, patient struggled with staff resulting in physically controlling the patient's violent aggressive behavior using CPI techniques." The medical record lacked documentation of the one hour face to face evaluation.

Review of the documentation in the medical record for patient #7 revealed that on 03/25/2014 at 1200, "two patients yelling at each other, patient threw plate, verbal separation tried, then used CPI techniques to hold the patient by the arms..." The medical record lacked documentation of the one hour face to face evaluation.

Review of documentation in the medical record for patient #8 revealed that on 03/25/2014 at 2000, "patient hit peer, staff verbally redirected, patient held..." The medical record lacked documentation of the one hour face to face evaluation.

During reviews of the above medical records, Staff A was present and interviewed. Staff A confirmed that all of the records lacked documentation of the one hour face to face evaluation. When queried about the lack of the evaluation staff A stated, "since we thought that we did not need to get an order for patients that were in a physical hold for a short time, we also did not think that we needed to do the face to face evaluation for those patients."

On 04/30/2014 at 1000 a review of the facility's policy titled, "Seclusion and Restraint,: Effective Date: 12/15/09, Review Date: 12/15/12, 4. Responsibilities, 4.9 It is the responsibility of the assigned psychiatrist, or his or her psychiatrist designee, or another psychiatrist to (bullet 3) conduct an in-person evaluation within one hour of the initiation of seclusion or restraint and provide a written order. The patient must be evaluated within one hour regardless of whether they are still in seclusion or restraint or have been released..."