HospitalInspections.org

Based on interview, policy and record review, the facility failed to inform the guardian of 1 of 1 patients with a guardian (patient #1) of a possible injury due to alleged staff abuse and hospital transfer, resulting in increased likelihood of all guardians not being informed in a timely manner of patient injuries and hospital transfers. Findings include:
***Policy 2.04 " Nursing Process Documentation " states that Nurses are responsible for charting of Unusual Incident, including completing Incident Reports per procedure 2.06.03.
1. On 9/13/11 at approximately 0940 hrs. the CEO was provided with a list of requested policies, including a policy on, " Family/Guardian notification of transfers to hospital or injury."
2. On 9/13/11 at approximately 1345 hrs. the Recipient Rights Officer was asked when patient #1 sustained the eye injury that resulted in transfer to a hospital Emergency Room and an allegation of staff abuse. Nurse #1 stated that patient #1 sustained an eye injury on 9/3/11-9/4/11 on the midnight shift at approximately 2400 hrs. - 2430 hrs. On 9/8/11, review of photographs submitted by the complainant revealed patient #1's left eye to be grossly swollen shut.
3. Nurse #1 stated that she didn't know whether it was facility policy to notify the guardian immediately in these situations but that it was an accepted standard of nursing practice. (The policy on family notifications, requested at 0940 hrs., was not provided by exit at approximately 1800 hrs.)
4. On 9/13/11 at approximately 1300 hrs. Nurse #1, the former Chief Nursing Officer who assisted with the investigation on 9/4/11, was asked when patient #1's mother had been informed of the injury. Nurse #1 responded that the guardian was first notified on 9/4/11 at approximately 1930 hrs.
5. Review of the Incident Report, completed by the Nurse on duty at the time of patient #1's injury (Nurse #3), left all blank spaces in the section for listing "all persons notified." Progress Notes did not indicate any attempts to notify the guardian. A second Incident Report was completed on 9/4/11 at 0730 hrs. (by Nurse #2) also left all blank spaces in the "List all persons notified" section and Progress Notes did not indicated attempts to notify the guardian. These findings were confirmed by the RRO and Nurse #1 on 9/13/11 during interviews from 1240 -1400 hrs.

Based on observation and interview, the facility failed to provide a safe setting for patients locked in the seclusion rooms on the 2 and 3 North units due to lack of visualization of the entire rooms from outside the rooms, resulting in increased risk of injury for all secluded patients on 2 and 3 North units. Findings include:

*** Facility policy 2.20 #.01 states: "Patients in restraints or seclusion will be on 1:1 staffing with continuous monitoring using dual audio/visual system by assigned staff."

On 9/13/11 from approximately 1000-1040 hrs., the Seclusion rooms on 2 and 3 North were observed. In both seclusion rooms it was not possible to visualize a person in one corner of each room from the outside windows. Patient #7 had been secluded on 2 North earlier in the day on 9/13/11. No staff members on 2 North were able to get the video monitoring system of the Seclusion room to work and only 1 staff member on 3 North was able to activate the video monitoring room system. These findings were confirmed by the Director of Patient Program on 9/13/11 at approximately 1040 hrs.

Based on interview and record review the facility failed to train staff to promptly and accurately report and respond to incidences of suspected patient abuse for 1 of 1 patients (patient #1) resulting in increased risk of untimely, inaccurate reporting of patient abuse and lack of response to abuse allegations for all patients. Findings include:
***Policy 0.02, #9.02.12 " Definitions and Reporting of Abuse and Neglect" states: " All incidents of patient abuse or neglect which are apparent to, or suspected by, staff...shall be immediately reported orally and in writing to the office of Recipient Rights and to the employee or volunteer ' s supervisor to another administrator and in accordance with procedures. "
" Failure to report abuse and neglect shall subject the employee to administrative and potentially disciplinary action, up to and including termination.
***Policy 2.04 " Nursing Process Documentation" states that Nurses are responsible for charting of Unusual Incident, including completing Incident Reports per procedure 2.06.03.
***Policy 0.02, #9.02.14 " Investigation of Abuse and Neglect" states:
1. "The Recipient Rights Office who has reasonable cause to suspect the criminal abuse of recipient immediately shall make or cause to be made, by telephone or otherwise, an oral report of the suspected criminal abuse to the law enforcement agency for the county or city in which the criminal abuse is suspected to have occurred."
2. " Within 72 hours after making the oral report, the reporting individual shall file a written report with the law enforcement agency to which the oral report was made "
3. " The report shall become a part of the recipient's clinical record. "

1) On 9/13/11 at approximately 1345 hrs. the Recipient Rights Officer (RRO) was interviewed regarding the allegation of staff abuse of patient #1. The RRO stated that her investigation revealed that the alleged incident occurred on the night of 9/3/11-9/4/11, at approximately 2400-2430 hrs. The RRO reported that MHA #4 had provided her with conflicting statements, one stating that she actually witnessed MHA #3 hit patient #1 and one stating that she "stopped the hit." Other witnesses made statements that MHA #3 told them of hitting patient #1. The RRO stated that she has concluded that it was most likely that patient #1 was abused by MHA #3.
2) The RRO stated that she reported the different versions of MHA #3's statements to the CEO and was told that no personnel or other action was indicated. On 9/13/11 at approximately 1900 hrs. the CEO was asked why he reached this conclusion. The CEO stated that he was unaware that MHA #4's statements to the RRO had been inconsistent regarding whether or not she saw MHA #3 hit patient #1.
2) An Incident Report by the Nurse (#3), on duty at the time of patient #1's injury, had all blank spaces in the section for listing all persons notified. A second Incident Report, completed on 9/4/11 at 0730 hrs., by Nurse #2 also left all blank spaces in the "List all persons notified" section, although there was documentation of MD notification in the latter report. These finding were confirmed by the RRO and Nurse #1 on 9/13/11 during interviews from approximately 1240 -1400 hrs.
3. On 9/13/11 at approximately 1500 hrs. the CEO stated that on 9/4/11 he called the Detroit-Wayne Police Department to report the abuse allegation. The CEO stated that the Police Officer that he spoke with stated that they would not need to investigate the matter if the facility would be doing an internal investigation and that there had been no further contact with the Police Department since then. Review of patient #1's clinical record revealed no documentation that the facility follow-up with the Police Department, nor was there a copy of a report being forwarded to the Police, per policy, within 72 hours of the oral report.