The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

UMHC-UHEALTH TOWER 1450 NW 10 AVENUE DRIVE MIAMI, FL 33136 Sept. 19, 2012
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure grievance process was initiated and documented for 2 out 12 sampled patients (SP). (SP#1 and SP#4).

The findings include:

Record review of SP#1 conducted from 09/17/2012 to 09/19/2012 revealed SP#1 was voluntarily admitted to facility's 10 North unit on 09/01/2012 with diagnosis of [DIAGNOSES REDACTED]. SP#1 has history of past suicidal ideas/intents, aggressive outbursts, depression, back pain and substance abuse.

Record review of SP#4 conducted from 09/17/2012 to 09/19/2012 revealed SP#4 was an involuntary admission (Baker Act) to 10 North on 08/24/2012 with diagnosis of [DIAGNOSES REDACTED][DIAGNOSES REDACTED], Hepatomegaly and [DIAGNOSES REDACTED].

Interview with SP#1 conducted on 09/17/2012 at 12:55 P.M. confirmed he was involved in an incident with SP#4. As per SP#1, SP#4 struck him on 3 separate occasions. On 09/11/2012, SP#1 stated that SP#4 "punched me in the neck during phone call with my mother".

Interview with SP#4 conducted on 09/17/2012 at 12:38 P.M. confirmed that she hit SP#1. SP#4 stated that SP#1 "was on the phone and he told me he was going to murder my mother, my sister and me."

Interview with SP#1's nurse for conducted on 09/18/2012 at 03:19 P.M. As per SP#1's nurse, at 07:40 P.M., the Mental Health Technician (M.H.T.) approached her and told her about the incident involving SP#1 and SP#4 but the incident was unwitnessed. SP#1's nurse stated she approached SP#1 and asked him what happened. As per the nurse, SP#1 told her "nothing really happened, she's very sick". The nurse further added that SP#4 is extremely paranoid and delusional. She's thinking that her twin sister grew a penis (hemaphrodite). SP#1's nurse contacted the Physician who is the same for SP#1 and SP#4 "to cover the incident and he ordered a 1:1 sitter. I didn't do an incident report because I approached SP#1 and he told me "nothing really happened, she's a sick lady". Surveyor asked the nurse about which are considered reportable incidents. The nurse replied "injuries, assault, when anything unusual happens, I involve everyone". Findings were confirmed at this time. No incident report was done. The Associate Vice President (A.V.P.) Psychiatric Department aware of incident and confirmed there was no report created.

Review of the facility's "Incident Reporting Policy" defines an "occurrence" or "incident" as:
Any unusual event involving a patient, employee, visitor or medical staff member.
Any event which either has caused or has the potential to have caused injury to a patient, employee, visitor or business invitee.
Any medication related event.

Interview with the A.V.P. Regulatory Compliance and Risk Management conducted on 09/18/2012 at 04:00 P.M. confirmed there was no incident report related to SP#1 and
SP#4's occurrence on 09/11/2012.