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HENRY FORD MACOMB HOSPITAL 15855 NINETEEN MILE RD CLINTON TOWNSHIP, MI 48038 Sept. 26, 2013
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview and record review the facility failed to investigate and respond to 2 of 2 patient's abuse allegations (filed by discharged patients #3 and #1) resulting in increased risk of injury for all patients. Findings include:

Policy Review:

On 9/25/13-9/26/13 from 9 am-4 pm record and policy review revealed:

1. Your Rights When Receiving Mental Health Services in Michigan, provided to all facility psychiatric patients, states: "You have the right: not to be physically, sexually, or otherwise abused...If you feel you have been abused you should immediately report it to a staff person and to the Office of Recipient Rights....Within five (5) business days after receiving your complaint, the Recipient Rights Office will provide you with a letter which tells you that your complaint was received and a copy of the complaint. The letter will also tell you whether your complaint is going to be investigated."
2. The "Recipient Rights Complaint" form instructions state: "you (or someone on your behalf) may use this form to make a complaint. A rights officer/advisor will review the complaint and may conduct an investigation."
3. The "RadicalLogic Online Redform: Risk-Reporting of Safety Events" policy, dated 1/17/13, states: "It is every (hospital name) employee's responsibility to report unusual safety events...A safety event is defined as any event that may not be consistent with the desired, normal, or usual operation of the hospital...An injury does not have to occur..."

Patient #3

Record Review:

1. On 9/26/13 from 10 am-2 pm record review revealed a Nursing Note dated 8/20/13 at 1:02 pm stating: "Writer (nurse P) spoke with pt's (patient's) husband this morning who said that he is surprised no one on staff saw his wife being pushed by another patient...also demanded that patient be transferred to a medical hospital to receive medical care for her back." The time of this "morning" communication was not noted.
2. On 9/26/13 from 10 am-2 pm record review revealed a "Significant Event Progress Note" by nurse P, dated 8/20/13 stating: "Pt. (patient #3) said her back pain after she was pushed was 7/10, pt said this other pt grabbed her wrist too, but that she had no pain in her wrist." This note states that a medical consult was ordered. The time and place where the alleged abuse occurred was not noted. (This note was modified by nurse P six times between 2:01 pm and 2:45 pm so the time of this note is unclear.)
3. On 9/26/13 at approximately 2:30 pm the Recipient Rights Advisor provided a hand-written note with patient #3's name at the top, stating: "8/20/13 reported that another pt. pushed her-said her back hurt...(Staff EM) heard (patient #3) yelling and went in the room- The male pt. had some papers in his hand- didn't think they were his papers".
4. On 9/26/13 from 10 am-2 pm record review revealed a Nursing Note at 2:34 pm on 8/20/13 stating that "patient #3 was moved to another floor".
5. On 9/26/13 from 10 am-2 pm review of patient #3's clinical record revealed an 8/21/13 pm "Consultation" note by physician O stating: "(patient #3) was complaining of lower back pain and she sustained injury while she was attacked by another patient...IMPRESSION: Acute lower back pain, probably back strain." The note did not mention an assessment of patient #3's wrists for pain, skin integrity or bruising.
6. On 9/26/13 from 10 am-2 pm record review revealed that there was no documentation of an abuse complaint regarding the above allegations by patient #3 on the Recipient Rights Complaint Log or entered into the facility's electronic system ("Radiculalgic Online Redform") for reporting safety events.

Interviews:

1. On 9/25/13 at 12:30 pm patient #3 was interviewed by phone. Patient #3 stated that a male patient entered her bedroom, took her things and pushed her down, injuring her back. Patient #3 stated that staff M witnessed the alleged attack and "pulled him off me."
2. On 9/26/13 at 12:30 pm staff M was asked for a statement regarding the above allegation. Staff M stated: "A man with dementia was going in rooms. He was taking (patient #3's) stuff. She yelled. I came in and saw them tugging at some things...fighting over (patient #3's) things." Staff M stated: "(Patient #3) told me that he hit me." Staff M stated that he did not witness patient #3 being hit and that he could not recall the male patient's name."
3. On 9/26/13 at 12:45 staff G, the Recipient Rights Advisor, stated that she received patient #3's complaint but did not complete a "Recipient Rights Complaint" form or acknowledge the complaint in a letter. Staff G stated that she was unaware of any interventions being initiated to protect patient #3 or other patients around the time of the alleged attack.
4. On 9/26/13 at approximately 2:30 pm nurse N stated that she was unaware of any facility policies or procedures for responding to allegations of patient to patient abuse. Nurse N stated that patient #3's "Significant Event Progress Note," dated 8/20/13, should have led to completion of a RadicaLogic report.

Patient #1

Record Review:

1. On 9/26/13 from 10 am-2 pm review of patient #1's record revealed that patient #1 filed two "Recipient Rights Complaint" forms alleging abuse with the Office of Recipient Rights.
2. The first allegation, dated 8/12/13, alleges multiple incident of abuse and names the alleged abusers. Patient #1's second complaint, dated 8/16/13, alleges verbal and physical abuse by two (identified) patients. The incidents occurred in the Dining Room or hallway.
3. Staff G, the Recipient Rights Advisor, responded to both of the above complaints with letters stating that the patient may request a "formal investigation into this issue." Only one interview with a possible witness was noted in response to the 8/12/13 allegations.

Interviews:

1. On 9/26/13 at approximately 1 pm staff G. stated that neither of patient #1's abuse allegations, submitted on "Recipient Rights Complaint" forms, dated 8/12/13 and 8/16/13, were formally investigated. Staff G stated that patient #1 was not asked to identify possible witnesses for either allegation. Staff G stated that she had no notes of interviews with staff or patients in regard to either allegation of patient abuse.
2. On 9/26/13 at approximately 2:30 pm nurse N stated that she was unaware of any facility policies or procedures for responding to allegations of patient to patient abuse. Nurse N verified that a RadicaLogic Online Report was not filed for the patient #1's 8/12/13 abuse allegation.