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.

HENRY FORD MACOMB HOSPITAL 15855 NINETEEN MILE RD CLINTON TOWNSHIP, MI 48038 Jan. 28, 2015
VIOLATION: PATIENT RIGHTS Tag No: A0115
This CONDITION is not met as evidenced by:

-The facility failed to provide patients on 1 of 3 units with information on how to file a complaint with the State agency, resulting in increased risk of all patients being denied grievance rights. (A-0118)
-The facility failed to establish a process for prompt resolution of patient grievances under CMS (Centers for Medicare and Medicaid) requirements resulting in 1 current patient being denied CMS grievance rights and increased risk of all patients being denied grievance rights. (A-0119)
-The facility failed to provide 1 of 1 current patients with fall risk safety interventions listed on the patient's care plan, resulting in increased risk of falls for all patients. (A-0144)
-The facility failed to provide 1 current patient and 1 discharged patient with timely, through investigations of abuse and neglect allegations and to require that all allegations of abuse and neglect be investigated, resulting in increased risk of all abuse and neglect for all patients. (A-0145)
-The facility failed to document clinical necessity or reasonableness of limitation when denying visitation to 1 of 1 current patients, resulting in increased risk of all patients being denied visitation rights (A-0217)
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on observation, interview and record review, the facility failed to provide patients on 1 of 3 units with information on how to file a complaint with the State agency, resulting in increased risk of all patients being denied complaint rights. Findings include:

Observation and Interview:
On 1/27/14 from 1230-1420 all 3 units were toured. On the 4 th floor unit, at 1410, there was no posting with information on how to file a complaint with the State Agency. This observation was confirmed by staff C. Staff C stated that the posting with this information frequently gets torn off the wall.

Record Review:
On 1/28/15 at approximately 1145 the facility's patient admission packet was reviewed. Information on how to contact the State agency to file a complaint was not included in the admission packet that is provided to patients on admission. On 1/28/15 at approximately 1145, staff D confirmed this finding.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on record review and interview, the facility failed to establish a process for prompt resolution of patient grievances under CMS (the Centers for Medicare and Medicaid) Conditions of Participation, resulting in 1 current patient being denied CMS grievance rights (patient #3) and increased risk of all patients being denied grievance rights. Findings include:

Record review:
On 1/28/15 at approximately 1010 a note by staff I was reviewed with staff D. The note, dated 1/15/15, stated that current patient #3's family complained that physician O was "quite rude" to patient #3. Staff I's note stated that he referred the complainants to the Office of Recipient Rights, "letting them know they can file an 'official' complaint if they chose to and it would be investigated."

Policy review:
On 1/27/15 at 1440 policy 201.03, titled, "Patient Concerns and Grievance," dated "9/2012", was reviewed. The policy stated, "Any grievance related to behavioral, Medicare or mental health treatment, shall be forwarded to the hospital's Recipient Rights Officer for appropriate investigation and resolution in accordance with the Michigan Mental Health Code." The policy contains no provision for providing investigations to ensure compliance with the CMS Conditions of Participation.

Interview:
On 1/27/15 at approximately 1440 staff N stated that the Office of Recipient Rights is responsible for handling all patient complaints and grievances at this facility. Staff N confirmed that the policy (above) does not state a process for ensuring that grievances are reviewed for compliance with CMS Conditions of Participation.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, 1 of 2 current patients (#2) was not provided with interventions identified in the patient's safety care plan, resulting in increased risk of falls for all patients. Findings include:

Record Review:
On 1/27/15 at 1320 patient #2's clinical record was reviewed. Patient #2, an 86 year old, was admitted on [DATE] with a diagnoses that included: confusion, impaired gait, osteopenia, lumbar canal stenosis, chr (chronic) mid back pain, pneumonia and congestive heart failure. On 1/4/15 patient #2 had episodes of sliding out of a geri chair on to the floor. Patient #4 sustained an injury on 1/4/15 when the patient: "lunged at door edge making a 1 cm. laceration on bride of nose."

On 1/27/15 at 1320 review of patient #2's clinical record revealed a "Physical Therapy Progress Note," dated 1/15/15, stating: that the patient's safety awareness and insight were impaired. For bed-chair transfer training, patient #2 was rated as needing "minimal physical assistance...1 person assist; verbal cues." Patient #2's list of "Safety Precautions/Fall Reduction" care plan interventions on 1/27/15 and 1/28/15 included "alarms." Nurse G confirmed the above findings during record review.

Interview:
On 1/27/15 at 1325 nurse G was asked how staff know when patient #2 needs assistance transferring from bed to wheelchair. Nurse G stated that patient #2 has a bed alarm on when he is in bed that sounds if he attempts to get out of bed without assistance.

Observation:
On 1/27/15 at 1335 patient #2 was observed sleeping in bed, with a wheelchair parked at the foot of the bed. The bed alarm was turned off. This observation was confirmed by nurses G and C.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to provide 1 current patient (#3) and 1 discharged patient (#1) with timely, through investigations of abuse and neglect allegations and to develop policies requiring that all allegations of patient abuse and neglect be investigated, resulting in increased risk of ongoing and uninvestigated abuse and neglect for all patients. Findings include:

Patient #3
Record Review & Interview:
On 1/28/15 at approximately 0940 grievance and complaint logs were reviewed with staff D. No grievances for patient #3 were logged. Patient #3 had two complaints listed on the facility's complaint log. Staff D confirmed that she was assigned to investigate patient #3's complaints. The first complaint was logged as received by staff D on 1/15/15. Staff D confirmed that her 1/15/15 investigation note stated that patient #3's family complained that physician O threatened the patient, stating: "If you don't be quiet, I'm going to take your rights away to have visitors" and that physician O told the patient to "shut up." The note stated, "staff wouldn't give (patient #3) a pad and she was bleeding all over."

On 1/28/15 at approximately 1000, a note by staff L, dated 1/12/15, was reviewed with staff D. The note stated, "Pt (patient) was on phone earlier, stating: "I'm being abused here." A second note by staff L, dated 1/15/15 stated, "Pt (patient) is telling peers 'Second shift is mentally, physically and emotionally abusing me.'" There was no documentation that staff L reported either of patient #3's abuse complaints to anyone.

Interview:
On 1/28/15 from approximately 1000-1010 staff D stated that she was not informed of staff L's documentation of staff abuse allegations in patient #3's clinical record. Staff D stated that she met with patient #3's family on 1/15/15 and logged their complaints under services not suited to the patient's condition, not as abuse or neglect allegations. Staff D stated that all of the allegations from 1/15/15 had not been fully investigated by the time of the patient's discharge on 1/27/15.

Patient #1:
Record Review:
Record review was conducted on 1/27/15 from 1400-1630. Patient # 1 was admitted on [DATE]. The patient had a diagnosis of "past medical history of autism." On 11/23/14, patient #1 stated that a male peer forced unwanted sexual contact on the patient. The accused patient (#5) admitted to going into a bedroom with patient #1 and touching the patient, but denied having sex with the patient, according to a note by nurse M, dated 11/23/14 at 1139. An internal investigation was initiated immediately.

A Safety/Security Event note regarding a second sexual abuse allegation by patient #1 was reviewed on 1/27/15 from 1400-1630. The Event note stated that on 11/24/14 at 2215 patient #1 stated that he had been molested by another patient. The report stated patient #1 identified patient #6 as the alleged perpetrator. The "Witnesses" section was blank, with no documentation of attempts to identify possible witnesses. The "Follow-Up Actions" section of the form, dated 12/16/14, stated that patient #6 "denied any contact with patient (#1)." The report contains no information of what the facility did to investigate the allegation, except for asking the accused patient (#6) if he molested patient #1.

Interview:
On 1/27/15 from 1400-1630, during record review, an Office of Recipient Rights staff member (staff D) confirmed the above findings. Staff D produced a one page note regarding the second abuse allegation. Staff D stated that there were no additional investigation notes for this allegation. Staff D confirmed that there was no documentation that the facility attempted to identify possible witnesses or to obtain detailed statements from patients #1 and #6 in regards to the 11/24/14 allegation.

Policy Review:
On 1/28/15 at approximately 1415 facility policies pertaining to abuse and neglect were reviewed.
Policy "Recipient Rights: Abuse/Neglect," not numbered, dated 8/9/2011, stated: "All apparent or suspected abuse and/or neglect of patients...must be reported immediately to the Recipient Rights Advisor." The policy does not require that patient allegations be reported unless they are deemed to be "apparent" or "suspected" by the staff member who receives the patient's abuse or neglect allegation.
Policy "Victims of Abuse and Neglect," #650.00, dated 12/10/13, stated, "The role of all (hospital) staff is to assist in the recognition and prevention of suspected abuse and neglect and take appropriate action by filing a report with the Department of Human Services (DHS). The role is not to make a conclusive decision as to whether the abuse/neglect occurred." The policy requires staff to report when there is "reasonable cause to suspect" abuse, neglect or exploitation. Hospital policy does not require hospital staff to report or investigate all patient complaints of abuse and neglect.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0217
Based on interview and record review 1 current patient (#4) was denied visitation rights without documentation of clinical necessity or reasonableness of the limitation, resulting in increased risk of all patients being denied visitation rights Findings include:

Policy Review:
On 1/28/15 at 1200 Policy 444, "VISITORS," dated 12/05/2011, was reviewed. The policy stated,
(1) "Limitation on visitation may be ordered when it is essential to prevent substantial and serious and/or physical harm. Mental harm may include to mean a visit, that in the opinion of the treatment team, would substantially upset the patient and interfere with ongoing treatment and rehabilitation."
(2) A visit may be limited or prohibited to prevent mental harm only if the person and limitations(s) are specifically identified in the patient's treatment plan and there is a physician's written order for it."

Patient #4:
Record review & Interview:
On 1/28/15 at approximately 1125 a note by nurse J, dated 1/18/15 at 1449 was reviewed. The note stated, "(Patient #4) was allowed to visit in hallway. (Patient #4) refused to pick up the food and other trash he and his visitor had left...dr. (the doctor) explained to patient if he and his visitors could not follow rules, visiting would be D/C (discontinued) for 3 days. (Patient #4) still refused to pick up trash, smiled and walked away."

On 1/28/15 at approximately 1130 review of "Orders" revealed a "Standing Order" by nurse J, dated 1/18/15 at 1449, stating; "No visiting x 3 days. Pt (patient) and visitors refused to follow unit rules."

On 1/28/15 from 1100-1130 staff D reviewed the contents of her note, dated 1/19/15. The note stated, "(Patient #4)...visiting restricted b/c (because) he wouldn't clean up mess from food his visitor brought in- * (Patient #4) will only eat packaged food.
-can visitors be reinstated?" Staff D stated that she received this verbal complaint from patient #4 on 1/19/15. Staff D stated that patient #4's visitor provided the patient's main meal since the patient refuses to eat unpackaged food. The note states that staff D asked patient #4's physician if the order could be discontinued (on 1/19/15). This order remained in effect until it was cancelled by nurse K on 1/20/15 at 1154. Staff D confirmed these findings during record review.

On 1/28/15 at approximately 1115 review of the facility's patient admission packet revealed a document titled "Patient Rights and Responsibilities" with a statement that patients are entitled to visitors "unless the visitor's presence compromises the patient's or others' rights, safety or health." There was no documentation indicating that the patient's alleged refusal to pick up litter caused a health or safety risk or of any facility efforts to notify the visitor of the facility's complaint. Staff D confirmed these findings during record review.

Interviews:
On 1/28/15 at 1110 patient #4 was interviewed. Patient #4 confirmed that he was denied visitation for 2 days. Patient #4 stated that he was not aware of any efforts by the facility to communicate with the visitor in regard to the littering allegation.

On 1/28/15 at approximately 1145 staff D confirmed that documentation to justify patient #4's visitation restriction, in keeping with facility policy, could not be found in the patient's clinical record or care plan.