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.


Based on medical record review and interview the facility failed to provide a copy of an "Important Message from Medicare" (IM) to 3 of 6 current patients (# 2, #3 and #4) and 2 of 4 former patients (#13 and #14) depriving them of information necessary to exercise their rights. Findings include:

1. During medical record review on the inpatient psychiatric unit, from approximately 11 am-12 noon, it was noted that 3 of 6 patients (#2,#3 and #4) who are Medicare beneficiaries had no documentation of being provided with "An Important Message from Medicare" (IM) at admission nor attempts to provide the IM to these patient's representatives.
a. Patient #2 was admitted on [DATE]
b. Patient #3 was admitted on [DATE]
c. Patient #4 was admitted on [DATE]
2. On 9/6/12 at approximately 2 pm, closed record review revealed that 2 of 4 discharged Medicare patients (#13 and #14) did not have documentation of receipt of the IM at admission or discharge.
a. Patient #13 was admitted on [DATE] and discharged on [DATE].
b. Patient #14 was admitted on [DATE] and discharged on [DATE].
3. These observations were verified by the Director of Accreditation who was present during open and closed record reviews.
4. The hospital was unable to produce a policy and procedure for ensuring that Medicare patients receive "An Important Message from Medicare."
Based on record review interview and policy review, the facility failed to provide written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for the resolution for 3 of 7 grievances reviewed (for patients #5, #11 and #12). Findings include:


The Patient Grievance Policy, #195, defines a patient grievance as: "A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP)...."

Patient Findings:

1. Patient #5 verbally complained about the facility's failure to involve him in discharge planning. On 4/22/11 the patient was informed of a plan to immediately transfer him to another facility. The patient voiced objections. There was no documentation that the patient's objections were considered. The patient's family member phoned in a complaint on 4/22/12 alleging patient mistreatment by staff. Security staff physically restrained the patient after he became upset with the facility's transfer plan. The facility classified the family member's complaint as a grievance.

There was no documentation that a letter was sent to the patient or family member providing the results of the investigation or resolution. The facility's only letter to the family member, dated 4/29/12, states: "As you requested, you will be contacted following the process and informed of the resulting action plan." These findings were reviewed with the Recipient Rights Advisor/Patient Relations Representative on 9/6/12 at approximately 3 pm.

2. Patient #12's grievance was received by e-mail on 4/11/11. The facility classified it as a grievance. The grievance concerned allegations that the patient requested help plugging in a "BiPack" (BiPap?) and staff assistance getting to the bathroom and that these requests were denied or ignored. There was no documentation that a letter was sent providing investigation results or resolution. These findings were reviewed with the Recipient Rights Advisor on 9/6/12 at approximately 3 pm.

3. Patient #11's grievance concerned a care incident that occurred during discharge on 11/22/11. On 11/23/11 a phone complaint, received on 11/23/11, was classified as a grievance. Facility documentation indicated that staff had received the grievance verbally on 11/22/12. It concerned an allegation of staff neglecting to reconnect a patient's oxygen promptly at discharge. There was no documentation that a letter was sent providing the results of their investigation or resolution. These findings were reviewed with the Recipient Rights Advisor on 9/6/12 at approximately 3 pm.
Based on policy and record reviews and interviews, it was determined that the facility failed to allow 1 of 1 patients transferred to another facility (patient #5) with the opportunity to participate in his transfer plan. Findings include:


"Patient - Rights and Responsibilities," dated 6/7/12 states:
A. "Patients will not be denied appropriate care on the basis of...source of payment."
N. "Patients have the right to expect reasonable continuity of care, including discharge planning and discharge instructions. Patients are entitled to information concerning continuing health needs, alternative for meeting those needs and be involved in discharge planning. Patients will receive an explanation as to why a transfer to another facility is necessary and any other choices available."

The facility was unable to provide policies and procedures stating how the determination is made that the empty beds on their psychiatric unit may not be filled. This was verified by the Director of Accreditation.

Record Review:

From 9/5/12-9/6/12 review of patient #5's clinical record revealed the following:

1. 4/21/11 patient #5 was treated in the Emergency Department (ED) for a drug overdose, then transferred to an inpatient Medical Unit with a sitter.
2. 4/21/11 the patient's Consulting Psychiatrist states: "The patient will need to be transferred to an inpatient psychiatric bed once he is medically stable. Please contact psychiatric access (phone #) when he is medically stable." (Psychiatric Access is a hospital department.)
3. There were 20-21 of 24 beds available on the hospital's inpatient psychiatric unit from 4/21/11-4/22/11.
4. 4/22/11 at 11:01 am, a Psychiatric Access Consult note states that the patient's insurance is Medicaid and the reason for transfer is "MD issues." It notes that the facility's Psychiatric Unit is "closed due to MD resources." There was no notation stating who made this determination. It quotes a statement from a Community Mental Heath agency staff member to "try BCM as patient was there before." The section for documenting "Pt and family been informed and disposition discussed" was left blank. The section for documenting patient and family concerns about transfer was also left blank. Neither issue was addressed in the patient's clinical record.
5. 4/22/11 at 1:13 pm, a note by Social Worker #1 states: "The patient is to be involuntarily transferred the BCM in (city name)." No notes indicating discussion with the patient or family were found unit the patient was notified of immediate transfer at approximately 2 pm.
6. 4/22/11 at 2 pm, a note by RN #1 states: Pt (patient) calm and cooperative with staff until 2 pm when told would be discharged to BCM. Pt. became extremely agitated, ripping things off the wall and throwing them. Physically combative. Security called and involved in restraining pt."
7. 4/22/11 at 3:09 pm, a note by Social Worker #1 states that the following information was provided to patient #5's mother as "the rationale for his transfer to BCM:" "No beds in Washtenaw County and Washtenaw CMH/Crisis Response (Community Mental Health) team requested we try BCM in (city name) as he has been there before."
8. No documentation of any attempt to involve the patient or his family in discussions of transfer plans or possible alternatives were noted in the patient's record. No response to patient #5's request to not be sent to BCM was found.
9. Copies of legal documents for Involuntary Admission were not found in patient #5's record.
10. All document reviews listed above were reviewed with the Director of Accreditation.


1. On 9/5/12 at approximately 9:15 am the Medical Director of the inpatient Psychiatric Unit stated that the unit isn't always able to admit patients, due to lack of Psychiatrists.
2. The complainant was interviewed by phone on 9/5/12 at 8 pm.. The complainant stated that she was told by hospital staff that the patient could not be admitted to their psychiatric inpatient psychiatric unit because there were no Medicaid beds available. The complainant stated that the patient (#5), "was fine until they told him they were sending him to (transfer facility location)."
3. The Attending Physician was interviewed on 9/6/12 at 10:15 am. He stated that the decision to admit or transfer a psychiatric patient is made by the Access Center (a hospital department), not the physician.
4. The Consulting Psychiatrist who attended patient #5 was interviewed by phone on 9/6/12 at 10:30 am. The Consulting Psychiatrist stated: "We always try to keep patients here. It's up to the Access Center." And, "I would have been willing to admit him."
5. On 9/6/12 at approximately 11 am Behavioral Services Specialist (BSS) #1 was interviewed. BSS #1 stated that she was present on 4/22/11 at approximately 2 pm when patient #5 was informed of the transfer plan and that the patient "exploded." BSS#1 stated that the ambulance was waiting for the patient downstairs when the patient was first told of the plan. BSS #1 was asked who decides if a patient can be admitted to their psychiatric unit. BSS#1 stated that the patient's doctor can decide to admit to the psychiatric unit if there are beds available. BSS#1 verified that the notes did not state that BCM was the only alternative for transfer or document any response to the patient's complaints regarding this plan.
6. On 9/6/12 at 1:30 pm Team Leader (TL) #1 from Washtenaw County Community Mental Health agency, the patient's health care insurer, was interviewed. TL#1 stated that their records indicate that there were no available inpatient psychiatric beds in Washtenaw County on 4/22/11. Asked if patient #5's record noted communication from the hospital the regarding the patient's anger over the transfer plan, TL #1 responded that there was no such documentation. Asked if CMH would have tried to accommodate the patient's desire to transfer to a different hospital, TL #1 responded "yes." Records on inpatient psychiatric bed availability that day in surrounding counties was not available.