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ST JOHN MACOMB-OAKLAND HOSPITAL-MACOMB CENTER 11800 EAST TWELVE MILE ROAD WARREN, MI 48093 Sept. 10, 2014
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on observation, interview and record review the facility failed to clarify the admission status of 1 of 3 current psychiatric unit inpatients (#11) and to provide a process for prompt resolution of patient grievances and respond to grievances filed by 3 of 3 patients (#6, #7 and #8), resulting in increased risk of all patients being denied their rights. Findings include:

Record Review and Interview:
On 9/9/14 at 1235 a sample of patient Adult Formal Voluntary Admission Applications were reviewed. Patient #11 applied for Voluntary Admission on 9/4/14. The section of the document for the Physician to sign-off on accepting the patient on a Voluntary basis was unsigned. On 9/9/14 at approximately 1240 staff D stated that patient #11 is currently a Voluntary patient and that the patient's psychiatrist should have signed this document to clarify the patient's legal admission status.

Policy Review: On 9/9/14 at approximately 1400, a review of facility policy titled,
"Complaint and Grievance Process, 1.4MO, dated 10/13, stated: A written complaint is always considered a grievance."

Observation:
On 9/9/14 at 1045 the inpatient psychiatric unit (3 West) was toured with the Psychiatric Unit Manager. At approximately 1100 a wooden box labeled "Rights/Suggestions" was observed in the patient Dining Room. Blank complaint forms were observed beside the box. This was the only complaint box and complaint form available on the unit. These findings were confirmed by the Psychiatric Unit Manager during the unit tour.

Interview:
On 9/10/14 at approximately 1200 staff F, responsible for reviewing patient's complaint forms, stated that a complaint that violates the Michigan Mental Health Code Standards is not reviewed for compliance with Centers for Medicare and Medicaid Services (CMS) Standards. Staff F stated that only complaints that do not violate a Michigan Mental Health Code Standard are referred for further review.

Record Review:
On 9/10/14 from 1110-1130 review of patient abuse complaints revealed the following:
1. On 8/20/14 physician I documented: "Staff reported that (patient #9) is more intrusive and impulsive and he is making inappropriate comments to other patients. He is hyperverbal, intrusive and impulsive."
2. On 8/20/14 at 2220 staff H documented that patient #9 was: "defiant, oppositional, intrusive with other patients, difficult to redirect, seeking of staff attention, argumentative with other patients and staff, calling another patient a 'bitch' in group."
3. On 8/20/14 three patients (#6, #7 and #8) filed complaints alleging that patient #9 had threatened them with physical or sexual abuse. Patient #8 also complained of being followed by patient #9 and feeling unsafe.
4. Patients #6, #7 and #8 received letters from the facility, dated 8/22/14, stating that their complaints were reviewed for compliance with the Michigan Mental Health Code and determined to be "unsubstantiated." The letter did not state that their grievances would be reviewed for compliance with CMS Standards.
5. There was no documentation of follow-up interviews with patients #6, #7 or #8, to determine whether they were satisfied with the facility's response to their abuse allegations.

Interview:
Staff F confirmed the above findings during record review on 9/10/14 from 1110-1130.

Record Review:
On 9/10/14 at approximately 1120 a complaint filed for patient #6 was reviewed, revealing the following:
1. On 8/14/14 patient #6 signed a consent form for ECT (Electroconvulsive Treatment).
2. In a letter to patient #6, dated 8/21/14, staff G stated that she received a telephone call form you (patient #6) stating, "I started ECT treatments, but I don't know if I'm going to like them. I want to be discharged by the psychiatrist."
3. Staff G provided information on the discharge process but did not address patient #6's statement that he may not wish to receive ECT treatments. Staff G's letter to patient #6 concludes: "this allegation is unsubstantiated."

Interview:
The above findings were confirmed during record review with staff G on 8/14/14 at 1120.