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.

MCLAREN OAKLAND 50 NORTH PERRY PONTIAC, MI 48342 May 7, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
This CONDITION was not met as evidenced by:

Based on record review, policy review, observation and interview, it was determined the facility failed to: inform patients how to file grievances, establish a process for compliance with CMS Standards pertaining to grievances and respond to the substantiated grievance of 1 of 1 discharged patient (#8), provide an environment free to of construction hazards to current patients, thoroughly investigate the abuse allegation of 1 of 1 discharged patients (#11), and to ensure that 8 of 12 current nursing staff meet training requirements for the use of physical restraints, increasing the risk of injury, abuse and unredressed grievances for all patients. Findings include;

-The facility failed to provide current patients with information on how to file grievances and establish a process for grievance resolution on the psychiatric unit and respond to 1 of 1 substantiated grievances (for discharged patient #8). (A-0118).

-The facility failed to supervise patient access to an hazardous materials, including an industrial fan, construction materials and a vacant wing. (A-0144).

-The facility failed to thoroughly investigate the abuse allegation of 1 of 1 discharged patients (#11). (A-0145).

-The facility failed to ensure that 8 of 12 nursing staff meet requirements for physical restraint training. (A-0194).

The cumulative effect of which compromises the safety of all patient's served by the facility.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on observation, interview, medical record and policy review, it was determined that the facility failed to provide patients on the inpatient psychiatric unit with information on how to file grievances, provide an effective process for grievance resolution and to resolve for 1 of 1 substantiated grievances (for discharged patient #8), reducing the rights of all patients to file grievances and receive timely resolution. Findings include:

I. Patient access to an established grievance process:

Policy Review:

1. Patient Rights"#1-001, revised 5/11: states:
"It is the policy of (Hospital name)...to observe Recipient Rights, as set forth in the Michigan Mental Health Code."
S "Each patient shall receive a copy of his or her rights in the form of a Patient Rights Booklet printed by the State of Michigan." (Your Rights When Receiving Mental Health Services in Michigan).
2. Your Rights When Receiving Mental Health Services in Michigan states:
"You may file a complaint by calling or visiting the Rights Office or by completing the recipient rights complaint form and returning it to the Rights Office."

Observations:

1. On 5/6/13 at 9:20 am, no complaint forms, complaint box or posted instructions for filing complaints were observed on the psychiatric inpatient unit. These findings were confirmed by the Unit Manager (UM).
2. On 5/7/13 at approximately 2 pm the Director of Behavioral Health (DBH) confirmed that there were no written materials provided to psychiatric unit patients or postings, with information on patient's right to file a complaint with the State Agency (State of Michigan Complaint Hotline.)
3. On 5/6/13 at approximately 10:10 am patient #1 was observed with a stack of papers that the patient described as "complaint letters." This observation was confirmed by the Unit Manager.

Interviews:

1. On 5/6/13 at approximately 9:55 am Behavioral Health Technician #3 verified that the Complaint Box and Complaint Forms were not available in patient areas on the psychiatric unit. BHT #3 stated that the the Complaint Box had been unavailable in patient areas for "about 1 month."
2. On 5/6/13 at approximately 9:55 am the Unit Manager stated that the Recipient Rights complaint box and complaint forms should be available to patients. The UM stated: "The (compliant) box has been down 2-3 weeks for painting. It should be up."
3. On 5/6/13 at approximately 10:10 am patient #1 stated that she had left 1-2 written complaints "at the desk" (nurses station) "about 1 week ago."
4. On 5/7/13 at approximately 2:30 pm the Recipient Rights Officer (RRO) stated that all complaints by psychiatric unit patients are routed to the Recipient Rights Officer. The RRO stated that there is no other hospital grievance process available to psychiatric unit patients.
5. On 5/7/13 at approximately 2:30 pm the Recipient Rights Officer (RRO) stated that she did not receive any written complaints from patient #1 last week.
6. On 5/7/13 at approximately 2:30 pm the Recipient Rights Officer verified that the Recipient Rights Office is located outside of the patient's (locked) unit and that the Recipient Rights Office is closed evenings and weekends.
7. On 5/7/13 at approximately 2:30 pm the Recipient Rights Officer (RRO) verified that the Patient Rights policy pertains only to the Michigan Mental Health Code, not CMS Conditions of Participation. The RRO stated that only complaints that violate a MI Mental Health Code right are investigated, not those that may be grievances under CMS requirements.

II. Resolution of patient #8's substantiated complaint:

Policy Review:

Patient Rights, #1-001, revised 5/11, states:
I. "Each patient's personal privacy shall be assured and protected..."
T. "All employees are expected to protect the confidential communications between the staff and patients..."

Record Review:

1. A complaint by discharged patient #8, dated 11/27/13, states: "Doctor came into crowded dining room when there was a lot of noise to speak to me about my new admission." The complainant stated that the "right to privacy while speaking with a doctor" was violated.
2. The Recipient Rights Officer documented the complaint as "substantiated" and recommended that the medical staff receive training on patient confidentiality.

Interview:

On 5/7/13 at approximately 2 pm the Program Director (PD) confirmed that this complaint was substantiated that the resolution was to be a training session with psychiatric unit physicians. The PD stated that there was no documentation that the training had occurred.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and interview the facility failed to protect patients from unsupervised access to an industrial fan, constructions debris and access to a vacant unit under construction, placing all patients at increased risk of injury. Findings include:

Observation:

On 5/7/13 at approximately 3 pm a patient hallway with an industrial fan in operation, construction debris, including sections of drywall and an open door to an unused unit under construction debris was observed. No staff or workers were present at the time of this observation. These observations were verified by the Program Director and Program Manager, who were called to the area at approximately the same time to confirm these observations.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on policy and record review and interview, the facility failed to thoroughly investigate the abuse allegation of 1 of 1 discharged patients (#11), increasing the risk of abuse for all patients. Findings include:
Policy:
Identifying and Reporting Recipient Abuse and Neglect, #I-004, reviewed 5/11, states:
"It is the policy of (the hospital's) Department of Psychiatry to identify and report recipient abuse and neglect and to act upon this information."
IV. A. "Patient Abuse or Neglect that Occurred while in the Hospital: Employee:"
1. "Who receives notice of or witnesses an incident of patient abuse or neglect while a recipient of services is the hospital must report the incident to their "immediate supervisor" and the Recipient Rights Advisor."
2. "Documents all information concerning the incident on a "Risk Identification Report" form and a "Recipient Rights Complaint" form."
D. Patient Rights Advisor:
1. "Investigates the alleged abuse/neglect complaint and makes recommendations to the Program Director."
Record review:
1. On 5/7/13 at approximately 2:30 pm the Recipient Rights Officer (RRO) reviewed documentation of patient #11's abuse allegation and verified:
a. A "Recipient Rights Complaint" form, dated 3/8/13, written by the RRO, was based on a telephone complaint by patient #11's family member. (This was the only complaint form involving this patient.)
b. The investigation "Summary Report," by the RRO, dated 3/8/13, states: "On 3/8/13 (complainant's name) contacted the Office of Recipient Rights to file a complaint...(Complainant) reported that patient #11: "was left with a bruise on her shoulder as a result of 'a tech in blue scrubs named (BHT #5)' dragging her down the hallway."
c. The "Physical Appraisal" form, by Nursing, dated 3/1/13, shows no bruises to either of patient #11's shoulders. It shows a bruise on the right upper arm, closer to the antecubital area than the shoulder.
d. The "Investigative Report," by the RRO, states: "There is no evidence to support the allegations that (BHT #5) used unreasonable force with (patient #11) resulting in bruising to her upper right arm." (The site of the alleged injury, a shoulder, was not mentioned.)
e. There was no documentation that BHT #5 was asked if he had laid hands on patient #11 at any time.
f. There was no documentation of any attempt to identify when the alleged incident occurred or identify witnesses.
Interviews:
On 5/7/13 at approximately 2:30 pm the Recipient Rights Officer (RRO) was interviewed, regarding patient #11's allegation of staff abuse, revealing:
1. The RRO stated that she "had heard about the abuse allegation" before patient #11's discharge, on 3/7/13, and inspected the patient's arms before discharge but not the shoulder areas. The RRO stated that this was not documented anywhere.
2. The RRO stated that she did not document the abuse allegation that was reported to her prior to patient #11's discharge.
3. The RRO stated that the complainant was not asked when the alleged incident occurred or for names of possible witnesses.
4. The RRO stated that the only staff member interviewed as part of the investigation was the accused (Behavioral Health Tech- BHT-#5).
5. The RRO stated that she was not familiar with the "Risk Identification" form, referenced in the above policy ("Identifying and Reporting Recipient Abuse and Neglect).and had never completed one.
On 5/7/13 at approximately 2:45 pm the Program Director stated that he was not familiar with the "Risk Identification" form.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
Based on record review and interview, the facility failed to ensure that nursing staff received training in the use of physical restraint. Findings include:
Policy Review:
Restraints, #III-010, reviewed 5/11, states:
C. "Non-violent Crisis Intervention training and use of restraint will be provided to all clinical staff at the time or orientation and annually thereafter as part of their mandatory training."
Record Review and Interview:
On 5/7/13 at approximately 12 noon, the training records of 12 nursing staff members (nurses and Behavioral Health Technicians) were reviewed. Record review revealed that 8 of 12 staff (A, B, C, D, E, F, G and H) did not have documentation of current CPI (Crisis Prevention Intervention) training. These findings were confirmed by the Program Director and Unit Manager. The Program Director confirmed that annual CPI training is a nursing department requirement for Psychiatric Unit staff.
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review and interview, it was determined the hospital failed to ensure the Informed Consent for "Treatment of Psychoactive Medication" form was properly executed and completed with the patient or legal guardian's signature with date, physician signature with date. The hospital also failed to inform the patient and/or guardian of the use of the drugs, their benefit(s) and/or side effects in 5 of 10 records reviewed (M.R. #2, 3, 4, 5, and 9). Findings include:

Agency Policy, "Use of Psychotropic Medications" dated 04/05 stated, "The patients should be informed and educated about the proper use of the drugs and their benefits."

During an interview conducted on 5/6/13 at approximately 2:30 PM, when queried regarding the hospital's process for informing the patient and/or guardian regarding the psychotropic medications, giving informed consent for the use of psychotropic medications and the hospital's process for completing the Informed Consent for Treatment of Psychoactive Medication form, RN #1 stated, "the nurses writes the names of the medication(s) on the top of the form, the doctors reviews the medications with the patient or their guardian, then they (patient or guardian) signs the form, then the physician fills out the other part and signs it (sic)."

M.R.#2, 3, 4, 5 and 9: During the 5/6/13 and 5/7/13 record review period it was noted the "Informed Consent for Treatment Psychoactive Medication" form was used to list the patients' psychotropic medications, and document the patient/legal guardian had received information regarding these medications. The patient's/legal guardian's signature, on the form, indicate their informed consent to treatment with the medications. The physician's signature is also documented on the form. The forms were either blank, not properly completed, there were no patient/legal guardian or physician signature and dates, and no documented evidence the patient/guardian had been informed and given consent regarding the use of the psychotropic medications. It was noted the Informed Consent for Treatment of Psychoactive Medication forms were not properly executed.

M.R. #3: This patient was admitted on [DATE] with the diagnosis of Major Depression. The patient's medications were documented on the "Informed Consent for Treatment Psychoactive Medication" form as; Buspar and Lexapro. There was no physician's signature on this form, the signature line was blank. There was no documented evidence that the patient and/or guardian had received information regarding the psychotropic medications.

M.R. #4: This patient was admitted on [DATE] with the diagnosis of Depression. The patient's medications were documented on the "Informed Consent for Treatment Psychoactive Medication" form as; Depakote, Risperdal and Ativan. There was no patient/legal guardian or physician's signature on this form. There was no documented evidence the patient or legal guardian had been informed and given consent regarding the use of the above medications.

M.R. #5: This patient was admitted on [DATE] with the diagnosis of Dementia with Aggressive Behavior. The patient's medications were documented on the "Informed Consent for Treatment Psychoactive Medication" form as; Restoril, Xanax, Seroquel and Haldol. There was no patient or guardian signature on this form. The Multi-Disciplinary Assessment Summary dated 5/2/13 documented the patient's daughter had DPOA (Durable Power of Attorney). The form was blank in the area to document, "I received verbal consent from the legal guardian or DPOA." There was no documented evidence the DPOA had been informed of the patient's medications or had given consent regarding the use of the above medications

M.R. #9: This patient was admitted on [DATE] with the diagnosis of Psychosis NOS (not otherwise specified) with Dementia. The patient's medications were documented on the "Informed Consent for Treatment Psychoactive Medication" form as; Haldol, Ativan, Depakene, Restoril and Exelon. During the 5/7/13 record review, it was noted a "Letter of Guardianship" dated 7/1/11, signed by a judge, appointing the son "Full Guardian" of the patient. An "Order Vacating Appointment of Fiduciary," dated 7/1/11, signed by the judge, documented, "The appointment of [daughter] as Co-Guardian is vacated and [son] shall act as sole guardian with Letters of Authority to be issued by the court," was also noted in the record. The Informed Consent for Treatment Psychoactive Medication form was signed by the patient's daughter. There was no documented evidence the legal guardian had been informed of the patient's psychotropic medications and given consent regarding the use of the above medications.

Also, during an interview on 5/6/13 at approximately 2:15 PM, when queried regarding the deficiencies of the above "Informed Consent for Treatment Psychoactive Medication" forms Director #1 stated, "Sorry, I can't tell you why these forms aren't completed properly, I don't have an answer why the forms are incomplete."





MR #2: This patient was admitted on [DATE] and discharged on [DATE]. On 5/7/13 at approximately 9:30 am record review revealed that patient #2's daughter was identified as the patient's DPOA (Power of Attorney) on the "Multi-Disciplinary Assessment Summary," dated 5/7/13, and a "Power of Attorney: Health" form, dated 7/2/11, naming the patient's (same) daughter as DPOA. On the "Informed Consent for Treatment Psychoactive Medication" form, the following medications were listed: "Remeron, Celexa, Seroquel, Ativan and Oxycodone." The "Informed Consent for Treatment Psychoactive Medication" form was unsigned on the line for "Patient or Authorized Decision Maker," for verifying "I have received medication information material on this medication." The line for "Physician's Signature," for documenting one of the following statements: "I have explained the above (medications)...,The Patient is unable to provide informed consent...,I received verbal consent from the legal guardian or DPOA" was left unsigned. These findings were verified by Social Worker #1 on 5/7/13 at approximately 9:30 am.
VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS Tag No: A0469
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and policy, it was determined the hospital failed to ensure the record was complete, including the final diagnosis within 30 days of the patient's discharge in 1 of 3 discharged records reviewed (M.R.# 9). Finding(s) include:

Agency Policy, Discharge Summary, review date 01/09 stated, "The Discharge Summary will include, at the least: a discharge [psychiatric] diagnosis, a list of discharge medications, prognosis... The Discharge Summary will be completed by the Psychiatrist, within 30 days of the patient's discharge."

M.R. #9: This patient was admitted on [DATE] with the diagnosis of Psychosis NOS (not otherwise specified) and Dementia. The patient's discharge date was 2/15/13. At the time of the 5/7/13 record review, it was noted the Discharge Summary was approved by the physician on 3/22/13, thirty-seven (37) days after the patient's discharge. The Discharge Summary was authenticated by the physician on 3/25/13, forty (40) days after the patient's discharge. Also, there was no final diagnosis documented on this patient's Discharge Summary. The hospital failed to ensure this record was complete with the final diagnosis, and completed within 30 days of the patient's discharge.