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BEAUMONT HOSPITAL - TAYLOR 10000 TELEGRAPH ROAD TAYLOR, MI 48180 May 21, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview and record review the facility failed to protect the rights of current and discharged patients, placing all 188 current patients at risk for loss of their rights.

Findings include:
---The facility failed to provide the Health Care Power of Attorney (HC-POA) and a family member of 1 of 1 patients with information on how to access the hospital's complaint/grievance process, increasing the risk of all 188 current patients not being informed of the grievance process. (A-0118)
---The facility failed to provide 1 current patient and the Health Care Power of Attorney for 1 discharged patient with the right to participate in health care decisions, increasing the risk of these rights being denied for all 188 current patients. (A-0131)
--- the facility failed to ensure thorough abuse investigations for 1 current patient and 2 discharged patients, and provide a procedure for investigating all allegations of patient abuse, increasing the risk of abuse for all 188 current patients. (See A-145)
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview and record review, the facility failed to inform two complainants for one patient (#12) who had grievances of how to access the hospital's complaint/grievance process, increasing the risk of grievances being unaddressed for all 188 patients. Finding include:

Policy Review:
Policy review was conducted on 5/21/14 from 1300-1500.
Patient Rights and Needs-Complaint and Grievance Resolution, Policy # 1020, dated 3/8/11, stated: "Anyone can receive an Issue. Issues are referred to the appropriate unit/department supervisor...If the unit/department supervisor is unable to resolve the Issue, the matter is referred for assistance to the Patient Representative. Complaining persons receive a copy of the (hospital name) pamphlet explaining how an Issue may be filed...They also are advised of their right to notify MDCH (Michigan Department of Community Health) or MPRO (Michigan Peer Review Organization)." The State of Michigan Complaint Hotline contact information for hospitals was not listed in this policy.

Record Review:
Record review was conducted from 0900-1500 5/20/14-5/21/14.
1. On 4/8/14 at 0100 a Progress Note by Nurse K states: "daughter...again accused staff of not taking good care of her mother." There was no documentation that staff J referred this family member (also the patient's Health Care Power of Attorney) to the hospital's grievance process or entered the complaint into the hospital's complaint/grievance process log for review.
2. On 4/10/14 Dr. J documented a conversation with another of patient #12's family members, in a Progress Note, stating that the family member had: "multiple other issues regarding the care at the hospital and not being satisfied with what is going on during this hospital stay." There was no documentation that staff J referred this family member to the hospital's grievance process or of the complaint being entered into the hospital's grievance process.
3. Neither of the above complaints were listed on the facility's complaint log.

Interview:
The above findings were confirmed during record review with staff F on 5/21/14 from approximately 1300-1500. Staff F stated that she did not feel that the above complaints required further follow-up since there was documentation of disruptive behavior by patient #12's HC-POA on 4/8/14.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on record review and interview, 2 of 2 patients or their representatives (for current patient #9 and discharged patient #12) were denied the right to make informed care decisions, increasing the risk of these rights being denied for all 188 current patients. Findings include:

Policy Review:
Policy review was conducted on 5/21/14 from 1300-1500.
1. Advance Directives, Policy # 1007, dated 7/16/13, states: "If a patient has a Patient advocate and a guardian, usually the Patient Advocate is the proper party to make medical or mental health treatment decisions if the advance Directive pre-dates the guardianship."
2. The Patient Handbook states: 'Patients are entitled to associate and have private communication and consultations with...any other persons of their choice...unless medically contraindicated as documented by the patient's attending physician in the medical record."
3. Corporate/Administrative Policy and Procedure: Patient Rights and Responsibilities, Policy #1039, dated 2/27/14, states: "Other visitation restrictions and limitations may be placed when visitors or support persons presence unreasonably and/or substantially infringes on another person's rights and/or safety." The policy does not state a procedure for implementing this policy, including who will decide what constitutes infringing and whether one episode of infringing will result in the visitor being permanently banned.
4. Safety Event Reporting (safety event reporting vendor A) for Patients and Visitors, Policy 916, dated 3/23/11, states:
II. "Safety event reports are to be submitted on all events that are not consistent with the routine operations of the hospital or the routine care of patients...Safety events are addressed immediately, and are documented and assessed using (safety event reporting vendor A) document...before the end of the shift by the person discovering the event, and (within) no more than 72 hours."
III. B. "Safety Event Report: All safety event, except employee incidents, are to be reported via vendor A risk safety reports...Reports may be submitted anonymously be users without passwords or in cases where the user is not comfortable attaching his/her name to the report."
IV.2.a. "The person discovering the event or the first person to become aware of the event shall submit the file above in (safety event reporting vendor A) document by the end of the shift during which the event occurred, and no later than 72 hours."
IV.2.b. "The reporting person is to include a complete, factual description of the event..."

Record Review for Patient #9, conducted May 19, 2014, at approximately 1100, revealed:
Patient #9 had two consent documents on file, a treatment consent marked "unable to sign, verbal consent obtained" but not identifying the specific person who consented and "An Important Message From Medicare," marked "Unable to sign, got verbal consent" and naming an individual as "Power of Attorney." No "Power of Attorney" documents were found in the patient's record.

Interview:
Patient #9 was interviewed 5/19/14 at approximately 1110. The patient was fully alert and able to participate in the conversation. Patient #9 stated that he signs his own consent forms. He stated that he has a "Power of Attorney" form at home, naming his grandson as his advocate.

Record Review for Patient #12, conducted May 20-21, 2014, from 0900-1700, revealed:
1. Patient #12's record revealed a properly executed Health Care Power of Attorney (HC-POA) document. The document was noted on the patient's record 4/4/14 in the "Admission Screening." The document states: "Patient Advocate may act immediately on my behalf and has...powers...to make all decisions and to take all actions regarding care, custody or medical and as applicable mental health treatment."
2. On 4/6/14 patient #12 had two episodes of unresponsiveness.
3. On 4/7/14 at 2030 patient #12's nurse (staff K) stated that the patient was "calling out" and "removing oxygen" and that the HC-POA became upset when informed that patient #12 received Haldol.
4. On 4/8/14 at 1230 a Security and Safety Department Incident Report states: "It was because of her (patient #12's HC-POA's) behavior, of constantly coming out of the Mom's room, staff wanted her taken off the premises."
5. An "Incident Report" (IR) was completed by "anonymous" at 0100. The report was not completed by patient #12's nurse, the person with first-hand knowledge of the incident.
6. On 4/8/14 staff G filed an Adult Protective Services (APS) referral.
7. On 4/9/14 the hospital filed for "an emergency guardian" for patient #12.
8. A Temporary Guardian was appointed on 4/16/14, with authority for "care, custody, and control of the individual." (There was no documentation indicating that the HC-POA had been revoked.)
9. A specific statement by patient #12's physician, stating that visits by the patient's HC-POA were medically contraindicated, was not found in the patient' medical record.

Interview:
1. On 5/19/14 at approximately 1345 an interview with patient #12's HC-POA stated that staff G told her that she was not allowed to visit the patient after the incident the night of 4/7/14 and that she was excluded from participating in the patient's care decisions after that date.
2. On 5/21/14 at 1015 during an interview with the Security and Safely Manager (staff I) stated that an accidently deleted roster showed that patient #12's daughter (HC-POA) was prohibited from visiting after the 4/7/14 incident. Staff I stated that "people are added to the roster if a Nursing Supervisor calls in a name."
3. On 5/20/14 at 1330 staff D confirmed that some of the events reported in the on-line Incident Report (IR) for patient #12 (on 4/7/12-4/8/12) reported statements and observations by the the patient's nurse, not the anonymous writer. Staff D could not explain why the patient's nurse did not write an IR, reporting her own first-hand observations.
4. On 5/21/14 at 1330 the patient's Social Worker (staff G) was asked if she was aware that patient #12 had a Decision Maker during her hospitalization . Staff G stated that she was not aware of this and did not include the HC-POA in care decisions or updates after the 4/7/14-4/8/14 incident.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview and record review the facility failed to establish a process for accurate reporting of patient abuse allegations and investigate 3 of 3 abuse allegations (for current patient #13 and discharged patients #12 and #15) in a thorough manner, placing all 188 current patients at increased risk of abuse. Findings include:

Policy Review:
Policy review was conducted on 5/21/14 from 1300-1500.
Abuse/Neglect/Assault: Identification and Intervention, Policy # 1011, dated 2/27/14 states:
"It is the policy of (hospital name) that patients are assessed and identified for, to the extent possible, protected from possible abuse...from...other patients, staff...If there is reason to believe abuse or neglect may have occurred, appropriate diagnostic and care procedures, internal and external resources, and reporting procedures are implemented to coordinate the care and protection of the suspected victim."
The policy states: "(Hospital name) will assess for the possibility of abuse, neglect, or exploitation: (d) In the clinical settings if the history, physical appearance, physical exam findings or other circumstances suggest the possibility of abuse, neglect or exploitation." There is no requirement that the facility ask patients alleging abuse for a statement regarding the allegation or investigate all allegations of patient abuse.

Safety Event Reporting (safety event reporting vendor A) for Patients and Visitors, Policy 916, dated 3/23/11, states:
II. "Safety event reports are to be submitted on all events that are not consistent with the routine operations of the hospital or the routine care of patients...Safety events are addressed immediately, and are documented and assessed using (safety event reporting vendor A) document...before the end of the shift by the person discovering the event, and (within) no more than 72 hours."
III.B. "Safety Event Report: All safety event, except employee incidents, are to be reported via (safety event reporting vendor A) document...Reports may be submitted anonymously be users without passwords or in cases where the user is not comfortable attaching his/her name to the report."
IV.2.a. "The person discovering the event or the first person to become aware of the event shall submit the file above in (safety event reporting vendor A) file by the end of the shift during which the event occurred, and no later than 72 hours."
IV.2.b. "The reporting person is to include a complete, factual description of the event..."

Record Review:
1. On 5/19/14 at approximately 1500 patient #13's abuse complaint was reviewed. There was no documentation of the patient interview on 5/13/14, as referenced in the "Complaint Acknowledgment/Intervention" letter to the patient, dated 5/15/14. The only patient interview date listed in the file was 5/15/14. The patient's specific allegations and interview statements were not part of the investigation documentation.
2. On 5/20/14 from 1300-1330 patient #12's abuse complaint was reviewed. A 4/13/14 Progress Note for patient #12 states: "Phone was ringing and (staff M) answered for patient. Patient began yelling that she was being abused and to come get her." An Incident Report (IR) by "Anonymous" reports what the staff member who first responded to the patient's abuse allegation (staff M) allegedly said and did. It was not completed by the person who discovered the event (staff M). Review revealed no documentation that the patient was asked to explain the allegation or identify an alleged abuser. The IR report states that the Event review was closed on 4/14/14.
3. On 5/21/14 at 12:15 patient #15's abuse complaint record was reviewed. The patient made an allegation of staff abuse on 4/7/14. The investigation file did not contain documentation of asking patient #15 to state the specifics of when and where the alleged abuse occurred. An investigation was conducted without documentation of these key facts.

Interviews:
1. On 5/19/14 at approximately 1530 staff L confirmed that there were no notes from patient interviews on any date, only the 5/15/14 letter summarizing past interviews, which did not contain the patient's statement of when and where the alleged abuse occurred.
2. On 5/20/14 at 1330 staff D confirmed that there was no documentation that patient #12 was asked to explain the abuse allegation or identify an attacker. Findings noted in the (above) Incident Report review were confirmed.
3. On 5/21/14 at 1100 staff L confirmed that there were no interview notes containing the patient's statement of when and where the alleged abuse occurred.