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HARBOR OAKS HOSPITAL 35031 23 MILE RD NEW BALTIMORE, MI Nov. 27, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, policy review and interview it was determined that the facility failed to protect 1 of 1 patient's from injury (patient #3) and to fully address patient grievances's for 2 of 2 patients (#1 and #3). Findings include:

--the facility failed to fully investigate 2 of 2 patient grievances (patients #2 and #3) resulting in failure to fully investigate an abuse allegation and denial of the right to choice of physician. (A-0118)

-- the facility failed to establish a process for grievance resolution and review by the governing body, reducing the grievance rights of all patients. (A-0119)

-- the facility failed to protect 1 of 1 patients from increased anxiety and improper physical restraint application (patient #3) contributing to injury risk. (A-0145)
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview, policy, record review, the facility failed to promptly resolve patient grievances for 2 of 2 patients (#3 and #1) resulting in failure to fully investigate an abuse complaint and denial of patient rights. Findings include:

Patient #3

Policy Review:

From 11/26-11/27, 2012 review of the facility policies revealed:

Policy 100.05 titled "Abuse and Neglect," dated 2/12/09, revealed:

"Neglect is omitting or ignoring basic health care needs and health care problems. Abuse is mistreatment, either physical or psychological." All staff is to report incidents of possible patient abuse or neglect in the following way:
II. The patient is provided with a Recipient Rights Complaint form.
III. Staff member contacts the CEO, and/or Administrator On-Call, even in circumstances when a slight suspicion of abuse or neglect exists. The attending physician, rights advisor....as well.
IV. The CEO, and/or the Administrator On-Call and the rights advisor will conduct investigation immediately.

Facility policy 100.3, "Complaint and Appeals Process," dated 11/08, states:

III. "The Recipient Rights Advisor will initiate investigation of suspected rights investigations in a timely and efficient manner."
V. "The Recipient Rights Advisor will determine whether a right was violated..."
VII. The Recipient Rights Advisor will submit a written investigation report to the CEO, upon completion of the investigation."

Record Review:

From 11/26/12-11/27/12 review of patient #3's clinical record revealed:

1. On 10/6/12 at 1 pm BHA #3 documented that patient #3 stated: "I was abused by staff last night...Staff tripped me, now I can't get my meds."
2. On 10/6/12, an unsigned Physician Progress Note states that the patient's chief complaint was: "I've been abused."

Interview:

1. On 11/27/12 at approximately 12 noon the Recipient Rights Officer (RRO) was asked why she did not initiate investigation of patient #3's allegation of staff abuse. The RRO stated that she did not investigate because the patient did not fill out a complaint form. The RRO stated that she could have opened an investigation of abuse or neglect without the patient's written complaint but did not do so because the video tape of the incident did not show abuse, in her opinion.
2. The RRO verified that facility policy requires a Recipient Rights investigation when abuse or neglect are suspected and that this was not done.

Patient #1

Policy Review:

From 11/26-11/27, 2012 review of the facility policy 100.09 titled "Change in Type of Treatment "dated 2/12/09, revealed:

"A recipient will be given a choice of physician or other mental health professional within the limits of available staff."

Record Review:

On 11/26/12 from 11:00 am-1:45 pm review of patient #1's complaint form and clinical record revealed:

1. On 9/30/12 patient #1 completed a "Recipient Rights Complaint" form. The patient stated: "I want to switch from doctor (A) to doctor (B) because I was not comfortable with Dr (A) and I am more connected with Dr. (B) because he is more detailed and gives me more time to talk."
2. On 10/1/12 the Recipient Rights Officer, signed for receipt of the form.
3. On 10/4/12 the Recipient Rights Officer sent patient #1 a letter stating that the Social Worker and both Psychiatrists had been informed of the request and the the accepting Psychiatrist must be willing to accept the patient. The letter also states that "your concern is a protected right according to the Michigan Mental Health Code."
4. Review of patient #1's clinical record revealed no notations regarding the patient's request.
5. A copied note, dated 10/8/12 states: "Update: Does not want to change physician's now." It was signed by the Recipient Rights Advisor.

Interviews:

1. On 11/26/12 at approximately 1:15 pm the Recipient Rights Officer (RRO) verified that there were no notations of responses to patient #1's request noted in the clinical record. The RRO stated that it was the responsibility of the patient's Social Worker to follow-up on this request and document doing so.
2. On 11/26/12 at approximately 1:45 pm patient #1's Social Worker (SW) was asked what occurred in regard to patient #1 's request to switch Psychiatrists. The SW stated that she recalled a discussion at a Team Meeting where Dr. A said he wanted to keep the patient. The SW was asked if Dr. B was available and accepting patients at the time of this request. The SW responded, "I think so." The SW stated that it was unclear to her who was responsible for following-up on this request. The SW stated that she was unaware of any facility policy regarding patient requests to change physicians and verified that there was no documentation that the patient received any response until 10/8/12.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on record and policy review, the governing body failed to establish a process for grievance resolution and review by the governing body. On 11/27/12 at approximately 11:50 am Board of Directors minutes were reviewed with the Director of Quality (DQ). The DQ stated that he was unable to provide documentation had that the facility's governing body had formally approved a grievance process.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on interview, policy and record review the facility failed to provide all patients with written notice that there is no physician present 24 hours a day and ensure physician availability to respond to treatment requests. Findings include:

Record Review:

On 11/27/12 from 12 noon-3 pm, review of the 2 closed records for patients #1 and #3 and records for 5 of 5 current inpatients (#5, #6, #8, #9 and #10) revealed no documentation of patients being advised of the facility's lack of 24 hour physician coverage.

Interview:

On 11/27/12 at approximately 11:40 am the Director of Quality (DQ) was asked if patients are informed that the facility does not provided 24 hour on-site physician coverage. The DQ stated that the facility does not and that there is no facility policy addressing this issue.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, policy and record review, the facility failed to protect 1 of 1 patients (patient #3) from increased anxiety and improper physical restraint application contributing to injury risk. Findings include:

Policy Review:

From 11/26-11/27, 2012 review of the facility policies revealed:

Policy 100.05, "Abuse and Neglect," dated 2/12/09, revealed:

"Neglect is omitting or ignoring basic health care needs and health care problems. Abuse is mistreatment, either physical or psychological." All staff is to report incidents of possible patient abuse or neglect in the following way:
II. The patient is provided with a Recipient Rights Complaint form.
III. Staff member contacts the CEO, and/or Administrator On-Call, even in circumstances when a slight suspicion of abuse or neglect exists. The attending physician, rights advisor....as well.
IV. The CEO, and/or the Administrator On-Call and the rights advisor will conduct investigation immediately.

Policy 100.3, "Complaint and Appeals Process," dated 11/08, states:

III. "The Recipient Rights Advisor will initiate investigation of suspected rights investigations in a timely and efficient manner."
V. "The Recipient Rights Advisor will determine whether a right was violated..."
VII. The Recipient Rights Advisor will submit a written investigation report to the CEO, upon completion of the investigation."

Record Review:

From 11/26/12-11/27/12 review of patient #3's clinical record revealed:

1. Patient #3 was admitted on [DATE].
2. Patient #3's Interdisciplinary Plan of Service (IPOS) completed 10/3/12 states: "Patient reports uncontrolled anxiety." Patient complaints of pain were also noted. Under "Treatment Interventions" it states: "Patient will take meds as ordered and verbalize the purpose of taking meds by discharge."
3. On 10/5/12 an untimed note by Psychiatrist B states: "Highly anxious...Xanax works but doesn't last long enough."
4. On 10/5/12 Psychiatrist B wrote an order (time illegible) for "Xanax 1 mg. 4 times daily as needed for anxiety." In the MAR, a notation of "every 6 hours" was added to the physician's order by a nurse.
5. On 10/5/12 at 1:30 pm Behavior Health Aid (BHA) #2 noted: "Patient stated positive for anxiety 10/10 (the highest rating)...Anxious about the patch it's not working and I (explicative) need to smoke. Smoking withdrawal 10/10."
6. Patient #3 did not receive the Nicotine Patch 21 mg. topical daily as needed on 10/5/12. There was no notation explaining whether the patch was offered to the patient.
7. On 10/5/12 at 5:30 pm MHA #1 documented that patient #3: "Patient appears anxious...said he feels anxious...patient complained of back pain."
8. On 10/5/12 at 11 pm RN #2 documented: "Patient becoming increasingly agitated. He is stating that he wants to go home...Dr. C called twice with messages left- no return called at this time. Dr. B called and message left."'
9. On 10/6/12 at 2:10 am a Late Entry note by Nurse #1 states: "at 11 pm patient was agitated...screaming that he wanted medications (.Xanax) right now or else he was going to flip out...Patient told that he had to wait until 1 am for his next dose of Xanax." Nurse #1 states: "Multiple attempts were made to contact Dr. C due to the patient's agitated state, by this writer and the afternoon RN. Dr. C did pick up the call ar around 1:15 am on 10/6/12."
10. On 10/6/12 at 1:10 am patient #3 was injured while being physically restrained by staff, sustaining a chin laceration requiring sutures and a sprained wrist.
11. Review of the Medication Administration Record (MAR) for 10/5/12 revealed that patient #2 received Xanax 1 mg. at 2 pm and 7 pm only. A separate "PRN Log" also lists a 7:30 am dose, but this is not substantiated by the pharmacy's electronic medication sign-out system or the MAR.
12. It is unclear why the patient was told by Nurse #1 that another 1 mg. of Xanax could not be given until 1 am on 10/6/12 since the order was written for 4 times daily and the facility does not have policies stating that this translates into every 6 hours.
13. On 10/6/12 at 1 pm BHA #3 documented that patient #3 stated: "I was abused by staff last might...Staff tripped me, now I can't get my meds."
14. On 10/6/12, an unsigned Physician Progress Note states that the patient's chief complaint was: "I've been abused."

Facility record review:

1. On 11/26/12 the Quality Director (QD) and Recipient Rights Officer (RRO), were asked to produce all documentation regarding the facility's investigation and response to patient #3's abuse allegation.
2. The QD provided the facility's Incident Report and a facility Quality/Risk report that included staff interviews and partial analysis of the incident. It did not address all components of the investigation process and facility responses stated in policies that were omitted.
3. A video tape of the alleged abuse incident was reviewed by administrative staff then erased.
4. There was no investigation conducted by the Rights Advisor (Officer of Recipient Rights).
5. The only investigative notes of this incident, by the Quality Director, did not identify problems with medication transcription and variances in documentation of administration times, lack or physician availability and the facility's failure to respond to patient #3's complaint of nicotine withdrawal and high anxiety in the hours prior to the injury.

Interviews:

1. On 11/26/12 at 3:30 pm. Nursing Supervisor #1 stated that there was no policy or reason that patient #3 could not have been given 1 mg. of Xanax on the evening of 10/5/12 since it was ordered for 4 times daily. The Nursing Supervisor stated that the transcribing nurse did not have authority to add the limitation "every 6 hours" to the physician's order.
2. On 11/27/12 at approximately 12 noon the Recipient Rights Officer (RRO) was asked why she did not initiate investigation of patient #3's allegation of staff abuse. The RRO stated that she did not investigate because the patient did not fill out a complaint form. The RRO stated that she could have opened an investigation of abuse or neglect without the patient's written complaint but did not do so because the tape did not show abuse, in her opinion.
3. On 11/27/12 at 11:40 am the Quality Director (QD) was asked what the video (now erased) of the above incident revealed. The QD stated that it revealed that staff did not implement CPI techniques properly in transporting patient #3 and that may have contributed to the patient's injuries. The QD stated that the transport involved holding patient #3 by the arms and walking him down the hallway and that the patient was injured when all three fell down.
4. The QD stated that staff involved in the incident had been informed of the need to review CPI techniques but was unable to provide documentation of retraining with both staff.
5. The QD also verified that investigation of the incident did not identify problems with: medication transcription, variances in documentation of administration times, lack or physician availability and the facility's failure to respond to the patient's complaint of nicotine withdrawal and high anxiety in the hours prior to the injury. The report also failed to identify: the facility's lack of a policy or procedure for nurses to follow when they are unable to reach the on-call or attending Psychiatrist and the RRO's failure to follow policy in responding to the patient's allegations.
6. On 11/27/12 at approximately 11:40 am the Director of Quality (DQ) were asked whether the facility has policies or Medical Staff Bylaws specifying how physician services are provided when there is no physician on-site. The DQ stated that he was unaware of any policies or Medical Staff Bylaws addressing this issue.