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.

HARBOR OAKS HOSPITAL 35031 23 MILE RD NEW BALTIMORE, MI Sept. 30, 2014
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview and record review, the facility failed to investigate 1 abuse complaint (for patient #6) and failed to establish a process for prompt resolution of patient grievances resulting in the potential for loss of complaint rights for all patients. Findings include:

Record Review:
1. On 9/30/14 from 1515-1540 the facility's policies and forms for filing written and verbal grievances were reviewed. The facility does not have a policy or procedure stating how grievances related to non-compliance with CMS (Centers for Medicare & Medicaid) Standards will be reviewed. Staff training materials address how violations of the Michigan Mental Health Code will be addressed but contain no process for responding to possible violations of CMS Standards.
2. On 9/29/14 at 1300 a review of the facility's "Recipient Rights Complaint Log" revealed that the last complaint alleging patient abuse was filed 5/27/14.
3. A "Recipient Rights Complaint" form, dated 8/20/14, alleging abuse of patient #6, was received by the facility's Recipient Rights Officer but not logged as a complaint. The complaint alleges that patient #6 was being "emotionally abused" by staff F. The complaint also alleges possible neglect.

Interview:
1. On 9/30/14 at 0930 staff A, responsible for Quality Assurance, stated that staff D is the staff member responsible for reviewing patient complaints for compliance with both the Michigan Mental Health Code and CMS Standards.
2. On 9/30/14 at approximately 1400 staff D stated that she reviews written and verbal complaints for compliance with the Michigan Mental Health Code, not for compliance with CMS Standards. Staff D stated that she is unaware of any facility process for reviewing complaints for compliance with CMS Standards.
3. On 9/30/14 at 1400 staff D stated that all complaints, including anonymous complaints, are investigated unless she feels the complaint is "unlikely to have occurred." Staff D stated that the above complaint alleging abuse and possible neglect was not investigated because she thought it was "unlikely."
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review the facility failed to protect the rights of current and discharged patients, placing all current patients at risk for loss of their rights.

Findings include:
---The facility failed to establish a process for reviewing complaints to ensure compliance with CMS (Centers of Medicare & Medicaid) requirements. (See A-118)

--- The facility's governing body failed to establish a process for ensuring that patient complaints/grievances are reviewed for compliance with CMS requirements. (See A-119)

---The facility failed to ensure that 2 patients (current patient #4 and discharged patient #6) were allowed to participate in making informed decisions regarding treatment, resulting in increased risk of all patients being denied informed consent rights. (See A-0131)

--- the facility failed to acknowledge or investigate 1 abuse/neglect complaint (for patient #6). (See A-145)
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on interview and record review, the hospital's governing body failed to establish a process for ensuring that patient complaints/grievances are reviewed for compliance with CMS requirements, increasing the risk of loss of rights for all patients. Findings include:

Policy Review:
No policies or procedures for reviewing complaints to ensure compliance with CMS Conditions of Participation were found during policy review on 9/30/14 from 1100-1500.

Interviews:
1. On 9/30/14 at 0930 staff A, responsible for Quality Assurance, stated that staff D is the staff member responsible for reviewing patient complaints for compliance with both the Michigan Mental Health Code and CMS Standards.
2. On 9/30/14 at approximately 1400 staff D stated that she reviews written and verbal complaints for compliance with the Michigan Mental Health Code, not for compliance with CMS Standards. Staff D stated that she is unaware of any facility process for reviewing complaints for compliance with CMS Standards.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on interview and record review 2 patients (current patient #4 and discharged patient #6) were denied the right to participate in making informed decisions regarding treatment, resulting in increased risk of all patients being denied informed consent rights. Findings include:

Patient #4:
Interview:
On 9/29/14 at approximately 1100 patient #4 stated; "I want to see my doctor. I want to go home."

Policy Review:
On 9/30/14 at approximately 1500, the following policy was reviewed.
"Notice of Intention To Terminate Formal Voluntary Admission," policy 2.26.00, dated "10/2013" states: "Upon notification of an adult voluntary patient's desire to terminate hospitalization , the staff will provide the Notice of Intent to Terminate Formal Voluntary Admission form to the patient."

Record Review:
On 9/29/14 from 1400-1415 review of patient #4's record revealed:
1. Patient #4 was admitted on an Involuntary basis on 9/20/14 but that (Involuntary) status has expired.
2. On 9/22/14 patient #4 signed an "Adult Formal Voluntary Application" form.
3. On 9/24/14 at 2010 Nurse I documented that patient #4 requested to be taken to the hospital.
4. On 9/27/14 at 0900 Nurse H documented that patient #4 demanded to be taken to the police.
5. On 9/29/14 at 1230 Nurse H documented that patient #4 was "screaming at the Dr. I want to go home."

Interviews:
1. On 9/29/14 at 1415 Nurse H was asked whether she had provided patient #4 with a Notice of Intention To Terminate Formal Voluntary Admission form. Nurse H stated that she had not done so.
2. On 9/29/14 at approximately 1420 Nurse B was asked whether patient #4 was a Voluntary patient. Nurse B stated that the patient was a Voluntary patient at this time.
3. On 9/29/14 at 1420 Nurse B was asked whether patient #4 should have been provided with the Notice of Intention To Terminate Formal Voluntary Admission form when the patient stated the desire to leave. Nurse B stated that this should have been done.

Patient #6:
Patient Admission Packet review:
The following document was reviewed on 9/30/14 at 1545.
"Your Rights When Receiving Mental Health Services in Michigan," provided to patients at admission, states: "You have the right...to choose, within certain limitations, the physician or other mental health professionals to provide services for you...from a licensed hospital."

Policy Review:
The following policy was reviewed on 9/30/14 at approximately 1535.
"Change in Type of Treatment," #100.09, dated 8/26/13, states: "When a patient completes a rights complaint either verbally or in writing regarding a request to change their physician, then the following will occur:
a. The Recipient Rights Officer will immediately notify the Director of Clinical Services and the attending physician regarding the request of the patient.
b. If another physician is available to provided services to the patient, then the two physician's will consult within 24 hours and grant the request if the transferring physicians agrees to accept the patient and the transfer is in the best interest of the patient."

Record Review:
On 9/30/14 from 1000-1500 review of patient #6's clinical record revealed:
1. A 8/20/14 note by Nurse G stated that patient #6: "requested new Dr. RR (Recipient Rights) phoned."
2. An 8/20/14 note by patient #6's physician, staff F, quoting patient #6 as saying: "I want a new doctor. I don't like you."
3. A 8/21/14 note by staff F quoting patient #6 as saying: "I want a new doctor."
4. No documentation of any follow-up to the above requests were noted in patient #6's record or other facility records and a change in physician was not made.

Interview:
On 9/30/14 from 1415-1430 Staff D stated that she was informed of patient #6's desire to change physicians on 8/20/14. Staff D stated that she did not view patient #6's request to change physician's as a "patient rights" complaint even though it is listed as a right in a document (above) provided to patient's at admission. Staff D stated that she did not interview patient #6 in regard to this request. Staff D stated that the only staff member she informed of the patient's request to change physicians was staff F, the patient's current physician. Staff D stated that staff F informed her that the patient's request was going to be denied because discharge was anticipated in the next few days.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview and record review the facility failed to investigate 1 of 1 abuse/neglect allegations (for patient #6) resulting in increased likelihood of all abuse and neglect complaints going uninvestigated. Findings include:

Policy Review:
On 9/30/14 at 1515 review of facility policies revealed that the facility does not have a policy stating that all complaints of patient abuse and neglect will be investigated.

On 9/30/14 at 1520 the facility's "Office of Recipient Rights Annual Update" training document was reviewed.
1. The "Update" states that rights complaint forms may be completed by anyone.
2. The "Update" defines Abuse III as: "language or other means of communication to degrade, threaten or sexually harass a recipient."
3. The "Update" defines Neglect III as: "Omission or commission by an employee that placed or could have placed a recipient at risk of harm."

Record Review:
On 9/30/14 from 1000-1600 patient #6's clinical record was reviewed, revealing the following:
1. Patient #6 was a patient at the facility from 8/2/14-8/25/14.
2. Physician F's "Inpatient Psychiatric Discharge Summary," dated 8/25/14, lists Moderate Mental Retardation as a diagnosis. It states: "Over the past 5 days, we have seen an increase in (patient #6) becoming aggressive...This has required as needed medication and restraints."
3. A "Recipient Rights Complaint" form, dated 8/20/14, was received by the facility's Recipient Rights Officer. The complaint alleges that patient #6 was being "emotionally abused" by his physician. The complaint also alleges possible neglect and states that the patient "has had negative side effects from increased medication dosages."
4. A 8/20/14 note by Nurse G states that patient #6: "requested new Dr. RR (Recipient Rights) phoned."
5. "ADL Sheets" for 8/19/14-8/22/14 revealed the following:
- On 8/19/14 patient #6 refused breakfast and dinner. The patient ate 100% of lunch and a bedtime snack.
-On 8/20/14 patient #6 ate 0% of breakfast and 10% of lunch. No documentation of dinner or snack intake was noted.
-On 8/21/14 patient #6 ate 0% of breakfast and 60% of dinner. No documentation of lunch or snack intake was noted.
-On 8/22/14 patient #6's daily food intake was not documented for meals or snacks.
6. "ADL Sheets" for 8/23/14-8/25/14 could not be found.
7. A 8/23/14 Nursing Progress Note states: "Pt (patient) has not been eating very well, poor appetite. Pt eating less 10% of meals."

Interviews:
1. On 9/30/14 at 1400 staff D stated that all complaints, including anonymous complaints, are investigated unless she feels the complaint is "unlikely to have occurred." Staff D stated that the above complaint was not investigated because she thought it was "unlikely."
2. On 9/30/14 at 1415 Staff D stated that she was informed of patient #6's desire to change physicians. Staff D stated that she did not interview patient #6 in regard to this request and that request was not honored.
3. On 9/30/14 at approximately 1500 nurse B confirmed that there was no documentation of any facility response to patient #6's decreased food intake from 8/19/14-8/23/14.