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.

HAVENWYCK HOSPITAL 1525 UNIVERSITY DRIVE AUBURN HILLS, MI 48326 Jan. 11, 2012
VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS Tag No: A0469
Based on staff interview, and document review, the facility failed to ensure that all discharged inpatient's clinical records were complete within 30 days following discharge. Findings include:

During an interview with staff V on 01/11/2012 at 0900 , it was determined that 97 incomplete inpatient clinical records, that had exceeded 30 days following the patient's discharge from the hospital were awaiting signatures from two physicians.

This was verified by Staff V upon completion of the document review.
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
Based on observation, interview and record review, the facility failed to follow facility policy and accepted standards of practice for storage of sample medications for 1 of 1 Partial hospitalization patients (#37) resulting in the facility's inability to notify the patient should a recall occur. Findings include:

Facility Policy: Nsg-IV-07/Pharmacy #61, states:
D. (1) Keys to the medication cupboards and medication room are to be carried by only licensed nursing personnel."

On 1/9/12 at 1120 hours an Adult Partial Program nurse (Nurse R) stated that on approximately 3 occasions in the past year, she assisted patients in receiving sample medication from a supply located "in the doctor's office" across the hall. On 1/9/12 at approximately 1400 hours Nurse S stated that she received the medication from staff U, who maintains the sample supply.

On 1/9/12 at 1130 hours the sample medication storage area was observed with Staff U and the Director of Admitting and Utilization Review. Staff U had a key to a closet where sample medications were stored. Staff U verified that she was not a licensed practitioner in any field. Staff U stated that the sample medications were utilized in the private practice of the Adult Services Medical Director (Dr. #1). A tracking sheet for dispensed medications was reviewed.

On 1/9/12 at1410 hours, a Nurse on the Children's Partial Program unit (staff S) identified a discharged patient who had received a sample of the medication Intuniv. Nurse S stated that she received the medications directly from Staff U for patient #37 who was under the care of Dr. #2. Review of the tracking sheet for dispensed medications maintained by Staff U revealed no record of this medication being dispensed to patient #37. An inventory of all medications received was not available.

On 1/9/12 from 1430-1700 hours, review of patient #37's clinical record revealed a progress note by Nurse S stating: "Mom notified of ...addition of Intuniv...Notification form and sample of Intuniv sent home."

The above findings were verified by the Director of Admitting and Utilization Review on 1/11/12 at approximately 1100 hours.




On 1/09/12 at approximately 1150 during a tour of the adult unit C-1's medication room, found in the medication cart a single medication storage box in a top drawer with multiple patients' multidose medication containers stored in a single storage box. Patients' medication included topical creams, eye drops, nose drops and ear drops. The medication cart had individual boxes marked with the patient's room and bed number available for use. When interviewing staff A regarding why multiple patients' medication was stored together and not stored in the patient's designated drawer she replied "I don't know". A review of facility policy titled "Medication Administration" dated 9/08 revealed "...2. Keep medication for external use in a separate cupboard from medication for internal use...". The policy fails to specify that each patient's medication should be segregated from other's medication.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation interview and document review the facility failed to monitor for a sanitary environment and ensure that new policies for mitigation of bedbug outbreaks are followed resulting in the potential for transmission of infectious agents among patients being treated by the facility staff and visitors. Findings include:

On 1/9/12 starting at approximately 1015 during facility tour found
a). the bottom of the day room refrigerator on the C 1 side was soiled and had a used plastic bag stuck between the bottom of the refrigerator and the crisper drawer
b). the laundry room had floor storage of a dusty backpack, a white sock and a wash basin surrounded by large amounts of accumulated dust
c). personal items in the double occupied semi private room, 235 were stored around the bathroom sink where there was no available storage space
d). storage units 1, 2, and 4, where patients personal belonging for C 2 are stored had accumulated dust on the floor and in corners of the closets, personal items not bagged or marked with patient names, and facility storage of pillows in the same storage units.
e). personal items in a double occupied semi private room , 232 were stored around the bathroom sink in addition to a large bar soap found in the soap holder in the shower
f). in a double occupied semi private room, 230 a toothbrush and opened toothpaste were stored around the bathroom sink
g). in the medication rooms for C 1 and C 2 , dust has accumulated underneath carts and in corners of the room
h). the storage room for the C 1 men's patient's belongs has accumulated storage of personal clothing and suitcases and various tote bags that are not stored in bags designating patient by name, are stored (piled) on the floor, where there is accumulated dust
i). in the room marked "Phlebotomy" in a room formerly used for seclusion there was floor storage of patient clothing, patient care items and much clutter. Patient belongings are not marked with a name nor stored in a bag. Bags that are in use are ripped open with content spilling over onto the floor
j). the food refrigerator in the C 1 medication room is soiled and had accumulated ice in the freezer section

The above observations were confirmed by staff B.
According to staff W, she conducts quarterly rounds inspecting for cleanliness. A review of the facility "Infection Control Plan 2011 Strategies include to provide a clean, safe hospital environment for personnel, patients, and visitors...". A review of facility documents on 1/11/12 at approximately 1030 reveals completed documents titled infection control rounds in which they find "100% compliance".

On 1/9/11 at approximately 1330 during record review found that Patient #26 was admitted on [DATE] with what appeared to be a bedbug who was full with a bloodmeal. Interview with staff J confirms that "we gave him a shower, washed his belongings and treated the room...". Interview with staff W regarding problems with bedbug infestation confirms that they had a problem starting in January 2011 with bedbugs coming in from the community. Reoccurrence occurred throughout 2011. Staff W indicated that after research, a new policy was developed and approved by the Infection Control Committee on 1/2011. A review of the checklist for implementation of the protocol on 12/29/11 reveals blanks in the areas requesting "date and time of contact", and "staff name who located". Additionally the check list that requests "all personal items located room should be inspected and bagged", "all furniture in room should be treated once bed bugs have been verified" and "environmental services will clean room including vacuuming furniture, carpeting and interiors of dresser/wardrobes..." had a "N/A" written on the checklist. Interview with staff W regarding monitoring of implementation for this new policy reveals that she was not aware that this was how the checklist had been completed. Additionally, staff W indicated that she was not aware of the status of the storage of patient personal belongings on the C unit that may contribute to transmission of bedbug infestation.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based upon observation and staff interview, the facility failed to properly maintain the physical environment to ensure the safety of patients, visitors and staff.

Findings include:
On 1/10/12 at approximately 9:55 AM, based on observation, the chemical dispensing system in the environmental room was discovered to be connected to the water supply downstream from the built in Atmospheric Vacuum Breaker (AVB) subjecting the device to constant pressure. During tours of patient units, chemical dispensing systems in janitors closets throughout were observed to have the same cross-connection.
On 1/10/12 at approximately 10:05 AM based upon observation, during tour of the rooftop, exhaust fan 11 was discovered to be vibrating loudly. Two Rooftop Units (RTUs) located above the A Unit were also observed to have birdscreen torn and missing at the air intakes. Interview with the Director of Facility and Plant Operations revealed that the HVAC preventative maintenance is performed by a contracted company on a quarterly basis.
On 1/10/12 at approximately 10:45 AM based upon observation during tour of the kitchen it was discovered that the drain line from the ice machine terminates inside of a PVC pipe mounted to the wall. This PVC pipe then discharges into the floor sink located beneath the ice machine, without a clear unobstructed air gap.
On 1/10/12 at approximately 10:15 AM based upon observation, drywall damage was discovered in the A Unit supply room; and at approximately 12:00 PM drywall damage was discovered in the C2 Unit Med Room where a cabinet had been removed.
On 1/10/12 at approximately 12:40 PM during tour of the dietary storage area located in the basement, the following was discovered: a large crack in the quarry tile flooring running the entire length of the walk in cooler and the flooring of the cooler is buckling and is peaked in the middle; cove base is missing to the left of the exterior of the walk in freezer; old or unused equipment stored in an unorganized manner hindering cleaning of the space.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based upon observation and staff interview the facility failed to provide a sanitary environment to prevent transmission of infections and communicable diseases in areas throughout the patient units and support spaces.

Findings include:
On 1/10/12 at approximately 10:15 AM, spray bottles with labels reading chart cleaner spray and dry erase board cleaner were discovered stored on shelving above coffee, coffee filters, sugar and creamer; and at approximately 12:15, a spray bottle labeled chart cleaner was observed stored adjacent to crackers, creamers and lids to cups in the pantry of C Unit.
On 1/10/12 at approximately 10:20 AM on the A Unit, a room labeled "clean linen room" was observed to contain clean linen and supplies, as well as contain a clinical sink and a broom and dust pan. At approximately 11:35 AM the clean supply room on the B Unit was observed to also contain a clinical sink.
on 1/10/12 at approximately 11:40 Am, based on observation, the shelving of the patient belonging storage area on B Unit was discovered to be constructed of bare unsealed wood and plywood.
On 1/10/12 at approximately 12:45 based upon observation it was discovered that there are two dumpsters outside of the facility for refuse disposal. These dumpsters were observed to be overflowing, and the lids could no longer be closed. Interview with the Director of Facility and Plant Operations revealed that the waste disposal company comes to empty the containers every other day and that they are regularly filled beyond capacity and the lids cannot be closed.
On 1/10/12 between the hours of 9:45 AM and 12:30 PM, the following conditions were observed: dust and debris accumulation beneath shelving in the A Unit supply room (10:15 AM); dust accumulation on the top of the refrigerator in the A Unit clean linen room (10:20 AM); dust and grease accumulation on wire shelving and tops of coolers in the kitchen (10:45 AM); debris and dropped supplies accumulation beneath shelving in the B Unit supply room (11:30 AM); debris and dust accumulation beneath the medication dispensing unit in the B Unit medication room (11:35 AM); dust and debris accumulation beneath the medication dispensing unit in the C Unit medication room (11:50 AM)); dust accumulation on sloped tops of cabinets in C Unit medication room (11:50 AM); dust accumulation on sloped tops of cabinets in C Unit day room (12:10 PM); dust accumulation on sloped tops of cabinets in C Unit pantry (12:15 PM); dust accumulation on tops of cabinets and refrigerators in the Pharmacy (12:30 PM); 2 tabletop fans with dirt accumulation on the fan blades in the Pharmacy (12:30 PM).
On 1/10/12 at approximately 12:40 PM, the following conditions were observed in the Dietary storage room located in the basement: housekeeping mop and bucket with dirty water in it stored behind a wheeled cart containing single service items; paper napkins stored adjacent to a soiled extension cord and pieces of cove base; feather duster stored adjacent to service equipment; mops and brooms stored on top of boxes of Styrofoam containers; staff coats stored on top of packages of clean linen.
On 1/10/12 at approximately 12:35 PM, 12 boxes of Boost nutritional supplement were observed stored directly on the floor in the corridor outside of the Pharmacy.
On 1/10/12 at approximately 12:15 PM, containers of Styrofoam cups were observed stored directly on the floor in the C Unit pantry.
VIOLATION: VERBAL ORDERS AUTHENTICATED BASED ON LAW Tag No: A0457
Based on medical record review and interview the facility failed to ensure all orders are authenticated by physicians for 8 of 16 medical records reviewed (#1, #2, #3, #4, #6, #38 #42, #45) resulting in the potential for medical errors. Findings include:

"Medical Staff Rules and Regulations," under "General Conduct of Care" state:
"Telephone orders for medication shall comply with all of the following requirements:"
(iv.) Countersigned, including date and time, by a member of the Medical staff within 48 hours.
Facility Policy Nsg-V-031 states:
(1) Physician orders will be:
(c) 'given verbally or by telephone to a Registered Nurse or Pharmacist and be signed by the physician within 48 hours.
The above policies were reviewed 1/9/12-1/10/12.

On 1/9/11 from 1055-1120 hours, record review revealed that verbal orders for current adult Partial Program patients were not counter-signed within 48 hours for:
1) patient #38, Physician Initial Orders, taken on 12/27/11, were not counter-signed by the physician until 1/9/12.
2) patient #42, Physician Initial Orders, taken on 1/5/12, were not counter-signed by the physician.
3) patient #45, taken on 12/12/11, for Wellbutrin XL, was not counter-signed.

The above findings were confirmed on 1/9/12 from 1055-1120 hours by the Admitting and Utilization Review Director.




Medial record review on Unit 2B, on 1/9/12 at approximately 1030 to 1200, revealed verbal orders on multiple patients that had not been authenticated by the physician within 48 hours. This was verified by the 2B Unit Secretary and 2B Unit Manager during that time.

Patient #1 had verbal orders for Klonopin 0.5 mg i po bid and Seroquel 300 i po hs dated 1/1/12 that had not been authenticated as of 1/9/12.

Patient #2 had a verbal order to increase Klonopin to 1 mg po bid dated 1/6/12 that had not been authenticated.

Patient #3 had verbal orders written on 1/5/12 for Acetaminophen 650 mg q 6 hours prn pain, Maalox plus 30 mg 4 times a day for gastric distress, Benadryl 50 mg po or IM for extrapyramidal symptoms, that had not been authenticated.

Patient #4 had a verbal order dated 1/5/12 for Methadone 10 mg po q 8 hours prn pain that had not been authenticated within 48 hours, and remained unauthenticated as of 1/9/12.

It was noted that verbal orders were flagged in the medical record and that some orders were signed and others were not. Further interview with the 2B Unit Manager, on 1/9/12 at approximately 1130, revealed that no one takes the flags off the orders on the Unit once the physician signs the orders.




Medical record review on Unit 2 B, on 01/09/12 at approximately 1030 to 1130, revealed that 3 of 6 orders in patient #6's chart had not been countersigned by a physician. This included an order taken at 8 pm on 01/01/12 for " 2:1 Direct Obs R/T Severe Agitation danger to Staff and Peers", and a order dated 01/06/12 at 2330 for Ativan 1 mg po q 6 hours PRN for severe anxiety. An order for Trazadone 100 mg q HS PRN insomnia dated 01/07/12 1920 along with the previous orders were still not signed upon recheck at 0900 01/11/12.

These findings were verified with the 2 B Unit Manager at the time of review on 01/09/12 and on 01/11/12 at approximately 0900.
VIOLATION: PHARMACEUTICAL SERVICES Tag No: A0490
Based on observation, interview and record review the facility failed to provide pharmaceutical services according to their policies and professional standards of practice resulting in patients receiving medications that were not supervised or distributed by a registered pharmacist.

Failures in the following Standards were noted:

-A0491- Failure to follow accepted standards of practice for storage of sample medications

-A-0500- Failure to control and distribute drugs in accordance with standards of practice consistent with Federal and State law.

-A-0501- Failure to dispense drugs under the supervision of a pharmacist

-A-0505- Failure to avoid exposing Partial hospitalization Program patients to a supply of outdated drugs
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
Based on observation and interview, the facility failed to control and distribute drugs in accordance with facility policy and standards of practice consistent with Federal and State law. Findings include:

Facility Policy: Nsg-IV-07/Pharmacy #61, states:
D. (1) Keys to the medication cupboards and medication room are to be carried by only licensed nursing personnel."

On 1/9/12 at approximately 1130 hours, Staff U, an unlicensed staff member, was identified by the Director of Risk Management, as the sole holder of the key to a supply of psychotropic medications. Staff U verified that she holds the key to the sample medication closet and does not know of another sample supply in the facility. The contents of the closet were observed with Staff U and the Director of Admitting and Utilization Review.

Expired medications included: Zyprexa, 3 boxes expired 8/1/08, Lamictal 100 mg., 5 boxes expired 3/10, Stavzor 500 mg. 1 bottled expired 11/10, Cymbalta, 8 boxes expired 3/11, and Geodon 20 mg., 1 box expired 5/11. Staff U was not able to identify the last time these medications were inspected for expiration dates. These findings were verified by Staff U and the Director of Admitting and Utilization Review.

On 1/10/12 at 1500 hours, during an interview, the Director of Pharmacy stated that she is not aware of sample medications being stored and dispensed to Partial Program patients.
VIOLATION: PHARMACIST SUPERVISION OF SERVICES Tag No: A0501
Based on observation and interview, the facility failed to dispense drugs under the supervision of a pharmacist placing patients at increased risk of unreported ill effects of medications. Findings include:

On 1/9/12 at 1120 hours an Adult Partial hospitalization Program Nurse (Nurse R) stated that on approximately 3 occasions in the past year, she assisted patients in receiving sample medication from a supply located "in the doctor's office" across the hall. On 1/9/12 at approximately 1400 hours Nurse S stated that she received sample medications from staff U, who maintains the sample medication supply utilized by the Children's Adult Partial hospitalization Program, located across the hall from both programs.

On 1/9/12 at approximately 1130 hours, Staff U, an unlicensed staff member, was identified by the Director of Risk Management, as the sole holder of the key to a supply of psychotropic medications. Staff U verified that she held the key to the sample medication closet and did not know of another sample supply in the facility. The contents of the closet were observed with Staff U and the Director of Admitting and Utilization Review.

On 1/10/12 at 1500 hours, during an interview, the Director of Pharmacy stated that she is not aware of sample medications being stored and dispensed to Partial Program patients.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation and interview, the facility failed to avoid exposing Partial hospitalization Program patients to a supply of outdated drugs resulting in the possibility of patients receiving expired, ineffective medications. Findings include:

On 1/9/12 at 1120 hours an Adult Partial hospitalization Program Nurse (Nurse R) stated that on approximately 3 occasions in the past year, she assisted patients in receiving sample medication from a supply located "in the doctor's office" across the hall. On 1/9/12 at approximately 1400 hours Nurse S stated that she received sample medications from staff U, who maintains the sample medication supply utilized by the Children's Adult Partial hospitalization Program.
.
On 1/9/12 at 1130 hours the sample medication storage area was observed with Staff U and the Director of Admitting and Utilization Review. The following expired medications were found: Zyprexa, 3 boxes expired 8/1/08, Lamictal 100 mg., 5 boxes expired 3/10, Stavzor 500 mg. 1 bottled expired 11/10, Cymbalta, 8 boxes expired 3/11, and Geodon 20 mg., 1 box expired 5/11. Staff U was not able to identify the last time these medications were inspected for expiration dates. These findings were verified by Staff U and the Director of Admitting and Utilization Review.
VIOLATION: CONTENT OF RECORD Tag No: A0458
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to perform a history and physical (H&P) within 24 hours of admission for 1 (#1) of 12 patients reviewed for H&P. Findings include:

Review of patient #1's medical record on 1/9/12 at approximately 1030 on unit 2B revealed that the patient was admitted on [DATE]. The H&P was not documented any where in the medical record. Interview with the 2B Unit Manager and Director of Social Work, on 1/9/12 at 1100, verified that the H& P had not been done. Review of the progress notes did not indicate any reason why the H&P had not been done. Review of the facility policy titled "Physical Examination", revision date 8/03, documented that "all patients admitted to the hospital will have a physical examination (H&P) within 24 hours after admission. This patient had been in the facility for 13 days without the H&P performed. Neither the Unit Manager of 2B, nor the Director of Social Work could determine why the H& P had not been done.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and policy review,the facility failed to follow the process for prompt resolution of patient grievances in 2 of 10 charts reviewed (patient's #22 and #24). Findings include:

On 01/10/12 at approximately 0945 during review of the documents noted for the grievance process patient #22 was admitted on [DATE] and discharged on [DATE]. He voiced a situation that happened to him while hospitalized , to his mother. The patient's mother called the facility the same day (01/03/12). As of 01/10 /12 there was no documentation that showed that the facility was following their policy for a prompt resolution to the grievance.

On 01/10/12 at approximately 1015 during review of the documents noted for the grievance process for patient #24. The patient entered the grievance process on 10/24/11. The patient did not receive any type of communication until 11/23/11.

On 01/11/12 at approximately 0945 the patient's Recipient Rights Representative confirmed these findings.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0709
Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated January 12, 2012 for Life Safety Code.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.