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 Oct. 15, 2014
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview the facility failed to provide safe care by taking vital signs as ordered by a physician in four of four patients (#2, #3, #6 and #7) reviewed for safely administering medications, resulting in unsafely administering medications to patients. Findings include:

On 10/15/14 at approximately 1030 during review of the medical record for patient #2, it was revealed that vital signs were ordered to be taken two times a day. The patient was on medications that had sedative affects and required vital sign monitoring to safely administer the medications. The patient was in the facility from 8/9/14 until 8/29/14, vital signs were not taken as ordered on the following dates in August 10 th, 11 th, 12 th, 13 th, 14 th, 15 th, 16 th, 17 th, 18 th, 19 th, 20 th, 23 rd, 24 th, 25 th, 26 th, 27 th, 28 th and 29 th.

On 10/15/14 at approximately 1130 during review of the medical record for patient #3, it was revealed that vital signs were ordered to be taken two times a day. The patient was on medications that had sedative affects and required vital sign monitoring to safely administer the medications. The patient was in the facility from 8/31/14 until 9/10/14, vital signs were not taken as ordered during the patients' entire hospitalization .

On 10/14/14 at approximately 1130 during review of the medical record for patient #6, it was revealed that the vital signs were ordered to be taken two times a day. The patient was on blood pressure medications that required vital sign monitoring to safely administer. The patient was a current patient that was admitted on [DATE] and at the time of the survey, had not had vital signs taken as ordered for his entire stay.

On 10/14/14 at approximately 1200 during review of the medical record for patient #7, it was revealed that the vital signs were ordered to be taken two times a day. The patient was on blood pressure medications that required vital sign monitoring to safely administer. The patient was a current patient that was admitted on [DATE] and at the time of the survey, had not had vital signs taken as ordered for his entire stay.

On 10/14/15 at approximately 1215 during an interview with staff D it was confirmed that there was no evidence of vital signs being taken for patient #6 and #7.

On 10/15/14 at approximately 1300 during an interview with staff A it was stated "We know that getting vital signs in the medical records is a problem, we have a process improvement started." This surveyor asked "Do you have evidence that vital signs were taken for patients [#2 and #3]?" Staff A stated "No, I could not find them." This surveyor asked staff A if the facility had a policy regarding vital signs, staff A stated "No, we follow the doctors orders."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview the facility failed to thoroughly investigate and respond to:
- 2 allegations of staff verbal abuse (by discharged patients #36 and #37)
- 2 allegations of patient sexual abuse (by discharged patients #26 and #28)
- 1 allegation of patient physical abuse (by current patient #12)
-- resulting in increased likelihood of abuse for all patients.
Findings include:

Policy Review:
Conducted on 10/15/14 at 1400 and 1730.
Identifying and Reporting Abuse and Neglect, dated 04/08, states:
"Abuse is a non-accidental act by an employee, volunteer, or agent of the hospital that may cause or contribute to:
1a. Emotional harm of a recipient"
2c. "Verbal abuse means the use of language or other means of communication by an employee, volunteer or agent of the hospital to degrade, threaten, or sexually harass a recipient."

The policy provided did not address the hospital's duty to protect patients from patient to patient abuse during hospitalization by investigating and responding to allegations of patient to patient abuse.

Patients #36 & 37

Policy Review:
Conducted on 10/15/14 from 1100-1400 and at 1715.
Complaint/Grievance and Appeal Process, dated 6/13, states:
"An intervention may be initiated to resolve a complaint when the following elements apply:
-The allegation does not concern abuse..."
-"The allegation does not involve possible mandatory disciplinary action."
-"The facts of the case are clear."
-"The remedy is clear."

Policy Review:
On 10/15/14 at approximately from 1100-1400 and at 1715 the facility's Complaint/Grievance and Appeal Process policy, dated 6/13, was reviewed. The policy states:

"Any verbal complaints that cannot be resolved at that moment or that day, by the present staff will automatically become a grievance. If the staff is not able to respond to the patient's concern then he or she is to immediately notify the Recipient Rights Office via e-mail or telephone. Grievances about such situations that endanger the patient, such as abuse or neglect, should be handled immediately..."

"All patient complaints and grievances are logged and filed by the Recipient Rights Office for trending purposes and future reference by the hospital or legal counsel."

Record Review & Interviews:
The following record reviews were conducted on 10/14/14 from 1400-1445.
1. On 10/14/14 at 1400 staff D, the Recipient Rights Officer, was asked to provide all complaint and grievance logs for the past 6 months. Staff D stated that there is only one log for both complaints and grievances and that grievance entries are marked with the letter "G" and complaints are listed with no "G". Staff D stated that all complaints and grievances are listed on a single log.
2. On 10/14/14 at approximately 1430 staff D provided two complaint forms alleging possible staff verbal abuse, dated 7/8/14. Neither complaint was listed on the Complaint/Grievance log.
3. On 7/8/14 patient #36 filed a written complaint stating that staff O yelled at her and was "picking at patients for the fun of it."
4. On 7/8/14 patient #37 filed a written complaint alleging that staff O made "a snide remark."
5. In an interview note dated 7/9/14 at 1330, patient #37 stated that staff O said that a peer's stomach "sticks out more than her behind does."
6. In an interview note on 7/9/14 at 1340, patient #36 stated that staff O said that she had a "booty-do" and called her "ugly."
7. Interview notes state that both patients #36 and #37 reported the incident to the charge nurse who allegedly advised them to staff away from staff O until he "cools down."
8. Two patients who were present when the incident occurred provided witness statements in support of the complainant's allegations. Patient #38 stated that staff O called patient #37 "a stupid bitch." Patient #39 stated that staff O told patient #36 "that she had more fat in her stomach than in her butt."
9. There were no notes indicating that all possible witnesses were identified and asked whether they heard staff O make any harassing or abusive statements to patients during dinner on 7/9/14.
10. There was no documentation of an interview with the Charge Nurse on duty during the incident as part of this investigation. The Charge Nurse's alleged statement (to patients #36 and #37), regarding staff O's need to "cool down," was not investigated.
11. On 7/9/14 staff D wrote to the complainants (patients #36 & #37). The letter states: "this complaint does not warrant an investigation."

Interview:
On 10/14/14 at approximately 1445 staff D confirmed the above findings. Staff D was asked why it was concluded that the allegations did not warrant investigation since the allegations involved possible verbal abuse and two witnesses stated that staff O made derogatory statements to patients #36 and #37. Staff D stated that this was his conclusion based on a preponderance of the evidence.

Patients #26 and #28:

Policy review was conducted on 10/15/14 from 1100-1400 and at 1715.
Complaint/Grievance and Appeal Process, dated 6/13, defines a grievance as:
"A formal or informal written or verbal complaint that is made by a patient...abuse or neglect..." The policy states:

"If the Recipient Rights Advisor or designee is not able to resolve the grievance to the grievant's satisfaction the grievant will be advised their grievance will be reviewed by the Grievance Committee.

"Any verbal complaints that cannot be resolved at that moment or that day, by the present staff will automatically become a grievance. If the staff is not able to respond to the patient's concern then he or she is to immediately notify the Recipient Rights Office via e-mail or telephone. Grievances about such situations that endanger the patient, such as abuse or neglect, should be handled immediately..."

"All patient complaints and grievances are logged and filed by the Recipient Rights Office for trending purposes and future reference by the hospital or legal counsel."

Record Review & Interviews:
1. On 10/14/14 at 1400 staff D, the Recipient Rights Officer, was asked to provide all complaint and grievance logs for the past 6 months. Staff D stated that there is only one log for both complaints and grievances and that grievance entries are marked with the letter "G" and complaints are listed with no "G". Staff D stated that all complaints and grievances are listed on a single log.
2. Patient abuse complaints by patients #26 and #28, documented in incident reports dated 9/16/14, were not listed on the complaint/grievance log provided on 10/14/14.
3. On 10/15/14 at 1210 staff D provided an untitled list of complaint/grievance notes for multiple patients with dates from 5/3/14-9/17/14. The list included the following statement, dated 9/16/14: "Patient (#28) reports that she was touched inappropriately by another female peer (patient #27) across the breasts and stomach during afternoon smoke break...Grievance officer investigation/follow-up: Pt. (patient) states she feels safer." Staff D stated that he had no investigation notes or witness statements.
4. On 10/15/14 at 1240 the incident report for the above allegation was reviewed. The report was written by nurse L who did not identify herself as a witness. Nurse L left the "Witnesses" section blank. Staff P was assigned to supervise the afternoon smoke break (per the 9/16/14 "Day Assignment Sheet"), and should have been present during the alleged incident.
5. On 10/15/14 at 1245 a second allegation of sexual abuse by patient #28, during the same smoke break (above) on 9/16/14, was noted in another incident report. Nurse M wrote that patient #28: "states peer touched her boobs and was rubbing her hands up and down." Nurse M did not identify herself as a witness. The section of the form for identifying witnesses was blank. There was no documentation of Grievance officer investigation/follow-up or any investigation. There was no documentation of asking patient #28 whether she was satisfied with facility efforts to address the alleged abuse.

Interview:
The incident report findings (above) were confirmed by staff A during record review on 10/15/14 from approximately 1240-1300. Staff A was asked why patients and staff present at the smoke break were not asked to provide witness statements. Staff A stated that staff are trained not to include patient witness statements in incident reports. Staff A stated that she did not know why there were no statements by staff witnesses since staff P should have been present to witness both allegations. Staff A stated that the incident reports were completed properly since staff are trained that the "Witnesses" section of the incident report form is optional.

Patient #12:

Policy Review:
On 10/15/14 at from 1100-1400 and at 1715 the facility's Complaint/Grievance and Appeal Process policy, dated 6/13, was reviewed. The policy states:
"Any verbal complaints that cannot be resolved at that moment or that day, by the present staff will automatically become a grievance. If the staff is not able to respond to the patient's concern then he or she is to immediately notify the Recipient Rights Office via e-mail or telephone. Grievances about such situations that endanger the patient, such as abuse or neglect, should be handled immediately..."

Interview:
On 10/14/14 at 1510 patient #12 stated that she was "hit on the head last night" by patient #9. Patient #12 stated the patient who hit her (patient #9) is still on the unit. Patient #12 stated that she was restrained by staff and given medication as a result of this incident and that she didn't think it was fair that she was punished for being hit. Nurse N was present during this interview.

Record Review:
1. On 10/14/14 at 1515 review of patient #12's record revealed that both she and patient #12 were physically restrained the evening of 10/12/14. Nurse N confirmed this finding.
2. On 10/15/14 at 1215 review of the facility's incident report log revealed that patient #9 "attacked" patient #12 on 10/12/14 at 2140 and 2315. There was no documentation of patient #12 being attacked on 10/13/14. It was unclear whether patient #12 was complaining about being attacked and restrained on 10/12/14 or alleging that another incident occurred on 10/13/14.

Interview:
On 10/15/14 at approximately 1215 staff D stated that he is not aware of any patient abuse allegations being received by staff in October 2014.
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
Based on record review and interview the facility's governing body failed to be responsible for operation of an effective grievance process resulting in all patients being at risk for loss of grievance rights. Findings include:

Policy Review:
1. On 10/15/14 from 1100-1400 and at 1715 the facility's Complaint/Grievance and Appeal Process policy, dated 6/13, was reviewed. The policy states:
"All patient complaints and grievances are logged and filed by the Recipient Rights Office for trending purposes and future reference by the hospital or legal counsel."

Record Review & Interview:
1. On 10/14/14 at 1400 staff D, the Recipient Rights Officer, was asked to provide all complaint and grievance logs for the past 6 months. Staff D stated that there is only one log for both complaints and grievances and that grievance entries are marked with the letter "G" on the log and complaints are listed without a "G".
2. On 10/14/14 from 1400-1415 staff D confirmed that the last log entry date for receipt of a patient complaint or grievance was 9/30/14.
3. On 10/14/14 from 1400-1445 staff D provided 3 complaint forms, for patients #15, #36 and #37. The complaints filed by patients #36 and #37 alleged staff verbal abuse. None of these complaints were listed on the log. All occurred prior to the last log date (9/30/14).
4. On 10/14/14 no documentation (complaint statements, investigations or response letters) could be found for 5 patient complaints listed on the log (for current patient #12 and discharged patients #13, #14, #16 or #17.)
5. All findings listed above were confirmed by staff D during record and log review on 10/14/14 from 1400-1445.
6. On 10/15/14 at 1210 staff D provided an untitled list of complaints and grievances and facility responses, 11 pages long, with dates ranging from 5/3/14-9/16/14. Names on this list did not match the list of logged complaints provided on 10/14/14. The 10/15/14 list was not in log form and consisted of brief descriptions of patient complaints or grievances and brief statements titled: "Grievance officer investigation/follow-up."
7. On 10/15/14 at 1215 staff D stated that he did not have additional documentation of complaint investigation and response letters for the complaint list provided on 10/15/14. Staff D could not explain why the complaints provided on 10/15/14 were not logged or provided (upon request) on 10/14/14.
VIOLATION: PATIENT RIGHTS Tag No: A0115
This CONDITION is not met.

Based on observation, interview and record review:

-- The facility failed to notify 1 of 1 current patients (#9) of a court hearing date resulting in increased risk of loss of legal rights for all patients. (A-0117)
-- The facility failed to establish a process for prompt resolution of patient grievances resulting in 1 current patient (#12) and 4 discharged patients (#13, #14, #16 and #17) not receiving through, timely complaint investigations. (A-0118)
--The hospital's governing body failed to establish an effective process for review of patient complaints and grievances resulting in increased risk for loss of complaint rights for all patients. (A-0120)
--the facility failed to provide care in a safe setting by failing to take vital signs before administering medications for 2 current patients (#6 and #7) and 2 discharged patients (#2, #3) resulting in increased risk of unsafe medication administration for all patients. (A-0144)
-- the facility failed to ensure timely and through abuse investigations for 1 current patient (#12) and 4 discharged patients (#26, #28, #36 and #37), resulting in increased risk of patient abuse. (A-0145)
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on document review and interview the facility failed to notify patients of their court hearing dates for one of one patients (#9) reviewed that were scheduled to go to court. Findings include:

On 10/14/14 at approximately 1245 during review of medical record #9 who was admitted involuntarily, it was revealed that the patient did not go to her mandated court date. No evidence in the medical record could be found to support that the patient was notified of the court date and time.

On 10/14/14 at approximately 1430 during review of the booklet titled "Your Rights When Receiving Mental Health Services in Michigan" that is given to every patient in the facility upon admission, it was revealed on page 22 under "Involuntary Admission" that "If you are involuntarily admitted (court ordered) to a psychiatric hospital or unit, you have the following rights: ... To a full court hearing... To be present at the hearing."

On 10/14/14 at approximately 1245 during an interview with staff F it was stated "I tried to have her sign it [referring to a document that is signed by the patient, notifying them of the court date and time], but she crumbled it up and threw it at me." This writer asked "Did you document that anywhere?" Staff F responded "No, we don't usually document that."
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record review and interview the facility failed to establish a process for the timely resolution of grievances, resulting in lack of a documented investigations and responses to 5 of 7 patient complaints (for current patient #12 and discharged patients #13, #14, #16 and #17) and the potential for loss of complaint rights for all patients. Findings include:

Policy Review:
On 10/15/14 from 1100-1400 and at 1715 the facility's Complaint/Grievance and Appeal Process policy, dated 6/13, was reviewed. The policy states:

"Any verbal complaints that cannot be resolved at that moment or that day, by the present staff will automatically become a grievance. If the staff is not able to respond to the patient's concern then he or she is to immediately notify the Recipient Rights Office via e-mail or telephone. Grievances about such situations that endanger the patient, such as abuse or neglect, should be handled immediately..."

"All patient complaints and grievances are logged and filed by the Recipient Rights Office for trending purposes and future reference by the hospital or legal counsel."

"Upon receipt of a complaint, the hospital Rights Advisor shall:"
a. "Record each complaint that is received by the Rights Office."
b. "Attempt to speak to the interested party..."
c. "Assist the recipient or other individual with the complaint process as necessary, or in the absence of assistance from advocacy organizations (i.e. filling out a MDCH (Michigan Department of Community Health) complaint form to contain all necessary information")
d. "Respond to each complaint in an acknowledgement letter with a copy of the complaint within 5 business days the complaint was received."

Record Review & Interview:
On 10/14/14 from 1400-1445 a complaint and grievance log and individual patient complaint/grievance files were reviewed with staff D, revealing the following:
1. On 10/14/14 at 1400 staff D, the Recipient Rights Officer, was asked to provide all complaint and grievance logs for the past 6 months. Staff D stated that there is only one log for both complaints and grievances and that grievance entries are marked with the letter "G" and complaints are listed with no "G". Staff D stated that all complaints and grievances are listed on a single log.
2. The last log entry date for receipt of a patient complaint or grievance was 9/30/14.
3. The log listed a complaint by current patient #12, received on 9/30/14. The section of the form for the patient's complaint statement (titled "Describe What Happened") was blank. Staff D could not find the patient's complaint statement on the complaint form, in a handwritten note or in computer files.
4. Documentation of complaint forms, investigation notes and response letters for the following patient complaints (listed on the log) could not be located (in hard copy or electronically) for:
-patient #13, received 9/4/14
-patient #14, received 8/22/14
-patient #16, received 7/22/14
-patient #17, received 7/16/14
All of the above complaints had been logged and assigned a complaint category without any documentation of a complaint statement or investigation notes.
5. Three complaint forms provided for review were not logged, for patients #15, #36 and #37. The complaints filed by patients #36 and #37, dated 7/8/14, alleged verbal abuse by staff O.
6. On 10/15/14 at 1210 staff D provided an untitled list of complaints and facility responses, 11 pages long, with dates ranging from 5/3/14-9/16/14. The 10/15/14 list was not in log form and consisted of brief descriptions of patient complaints or grievances along with brief statements titled: "Grievance officer investigation/follow-up." The log provided on 10/14/14 did not correspond to the list of complaints and grievances provided on 10/15/14.

Interview:
On 10/15/14 at 1215 staff D stated that he did not have complaint forms, investigation notes or response letters for the complaints/grievances on the list provided on 10/15/14. Staff D could not explain why the complaints provided on 10/15/14 were not logged or provided upon request on 10/14/14.