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.

KALAMAZOO REGIONAL PSYCHIATRIC HOSPITAL 1312 OAKLAND DR KALAMAZOO, MI Jan. 26, 2012
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to provide the legal representatives of 2 of 2 (#2 and #5) Medicare patients with "An Important Message from Medicare" after admission, resulting in patient's legal representatives not receiving this information. Findings include:

On 1/26/12 review of medical records of patient #2 (discharged ) and patient #5 (an inpatient) revealed that both had no documentation of legal representatives signing "An Important Message From Medicare About Your Rights" or receiving this document. Patient # 2 was admitted [DATE] and transferred out on 10/24/11. Patient #5 was admitted on [DATE] and was still hospitalized at the facility. These findings were confirmed by the Geratic Medical Unit Social Worker on 1/26/12 at approximately 1040 hours.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview and record review the facility failed to ensure that 1 of 1 current patients alleging sexual abuse (patient #1) was offered a rape kit and laboratory testing for sexually transmitted diseases. Findings include:

From 1/24/12-1/26/12 the patient #1's allegation of sexual abuse by Resident Care Attendant (RCA) #1 was investigated. On 1/24/12 at 1145 hours patient #1 was interviewed on the facility's Flunt Unit. Patient #1 stated that RCA #1 "touched me" and "we had sex."

On 1/24/12 from 1300-1700 hours, patient #1's clinical record was reviewed. Patient #1's allegation of sexual abuse by RCA #1 was documented in RN #2's progress notes dated 12 30/11. On 1/24/12 at approximately 1500 hours, RN #2 verified that on the evening of 12/30/11, patient #1 reported that RCA #1 had sex with her on 12/29/11. RN #2 stated that she reported these allegations to the DON and the on-call physician (MD #1) on the evening of 12/30/11. RN #2 was asked whether she had knowledge of patient #1 being offered testing for sexual contact or sexually transmitted diseases. . RN #2 stated that she did not receive orders to arrange for these tests or discuss them with patient #1. Record review revealed no documentation indicating that these tests were offered or done at any time.

On 1/26/12 at approximately 1130 hours the DON verified that the facility does not have a policy or procedure that requires a rape kit or testing for sexually transmitted diseases be offered to patients alleging sexual abuse or contact. The DON stated that policies revisions to address these issues are needed.

A full investigation of patient #1's allegations and past allegations involving the alleged perpetrator was in process at the time of the survey.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on observation, interview and record review the facility failed to accurately complete post-fall assessments and update patient care plans after falls by and adding interventions for 3 of 3 patients (#2, #5 and #6) on the Geriatric Medical Unit (GMU) resulting in increased risk of falls. Patients #5 and #6 were current patients and patient #2 had been transferred to an acute care hospital. Findings include:

On 1/25/12 and 1/26/12, patient #2's medical record was reviewed. Patient #2 was found on the floor or observed falling on: 10/8/11, 10/11/1, and twice on the morning of 10/24/11. The injuries that patient #2's sustained in the second fall on 10/24/11 led to his transfer to an acute care hospital. The facility's "Nursing On-Going Fall Assessment" was not updated between 10/7/11 until 10/24/11. The initial assessment, dated 10/7/11 was inaccurate since patient #2 was coded as having no deficits in orientation or sensory impairment. Documentation of impairments in both areas were noted in the "Admission Psychological Assessment," completed 10/7/11. Despite repeated falls, patient #2 was not coded as "high risk" for falls until 10/24/11. Patient #2's Nursing Care Plan for "fall potential" was not updated since it was initiated on 10/7/11. Patient #2's discharge diagnosis was subdural hematoma. The above findings were verified by the DON on 1/26/11 at approximately 1130 hours.

On 1/25/12 at 1420 hours, patient #6's medical record was reviewed with ADON (Assisted Director of Nursing) #1, assigned to the facility's GMU (geriatric medical unit). Patient #6 had documented falls on 12/22/11, 12/25/11 and 12/26/11. Despite repeated falls, the only update to the patient's "fall potential" care plan was a notation that an MRI had been scheduled. A "Nursing On-Going Fall Assessment form was not located. These verified by ADON #1.

On 1/25/12 at approximately 1445 hours, patient #5's medical record was reviewed with ADON #. Patient #5 had documented falls with head trauma on 12/18/12 and 12/29/12. The "Nursing On-Going Fall Assessment was not updated after the 12/18/12 fall and not updated until 6 days after the 12/29/11 (on 1/4/12). Patient #5's "Nursing Care Plan" was not updated with any new goals or interventions following these falls. A policy for assessing patient fall risk and responding with interventions was not located on the GMU. These findings were confirmed by ADON #1.