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KALAMAZOO REGIONAL PSYCHIATRIC HOSPITAL 1312 OAKLAND DR KALAMAZOO, MI May 31, 2013
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on observation and interview, it was determined that the facility failed to provide all patients with information on how to a file a complaint with the State agency, limiting patient's complaint rights. Findings include:

On 5/30/13 from 2-4 pm all 7 units were toured with the Director of Nursing (DON). The DON was unable to locate a posting for the State agency, the State of Michigan Complaint Hotline, on any unit. On 5/30/13 at approximately 4:10 pm the DON verified that the Admissions Packet provided to new patients does not contain information on how to file a complaint with the State agency.

On 5/31/ at 9 am the Standards Compliance/Psychology Director (staff A) stated that there was a posting on each unit providing the phone number for the State of Michigan Complaint Hotline that neither the DON or surveyor was able to find on any unit. Staff A provided a document titled "Public Notice" that he stated is posted in various (non-uniform) locations on each unit. The notice states: "Consumers who have concerns about quality or safety are also encouraged to contact Michigan Department of Community Health, Division of Licensing and Certification at 800-882-6006." The notice does not explicitly state that it is an avenue for filing a complaint. The word "complaint" does not appear anywhere in the "Public Notice." Staff A also confirmed that the "Public Notice" does inform patients of the right to file a complaint or concern regarding issues not pertaining to quality or safety.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, policy and record review, the facility failed to: protect patients on 6 of 7 units from a staff member accused of abusing 1 patient (#2) during the investigation, conduct timely investigations of 5 of 5 abuse allegations (for current patients #2, #7, #8 and discharged patients #6 and #9), develop policies to protect patients during abuse investigations and ensure timely investigations. Findings include:

Policy Review:

On 5/31/13 from 1-5 pm, review of the Michigan Mental Health Code, the Employee Handbook and facility policies and procedures revealed:

Michigan Mental Health Code, AR 330.7001, defines Abuse class II as:

(b)(i) "A non accidental act or provocation of another to act by an employee...that caused or contributed to nonserious physical harm to a recipient."
(b)(ii) "The use of unreasonable force on a recipient by an employee...with or without apparent harm."

State of Michigan, Department of Community Health, Employee Handbook, dated 2009, lists the following protocol for disciplining an employee with a substantiated Abuse class II finding:

Recipient abuse II;
1st violation: "Reassignment and/or demotion and/or 5-day suspension."
2nd violation: "Reassignment and/or demotion and/or 5-day suspension to dismissal."
3rd violation: "Dismissal"

Abuse and Neglect, Attachment A, #03-01-001 states:

"Hospital Director/Designee: Reviews preliminary abuse and/or neglect allegations and takes all necessary actions to ensure the safety of consumers. Removes staff suspected of abuse and/or neglect immediately if not already done from consumer care unit."

Complaint Investigation, Reports and Remediation, dated 8/11/08 states: "ORR (Office of Recipient Rights) shall initiate investigation of apparent or suspected rights violation in a timely and efficient manner. Investigation shall be imitated immediately in cases involving alleged abuse, neglect...Subject to delays involving pending action by external agencies...the office shall complete the investigation not later than 90 calendar days after it receives the rights complaint."

Patient # 2:

Record Review:

From 5/30/13-5/31/13 record review revealed:

l. A "Recipient Rights Complaint" form, completed by "ORR" (Office of Recipient Rights) on behalf of patient #2, dated 2/5/13, states: "Staff (Resident Care Aide #1) was allegedly involved in a physical altercation with patient (#2)."
2. A handwritten statement by RN Manager #1 regarding the (above) interaction states: "Physical altercation both hitting each other with open hands." RN Manager #1 stated that patient #2 "fell down" and that patient's "middle-finger was bleeding" following the incident.
3. Recipient Rights Advisor #1's notes state: "(RN Manager #1) stated that she saw (RCA #1) and (patient #2) having a physical altercation." (RN Manager #1) related: "telling both the patient (#2) and staff (RCA #1) to stop." (RN Manager #1) "stated that (patient #2) was pushed to the floor."
4. In a "Final Report" regarding this investigation, dated 5/2/13, RRA #1 substantiated a finding of "Abuse II-Unreasonable Force" against RCA #1.
5. A 5/2/13 interview statement with the facility's NAPPI (Non-Abusive Psychological and Physical Intervention) Trainer, included in the "Final Report," states: "staff (RCA #1) should not have aggressed toward the patient."
6. Review of video evidence on 5/31/13 at approximately 2:15 pm revealed a clip of the 2/5/13 incident showing RCA #1 walking toward patient #2, grabbing the patient's forearms and pushing the patient backwards across the day room. These observations were verified by Security Officer #1 during video review.
7. RCA #1's undated review of the above video clip states: "(Patient #2) again steps back and (RCA #1) moves toward (Patient #2) engaging her with arms out in front of her moving (patient #2) back across the room. Patient #2 loses her balance and began falling backwards out of camera range."

Interviews:

1. On 5/31/13 at 12:40 pm the Interim Human Resources Director (IHRD) stated that RCA (Resident Care Aide) #1 has continued working as an RCA since the abuse allegation was filed on 2/5/13. The IHRD stated: "We don't necessarily suspend people during abuse investigations. It's not required. The IHRD stated that (RCA #1) could be assigned to any unit except the alleged victim's unit during the investigation.
2. On 5/31/13 at approximately 11:15 am Recipient Rights Advisor (RRA) #1 stated that this abuse complaint "has not been finalized as yet by the Hospital Director."
3. On 5/31/13 at approximately 1:45 pm the Human Resources Director (HRD) stated that no disciplinary action against Resident Care Attendant #1 had occurred since the 2/5/13 abuse allegation was filed.
4. On 5.31/13 at approximately 3:50 pm the DON stated that there was no documentation that RCA #1 received training in physical management of patients as a result of the 2/5/13 incident.
5. On 5/31/13 at approximately 4:30 pm the Hospital Director stated that the hospital does not have policies requiring staff suspension during abuse investigations or requiring dismissal of staff found guilty of Abuse class II until their third substantiated complaint.

Patients #2, #6, #7, #8 and #9: Lack of timely abuse complaint investigations:

Record Reviews:

Patient #2, a current patient, filed an abuse complaint on 2/5/13, alleging abuse by Resident Care Aide (RCA) #1. The investigation has not been completed. (See details above.)
2. Patient #6, discharged in April 2013, filed abuse complaints against RCA's #2 and #4 on 4/8/13. Recipient Rights Advisor (RRA) #1 verified that these investigations have not been completed.
3. Patient #7, a current patient, filed an abuse complaint on 4/17/13, alleging abuse by 2 staff members identified by first names and work shifts. No interview notes were noted in the investigation file. RRA #1 verified that the investigation has not been completed.
4. Patient #8, a current patient, filed an abuse complaint on 2/11/13, alleging abuse by RCA #5. RRA #1 verified that the investigation has not been completed.
5. Patient #9, discharged [DATE], filed an abuse complaint on 2/11/13. RRA #1 verified that the investigation has not been completed.

Interview:

On 5/31/13 at approximately 4:30 pm Resident Rights Advisor (RRA) #1 stated: "We have 90 calendar days after receiving an abuse complaint to complete the investigation." RRA #1 stated that witness interviews had been completed in only 1 (patient #2's) of the 5 abuse complaints listed above. RRA #1 was asked whether witnesses are able to recall specifics when interviewed weeks or months after the alleged incident. RRA #1 stated: "That can be a problem."