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 Nov. 6, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
This CONDITION is not met as evidenced by:

Based on interview and record review the facility failed to protect patients from abuse and neglect, placing all patients at increased risk of abuse and neglect. Findings include:

-The facility failed to protect 7 of 8 current patients (#3, #4, #12, #14, #21, #22 and #26) and 1 of 2 discharged patients (#25) from abuse and neglect by failing to provide timely, thorough investigations of abuse and neglect allegations, protect patients during investigations and respond to substantiated allegations in a timely manner. See citations at A-0145.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on document review, observations and interviews the facility failed to provide 7 of 8 current patients (#3, #4, #12, #14, #21, #22 and #26) and 1 of 2 discharged patients (#25) with timely, thorough investigations of abuse and neglect allegations, protect patients during investigations and respond to substantiated allegations in a timely manner. Findings include:

Policies and Procedures:
Abuse and Neglect, dated 5/14/10:
-Does not include patient to patient abuse in the definition of "abuse."
-Defines "neglect" as: "acts of commission or omission by an employee...which result from non-compliance with a standard of care or treatment required by law, rules, policies, guidelines, written directives, procedures...which either placed or could have placed, a recipient at risk of physical harm."
E.3. "The ORR (Office of Recipient Rights) shall be responsible for:
a. The timely investigation of reports of abuse or neglect of recipients.
b. Monitoring progress toward remediation of all substantiated violations of rights."
E. 5. "The Hospital or Center Director shall be responsible for assuring that:
a. Immediate safeguards are put in place to protect recipient(s) during the pendency of investigations into the alleged abuse or neglect.
g. Appropriate disciplinary action is taken on substantiated abuse or neglect."

Complaint Investigation, 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 initiated immediately in cases involving alleged abuse, neglect...or suspected rights violation. The office shall complete the investigation not later than 90 calendar days after it receives the complaint."
9. "At a minimum, each investigation by ORR shall consist of:
a. An interview with the complainant.
b An interview with recipient(s)
c. An interview with all witnesses and others who may provide relevant information.
d. An interview with the individual (s) who is (are) alleged to have violated a recipient's
right(s).
e. Obtaining written statements from staff, recipients, or relevant others
f. Review of the case records of recipients involved when pertinent."

Memorandum, dated 8/9/13 from the Hospital Director states:
"It is the policy of (hospital name) that no consumer shall be abused or neglected and that all allegations of abuse and neglect shall be promptly reported and investigated, with corrective actions implemented immediately to ensure the safety of all consumers."
"Pending investigation, staff accused of abuse/neglect shall be relieved of all consumer care duties immediately by the RN Shift Supervisor and directed to the Central Nursing Office (CNO) where they may be transferred to non-consumer care area or directed to leave the hospital grounds until notified by the Human Resource Department of a return date."

Memorandum, dated 8/6/13 from the Hospital Director states:
4. "The Hospital Director/Designee, in the event that there is any reasonable suspicion that abuse or neglect has occurred, will direct the suspension of involved staff or the reassignment of the involved staff to duties that do not involve patient care."
The role of the Recipient Rights Officer, responsible for abuse and neglect complaint investigations, is not addressed in this document.

Record Review:
1. On 11/5/13 at approximately 1155, review of an Incident Report on the Mental Health (MH) Role unit revealed that patient #3 had been assaulted by patient #4 that morning.

Observations and Interviews:
-On 11/5/13 at 1145 patient #3 stated that he had been hit by patient #4 that morning and did not feel safe on the unit. Patient #3 stated that the assault occurred while patient #4 was on 1:1 supervision by a male staff member but that "staff couldn't stop him."
-On 11/5/13 at 1200 patient #4 was observed receiving 1:1 supervision by a female staff member.
-Nurse K was present when patient #3 stated that he was hit and does not feel safe and observed that patient #4's level of supervision changed from 1 male staff to 1 female staff following the assault.
-On 11/6/13 at approximately 0915 Recipient Rights Officer J stated that she had not been informed of patient #3's 11/5/13 verbal complaint of being assaulted and not feeling safe.

Record Review:
On 11/6/13 from approximately 0915-1500 review of patient #12's record revealed:
-A 9/17/13 Incident Report with an allegation by patient #12 that Staff M attempted to hit him.
-A 9/18/13 "Recipient Rights Complaint" form by patient #12 stating: (staff M) beat me up last night."
- Interview statements with patient #12 and Staff M indicate that part of the incident occurred at the door to the nursing station, providing video evidence for review, and part of it occurred inside the nurse's station, outside of video surveillance.
-A 10/16/13 letter from the Office of Recipient Rights (ORR) to patient #12 stating this investigation will be completed by 12/17/13.
On 11/6/13 from 1100-1130 review of staff M's personnel file revealed no documentation pertaining to the abuse allegation or temporary suspension.

Interview:
-On 11/6/13 at approximately 0950 Recipient Rights Officer (RRO) J stated that she had not reviewed video evidence of the hallway outside the Nursing Office yet. Staff J stated that taking up to 90 business days (4.5 months) to investigate an abuse or neglect allegation is considered timely because facility policy allows it. (Note: the Complaint Investigation policy allows 90 business days for investigations but the Abuse and Neglect policy requires "timely investigation of reports of abuse or neglect" and does not mention the 90 business day timeframe for completing investigations.)
-On 11/6/13 at 1105 Human Resources staff L stated that staff M was not suspended from patient care duties during this investigation. Staff L stated that an abuse or neglect investigation does not have to be completed before the accused staff member resumes direct patient care duties. Staff L stated: "Usually the Hospital Director does a preliminary investigation and sends out an e-mail stating whether staff will be suspended or assigned to the CNO (Central Nursing Office). They (the CNO) decide if the person can work with patients during the investigation." Staff L stated that there was no documentation in staff M's personnel file indicating clearance to work with patients during the investigation.
-On 11/5/13 at approximately 1600 the Hospital Director stated that he reviews video evidence, taken at the time and place where an alleged incident of abuse occurred, to decide if the patient can work during an investigation. The Hospital Director confirmed that an investigation does not need to be completed for an employee accused of abuse to resume working with patients.

Record Review:
On 11/6/13 from approximately 0915-1500 review of patient #4's record revealed:
-A 10/23/13 Incident Report by Nurse N stating: "(patient) accusing (staff O) hit him in the eye while he was in the restraint" and noting "redness around right eye." The report states "he (staff O) stated he was just walking past the restraint room."
-A 10/24/13 e-mail from the Hospital Director to the Recipient Rights Officer J stating that patient #4 had made the above staff abuse allegation.
-A 10/28/13 e-mail from staff J stating that a Patient Rights investigation was being initiated, 5 days after the patient's allegation.
-A 10/30/13 letter to patient #4 stating that "the investigation will be completed within 90 days."

Interviews:
-On 11/6/13 at approximately 0940 Recipient Rights Officer (RRO) J stated that this investigation is her responsibility and, "I am just getting started. I have 90 days to finish it." Staff J stated that she had not reviewed video evidence of the hallway outside the Restraint Room during the time of the alleged incident.
-On 11/6/13 at 1110 Human Resources staff L stated that staff O was not suspended from patient care duties during the investigation. Staff L stated that an abuse investigation does not have to be completed before a staff member accused of patient abuse resumes direct patient care duties.
-Staff L was asked for documentation that staff O had been cleared to work directly with patients. Staff L was unable to provide this documentation.

Record Review:
On 11/6/13 from approximately 0915-1500 review of patient #14's record revealed:
-A 9/30/13 "Recipient Rights Complaint" form, signed by patient #14 states: "(Patient #24) hit me a couple times and I don't feel safe."
-This above form was stamped as received (by Recipient Rights) 7 days later, on 10/7/13, 7 days after the complaint was written.
-On 11/6/13 from 1300-1530 review of patient #24's record revealed that he hit other patients on: 9/1/13, 9/4/13, 9/9/13, 9/16/13, 9/26/13, 9/30/13, 10/2/13, 10/5/13 and 10/9/13. Many of these assaults were described as punches in the face. Patient #24''s level of staff supervision was not increased from 15-minute checks to 1:1 supervision at any time during September or October despite 9 documented assaults on other patients from September-October 2013.
-A 10/9/13 letter stating: "the Office of Recipient Rights has completed an intervention on your behalf" was sent to patient #14. An Intervention was done in place of an investigation. The letter did not address the allegation of peer abuse. The intervention interview did not contain documentation of patient #14 being asked about the peer abuse allegation.

Interview:
-On 11/6/13 at approximately 0945 Recipient Rights Officer J stated that patient #14 was not asked about the patient abuse allegation as part of this investigation. Staff J stated that patient #14 had the right to file criminal charges against patient #24. Staff J stated that she did not know whether anybody had informed patient #14 of this right.
-On 11/6/13 at approximately 1500 staff T confirmed the above findings regarding patient #24's frequent episodes of patient assault and that the level of patient #24's supervision was not increased from 15-minute to 1:1 during September and October 2013.
-On 11/6/13 at approximately 1515 RRO J was asked how many patient complaints of being assaulted by patient #24 had been received during September and October 2013. Staff J stated that she could not provide that data without individually reviewing all patient complaints for that time period.

Record Review:
On 11/6/13 from 0915-1500 review of patient #26's record revealed:
-On 10/4/13 and 10/7/13 patient #26 filed complaints with Recipient Rights Officer (RRO) J alleging sexual abuse (unwanted touch) by a peer.
-On 10/8/13, four days after the first complaint, both complaints were stamped as "Received" by the Office of Recipient Rights.
-On 10/9/13 staff J sent a letter to patient #26 stating that these complaints would not be investigated. Staff J stated: "I already had been aware of this issue due to patient complaints."

Interview:
On 11/6/13 at approximately 10 am staff J, responsible for responding to this complaint, stated that neither complaint was going to be investigated. Staff J stated that a determination that the facility was providing a safe environment was made without an investigation.

Record Review:
On 11/5/13 at 1535 review of patient #25's record revealed:
-A 7/16/13 complaint by patient #25 alleging staff neglect. The complaint states that patient #25 was on 1:1 supervision on 7/14/13 but was able to tie pants around her neck and attempt to choke herself because staff U had fallen asleep.
-A 10/21/13 "Summary Report" substantiates the allegation and recommends disciplinary action and staff training for staff U.
-On 11/1/13 a written reprimand for staff U was documented in response to the complaint filed on 7/16/13, 3.5 months ago. he




On 11/6/13 at approximately 0900-1300 the following records of inpatient "abuse and neglect allegations" were selected for review from the complaint log. Findings include:

Patient #21: an incident report dated 12/14/12 alleged the patient was "held in prone position longer than 2 minutes"
12/21/13 letter to resident of "intention to investigate"
1/18/13 30 day letter of "ongoing investigation"
2/18/13 60 day letter of "ongoing investigation"
3/21/13 interview of staff involved in incident.
4/24/13 ORR report date
5/23/13 final report letter-"resolved"- "Substantiated"
7/26/13 staff members from incident "received remedial training for prone position restraint"

Patient #21: an incident report dated 12/18/13 alleged the patient "swallowed a tack while on 1:1 precautions"
12/21/12 letter to resident of "intention to investigate"
1/18/13 30 day letter of "ongoing investigation"
2/18/13 60 day letter of "ongoing investigation"
3/19/13 "Investigative report"
5/23/13 letter of competition-"resolved."

Patient #22: an incident report dated 12/30/12 alleged "inappropriate touching and kissing by staff"
1/2/13 accused staff to have another staff with her during room rounds
1/5/13 letter to resident of "intention to investigate"
2/5/13 30 day letter of "ongoing investigation"
3/7/13 60 day letter of "ongoing investigation"
3/5/13 all members of third shift questioned about incident
5/15/13 "final report of investigation"

Interviews:
-On 11/6/13 at approximately 0940 staff J the Recipient Rights Officer (RRO) stated that "We have 90 days to finish complaint investigations of the alleged incident."
-On 11/6/13 at 1110 Human Resources staff L stated that "an abuse investigation does not have to be completed before a staff member accused of patient abuse resumes direct patient care duties."
-On 11/6/13 at approximately 1300 staff J the RRO stated "I am aware of the timelines including the final reports."