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KALAMAZOO REGIONAL PSYCHIATRIC HOSPITAL 1312 OAKLAND DR KALAMAZOO, MI 49008 Nov. 23, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview and document review the facility failed to protect the rights of patients current and discharged , placing all 129 current patients at risk for loss of their rights.

Findings include:
---the facility failed to document a grievance and implement a grievance process for a patient's responsible party's grievances and complaints about treatment. (See A-118)

--- the facility failed to notify the patient's legal guardian and get consent for the patient to be released on a leave of absence. (See A-131)

---the facility failed to ensure that confidential health care information from the medical record was not released to an unauthorized person. (See A-147)
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

This citation pertains to MI 764

Based on interview and record review, the facility failed to document a grievance, implement a grievance procedure and provide written notice of the results of a grievance to a patient's guardian in a timely manner for one (#10) of 20 patients reviewed for patient rights out of a total sample of 20, resulting in guardian dissatisfaction with the facility's actions. Findings include:

On 11/22/16 at 1300, the facility list of grievances was reviewed with the Director of Quality and Compliance, Staff B. There was no documentation that Patient #10's legal guardian had made a grievance to the facility regarding Patient #10's unauthorized leave of absence (LOA) from the facility on 11/22/16. Random audits of three names on the list of grievances revealed all were related to complaints about the food that were immediately resolved.

On 11/22/16 at 1410, the Director of Quality and compliance, Staff B was asked if there had been any complaints about patients leaving the facility on unauthorized leaves of absences during the past 6 months. Staff B reported that there had been one recent unauthorized leave of absence, where a patient was released on LOA to his mother without permission from his legal guardian. Staff B stated that the guardian had been very angry and upset when she had learned that the patient had left the hospital with his mother, and had insisted that the facility find the patient and have him returned to the hospital as soon as possible. All documentation related to the incident, and the patient's clinical record were requested at this time. When asked why there was no grievance documented for the guardian's complaint about Patient #10's unauthorized leave of absence (LOA) and why there was no Incident report or Adverse Event report or documentation of the incident on the facility Incident/Adverse Event log, Staff B reported that the facility was working on improving their system, but were unable to provide documentation of this.

On 11/22/16 at 1410, Patient #10's clinical record and a facility "Administrative Report" dated 11/16/16 were reviewed with the Unit Manager/Assistant Director of Nursing, Staff O, and the Director of Quality and Compliance, Staff B, and the following was revealed:
A face sheet documented that Patient #10 was a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses of Schizophrenia - Disorganized Type, Bipolar Disorder I, Mild Mental Retardation, Borderline Personality Disorder, Attention Deficit Hyperactivity Disorder (ADHD), and Asthma. Patient #10 was discharged from the facility on 11/1/16, and had a leave of absence from the facility from 10/12/16 to 10/19/16, that was not authorized by the guardian.
A Probate Court "Letters of Guardianship", filed 5/20/14 revealed that a Professional Guardianship Service was appointed full guardianship of Patient #10, a "legally incapacitated individual." Review of additional Probate Court documents revealed the guardianship was still in effect.
A Physician's order, dated 10/12/16 at 10:10, signed by Patient #10's psychiatrist, Staff V, noted, "Leave of Absence (LOA)/Transfer/Discharge. Place patient on LOA. LOA to discharge within 5 days. Patient will be with his mother."
On 11/22/16 at 1500, the Director of Quality and Compliance, Staff B was interviewed regarding Patient #10 ' s LOA from the facility on 10/12/16 and stated, "The social worker tried to contact the guardian, but the doctor decided to discharge him right away before she got hold of the guardian. The guardian was very upset and insisted we bring the patient back to the hospital as soon as possible. We had to pay a fortune for the patient to come back by ambulance (approximately 150 miles)." Documentation of discussions with Patient #10's guardian, CMH case manager and the patient's mother regarding this incident were requested but not provided.
On 12/3/16 at 0920, Patient #10's legal guardian, Guardian X was interviewed by phone and reported that she and her staff had spoken with the facility multiple times regarding their complaint about Patient #10's unauthorized discharge, and that one of her staff had gone to the facility for a meeting with the administrative staff and the psychiatrist on 10/27/16 to voice their complaints and discuss the incident. When queried, Guardian X stated that neither she, nor her staff had ever been advised of the facility grievance procedure, or told that their voiced complaints and concerns about Patient #10's unauthorized leave of absence would be treated as a grievance. Guardian X stated that there had been nothing given to them in writing about their complaint, and no letter summarizing what had been done to investigate or resolve their grievance. Guardian X stated, "This was a serious mistake. He never should have been released like that without planning and resources in place.They probably didn't tell me he was going on a LOA with his mother because they knew I wouldn't agree to it. I wouldn't have let him go for one day, much less 5 days."
A grievance policy was not provided.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

This citation pertains to MI 764
Based on interview and record review, the facility failed to inform the patient's legal guardian and get consent for the patient to be released on a leave of absence, for one (#10) of 20 patients reviewed for patient rights, resulting in a patient who was at risk for harming himself or others, leaving the facility against the guardian's knowledge or consent. Findings include:
On 11/22/16 at 1410, Patient #10's clinical record and a facility "Administrative Report" dated 11/16/16 were reviewed with the Unit Manager/Assistant Director of Nursing, Staff O, and the Director of Quality and Compliance, Staff B, and the following was revealed:
A face sheet documented that Patient #10 was a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses of Schizophrenia - Disorganized Type, Bipolar Disorder I, Mild Mental Retardation, Borderline Personality Disorder, Attention Deficit Hyperactivity Disorder (ADHD), and Asthma. Patient #10 was discharged from the facility on 11/1/1, and was on a leave of absence (LOA) from the facility from 10/12/16 to 10/19/16.
A Probate Court "Letters of Guardianship", filed 5/20/14 revealed that a Professional Guardianship Service was appointed full guardianship of Patient #10, a "legally incapacitated individual." Review of additional Probate Court documents revealed the guardianship was still in effect.
The Probate Court Petition, dated 10/5/16, seven days before Patient #10 was discharged on LOA, noted, "continues to be a person requiring treatment,..and can reasonably be expected in the near future to intentionally or unintentionally seriously physically injure self or others, and has engaged in an act or acts or made significant threats that are substantially supportive of the expectation. It is ordered that the individual undergo a second or continuing order of combined hospitalization and alternative treatment for a period not to exceed one year."
A Physician's order, dated 10/12/16 at 10:10, signed by Patient #10's psychiatrist, Staff V, noted, "Leave of Absence (LOA)/Transfer/Discharge. Place patient on LOA. LOA to discharge within 5 days. Patient will be with his mother."
Discharge Instructions for Patient #10, dated 10/12/16 documented the patient's risk analysis as, "Assaultive/violent Behavior in past month, Self-Abusive/Suicidal Behavior past month."
A Physician's Progress noted dated 10/14/16 (during the LOA) documented, "I am confident to discharge patient because I know him much better than the guardian and I am a psychiatrist."
Review of Nursing Notes for patient #10 revealed the following note dated 10/11/16 (one day before the LOA), "Patient had several outbursts of punching wall and threatening behavior this week."
Review of an Incident Report dated 10/5/16 at 2128 (7 days before LOA) documented, "patient was talking to Doctor. Patient got upset ...Patient grabbed the trash can and threw it up at the light. Patient was making verbal threats towards staff, " I'm going to cut you if you come close", and, "I'm going to kill myself." Patient placed in manual hold and put in restraint."
Review of Nursing Notes for patient #10 revealed the following note dated 10/12/16, "Patient seen by Dr (Staff V) at 11:30 and discharged , accompanied by Mom." There was no documentation that the guardian was told the patient was being released from the hospital on LOA with his mother. There was no guardian's consent to release the patient on LOA prior to the patient leaving the hospital on [DATE].
Review of a Social Work note dated 10/13/16 at 11:54 revealed the following, "on 10/11/10 (Patient #10 ' s mother) came to visit with a male companion. The family returned the following morning 10/12/16, (Patient #10) was requesting discharge with the family. The psychiatrist was present as this social worker discussed the need to facilitate appropriate discharge with guardian approval. This worker came to the unit around 1500, but this worker was informed by nursing staff that (Patient #10) had been given LOA to discharge by psychiatrist already."
On 11/22/16 at 1500, the Director of Quality and Compliance, Staff B was interviewed regarding Patient #10 ' s LOA from the facility on 10/12/16 and stated, "It was an error. It happened so fast. The social worker tried to contact the guardian, but the doctor decided to discharge him right away before she got hold of the guardian."
On 11/23/16 at 0835, Social worker, Staff W was interviewed and stated, "I didn't even know he was gone (patient #10). The guardian didn't want to sign any release for (patient #10) to go on LOA with the mother. She was absolutely against it. According to the guardian, there was a negative history there. The mother had lost custody when he was still a child, and hadn't been in contact with him for years. The guardian was really upset and insisted we get him back right away."
On 11/23/16 at 0920, the psychiatrist, Staff V was interviewed regarding Patient #10's LOA on 10/12/16 without guardian notification or consent, and stated, "It was my fault. It was a lack of communication. I gave him a LOA against hospital rules."
On 11/23/16 at 1000, the facility Director, Staff A was interviewed and stated, "The guardian was furious and insisted we get him back right away. We're lucky he agreed to come back willingly. We had to pay for an ambulance to get him back all the way from (approximately 150 miles)."
On 12/3/16 at 0920, Patient #10's legal guardian, Guardian X was interviewed by phone and stated, "They probably didn't tell me he was going on a LOA with his mother because they knew I wouldn't agree to it. I wouldn't have let him go for one day, much less 5 days."
A policy on consents from responsible party for LOA and or discharge was requested but not provided.
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

This citation pertains to MI 764
Based on interview and record review, the facility failed to obtain written authorization for release of information from the medical record to an unauthorized individual, for one (#10) of 20 patients reviewed for patient rights, resulting in a violation of confidentiality. Findings include:
On 11/22/16 at 1410, Patient #10' s clinical record and a facility "Administrative Report" dated 11/16/16 for Patient #10 were reviewed with the Unit Manager/ Assistant Director of Nursing, Staff O, and the Director of Quality and Compliance, Staff B, and the following was revealed:
A face sheet documented that Patient #10 was a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses of Schizophrenia - Disorganized Type, Bipolar Disorder I, Mild Mental Retardation, Borderline Personality Disorder, Attention Deficit Hyperactivity Disorder (ADHD), and Asthma. Patient #10 was discharged from the facility on 11/1/16, and was on a leave of absence (LOA) to discharge from 10/12/16 to 10/19/16. The patient's mother was not listed as a contact authorized to receive protected health information.
A Probate Court "Letters of Guardianship", filed 5/20/14 revealed that a Professional Guardianship Service was appointed full guardianship of Patient #10, a "legally incapacitated individual." Review of Probate documents revealed that guardianship was still in effect.
A facility Administrative Report, dated 11/16/16 documented that the Unit Psychiatrist, Staff V had multiple telephone discussions with Patient #10's mother about the patient's progress, treatment, diagnoses and medications, without guardian consent, prior to releasing the patient to go on LOA on 10/12/16, also without guardian consent.
The 11/16/16 facility Investigation documented an interview with Staff V on 10/19/16. Staff V was documented as stating that he had spoken to Patient #10's mother by telephone 3-4 times before 10/12/16, but did not document the conversations. The interview documented, "(Staff V) asked why we needed the guardian's consent. (Staff V) said it is not uncommon for him to talk with parents, and that he talks to families of all his patients."
Review of Discharge instructions provided to Patient #10's mother on 10/12/16, per nursing notes dated 10/12/16, and confirmed by interview with the Unit Manager, Staff O on 11/22/16 at 1410, revealed documentation that health information from the medical record was provided to patient #10's mother, without consent from the guardian. A medication Reconciliation form, documented as given to Patient #10's mother on 10/12/16, documented Patient #10's psychiatric diagnoses and a list of prescribed medications were given to the patient's mother without the guardian's consent to disclose the information.
On 11/23/16 at 0920, the psychiatrist, Staff V was asked about discussions he had with patient #10's mother about information in the patient's medical record. Staff V stated , "(Patient #10) was abused by his step father, and because of that, his mother lost custody. He lived in a group home for 15 years. I talked to the mother 3 times. It was hard for her to visit because of economics. She did in past promise to come and didn't show up. I told her if she would come, I would pay for the gas. She never visited him in the group home. I felt family was more beneficial than medication."

On 11/23/16 at 1000, the facility Director, Staff A was interviewed and reported that per facility policy, and health care privacy laws, consent must be obtained in writing from the responsible party before information from a patient's medical record can be disclosed to an unauthorized individual. When queried, Staff A stated that the facility was not aware that Staff V had disclosed protected information to Patient #10's mother without consent from the guardian until the guardian had objected to Patient #10's unauthorized Leave of Absence (LOA) on 10/12/16, and a facility investigation into the incident was started.

On 12/3/16 at 0920, Patient #10's legal guardian, Guardian X was interviewed by phone and stated, "We weren't allowing his mother to contact him or talk to him on the phone. We sent (the facility) several letters stating that. I'll read you what we wrote. On 2/5/15 we sent them a letter stating we are not allowing any phone contact with his mother, and due to confidentiality, staff are not allowed to give her any information regarding (Patient #10). We sent another letter repeating this on 10/8/15."

A facility policy on disclosure of protected health information was not provided.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on interview and record review, the facility failed to update the infection control program on an annual basis and the facility failed to ensure that employees received yearly training and education on how to prevent the spread of blood borne pathogens for 5 of 10 employees reviewed for blood borne pathogens and personal protective equipment training, out of a total of 450 staff employed by the facility resulting in the potential for staff being unprepared for exposure to infectious agents. Findings include:

On 11/22/16 at 1430 during document review it was revealed the facility failed to update the infection control program on an annual basis. The document titled "Infection Control Program" was approved on 10/28/15. On 11/23/16 at 0930 an interview was conducted with the infection control preventionist (ICP). The ICP was queried if the infection control plan for the infection control program had been approved on an annual basis since 10/28/15. The ICP responded that the plan had not been approved and she was aware that it was delinquent for approval.

On 11/23/16 at 1100, 10 direct care employee training/continuing education records (in-service records) for the past 12 months were reviewed with the Director of Staff Development, Staff K. 5 of 10 staff reviewed failed to have documented yearly training on blood borne pathogens (includes HIV, Hepatitis B and Hepatitis C), personal protective equipment (PPE), or on Infection Control. When asked about this, Staff K stated that the staff could have been off on leave when the in-services were done. When asked how the facility kept track of staff who missed required in-services, Staff K said, "I've asked Human Resources to let me know when someone's out on medical." When asked, Staff K was unable to provide any documentation of this.

A facility policy on staff training and on tracking of staff training was not provided.
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

This citation pertains to MI 764
Based on interview and record review, the facility failed to ensure that discharge planning was implemented, care team discharge readiness assessments were done, required release forms were completed and signed, guardian, case management, health insurance coverage and Community Mental Health (CMH) notifications, referrals and paperwork were completed, and appropriate post-hospital care and community services were arranged prior to a leave of absence to discharge for one (#10) of 20 patients reviewed for discharge planning out of a total sample of 20, resulting in lack of coordination of care, lack of access to outpatient services and follow-up, and an unplanned transfer back to the facility by ambulance. Findings include:

On 11/22/16 at 1410, Patient #10's clinical record and a facility "Administrative Report" dated 11/16/16 were reviewed with the Unit Manager/Assistant Director of Nursing, Staff O, and the Director of Quality and Compliance, Staff B, and the following was revealed:
A face sheet documented that Patient #10 was a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses of Schizophrenia - Disorganized Type, Bipolar Disorder I, Mild Mental Retardation, Borderline Personality Disorder, Attention Deficit Hyperactivity Disorder (ADHD), and Asthma. Patient #10 was discharged from the facility on 11/1/16, and had a leave of absence from the facility from 10/12/16 to 10/19/16, that was not authorized by the guardian.
A Probate Court "Letters of Guardianship", filed 5/20/14 revealed that a Professional Guardianship Service was appointed full guardianship of Patient #10, a "legally incapacitated individual." Review of additional Probate Court documents revealed the guardianship was still in effect.
Probate Court Petitions for mental health hospitalization dated 2/10/16, 3/8/16, 5/4/16, 7/20/16, 10/5/16 and 10/19/16 documented that Patient #10 continued to require mental health hospitalization and treatment.
The Probate Court Petition, dated 10/5/16, seven days before Patient #10 was discharged on LOA, noted, "It is ordered that the individual undergo a second or continuing order of combined hospitalization and alternative treatment for a period not to exceed one year. Alternative/assisted outpatient treatment shall be under the supervision of a (County) community mental health (CMH) services program."
A Physician's Progress noted dated 10/14/16 appeared to contradict the documentation on the probate court petitions reviewed. The note documented, "In three occasions, the judge ordered discharge because patient was consistently cleared psychiatrically according to my presentation in court. The CMH was consistently nonchalant in planning to discharge. I am confident to discharge patient because I know him much better than the guardian and I am a psychiatrist."
A Physician's order, dated 10/12/16 at 10:10, signed by Patient #10's psychiatrist, Staff V, noted, "Leave of Absence-LOA)/Transfer/Discharge. Place patient on LOA. LOA to discharge within 5 days. Patient will be with his mother."
The LOA Discharge Instructions for Patient #10, dated 10/12/16 documented the patient' s risk analysis as, "Assaultive/violent Behavior in past month, Self-Abusive/Suicidal Behavior past month. "
Review of Nursing Notes for patient #10 revealed the following note dated 10/11/16, (the day before the unplanned LOA) "Patient had several outbursts of punching wall and threatening behavior this week."
Review of an Incident Report dated 10/5/16 at 2128 (7 days before LOA) documented, "patient was talking to Doctor. Patient got upset ...Patient grabbed the trash can and threw it up at the light. Patient was making verbal threats towards staff, " I'm going to cut you if you come close", and, "I'm going to kill myself." Patient placed in manual hold and put in restraints."
Review of Nursing Notes for patient #10 revealed the following note dated 10/12/16, "Patient seen by Dr (Staff V) at 11:30 and discharged , accompanied by Mom." There was no documentation of Multidisciplinary Team discussion of patient readiness for discharge or of any team discussion of discharge readiness with the psychiatrist. There was no documentation that the guardian was told the patient was being released from the hospital on LOA with his mother. There was no guardian's consent to release the patient on LOA prior to the patient leaving the hospital on [DATE]. The patient's care plans were not updated to reflect the LOA to discharge prior to the patient's return on 11/19/16. There was no documentation that Patient #10's case manager or Community mental Health Services (CMH) were notified that Patient #10 was going on LOA to discharge, and no documentation of community services and follow up put in place for the LOA.
Review of a Social Work note dated 10/13/16 at 11:54 revealed the following, "10/12/16, (Patient #10) was requesting discharge with the family. The psychiatrist was present as this social worker discussed the need to facilitate appropriate discharge with Community Mental Health (CMH) approval and guardian approval. This worker left the meeting to make contact with guardian and CMH.This worker came to the unit around 1500 to explain that discharge would not be facilitated at that time, but this worker was informed by nursing staff that (Patient #10) had been given LOA to discharge by psychiatrist already. This worker was not able to plan discharge paperwork, or provide notice to appropriate staff due to the unknown LOA to discharge provided on 10/12/16."
On 11/22/16 at 1500, the Director of Quality and Compliance, Staff B was interviewed regarding Patient #10 ' s LOA from the facility on 10/12/16 and stated, "It was an error. It happened so fast. The social worker tried to contact the guardian, but the doctor decided to discharge him right away before she got hold of the guardian. Normally CMH should have had paperwork before the LOA took place. CMH didn't know about the LOA to discharge on 10/12/16, so couldn't set up the necessary follow up. There should have been a patient LOA request form filled out and signed by the clinical director. It wasn't done to my knowledge. The guardian was very upset and insisted we bring the patient back to the hospital as soon as possible. We had to pay a fortune for the patient to come back by ambulance (approximately 150 miles). We got him back, but he did have some behavior outbursts because he was angry at being back here."
Review of Patient #10 ' s clinical record at this time with Staff B and Staff O revealed no documentation of a completed Patient LOA Request form for Patient #10 ' s LOA to discharge on 10/12/16, or any documentation that the Unit treatment team had evaluated Patient #10 to approve or disapprove a LOA on 10/12, or had discussed this with the psychiatrist. There was no documentation that the Unit Manager had provided any input into Patient #10 ' s LOA on 10/12/16, or had filled out paperwork or approved the LOA. There was no evidence of any discharge planning implemented prior to the LOA on 10/12/16.
On 11/23/16 at 0835, Social worker, Staff W was interviewed and stated, "The LOA wasn't a planned one. None of the required paperwork was done. We didn't even do the necessary forms for him to get medical care in the community. The case manager wasn't notified. The guardian insisted we get him back right away."
On 11/23/16 at 0900, review of Social work notes for Patient #10 with the unit social worker, Staff W revealed the following:
A Social work annual assessment for Patient #10, dated 7/7/16 documented the following multiple instances of Patient #1 physically attacking others and self harming behaviors, one of which required treatment at a medical facility. The assessment noted, "Many of his self harm behavior (in the facility) have been observed to be based on impulsive acts." The report documented that Patient #10 had a history of multiple "significant" mental health hospitalization s, and a juvenile incarceration for 4 years for physical violence to his mother and attempted arson to their family home..
On 11/23/16 at 0920, the psychiatrist, Staff V was interviewed regarding Patient #10's LOA on 10/12/16 without staff completing discharge/LOA paperwork and plans, and without community and CMH services set up. Staff V stated, "It was my fault. It was a lack of communication. I gave him a LOA against hospital rules. My feeling was that everybody was just scared to discharge him."
On 11/13/16 at 1200, review of the facility policy entitled, "Patient Leaves of Absence", dated 11/13/14, revealed the following notations:
1. Social worker, designated unit staff, CMH, family or friend completes a Patient Leave of Absence Request form (DCH-J506) and submit to unit psychiatrist.
2. Unit treatment team reviews the Patient Leave of Absence Request, recommends approval/denial, and gives to psychiatrist.
3. Unit psychiatrist evaluates patient ' s clinical condition, including physical and mental stability, court restrictions if LOA is recommended by the treatment team.
4. Clinical Director reviews patient LOA Request form for disposition, approves/disapproves and returns to unit psychiatrist.
17. Rn shift supervisor sends white copy of Patient LOA Request to the Medical Records Department, where it shall be retained for 3 years. "