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WALTER P REUTHER PSYCHIATRIC HOSPITAL 30901 PALMER RD WESTLAND, MI Sept. 9, 2013
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on policy and record review and interview, the facility failed to fully investigate allegations of abuse and neglect, including documenting the alleged victim's statements, and to follow through on a physician's order for x-rays for 1 or 3 patients (#7) resulting in the potential for unidentified abuse and neglect and untreated physical injuries. Findings include:

Policy Review:
10.3.2 - Definitions and Reporting of Abuse and Neglect, effective 9/29/13, states:.
Hospital Director/Designee: "Receives Investigative Report submitted by ORR (Office of Recipient Rights), and acts to remediate substantiated recipient rights violations within ten (10) business days by coordinating a meeting to review."

Record Review:

Record Review:
Patient #7's medical record and Incident Reports were reviewed on 9/9/13 from 12:30 pm-1:30 PM.
1. On 9/9/13 at 12:30 PM review of a facility "Incident Report" revealed that patient #7 was physically restrained on 5/25/13 at approximately 1:20 PM.
2. On 5/25/13 at 1:30 PM physician #12 documented that patient #7 had: "three linear ecchymoses at the left infraclavicular are- acute vs. subacute? No clear injury to patient..."
3. On 5/28/13 at 10:50 am a note by physician #11 documented: (patient #7) "stated staff is abusing him it is verbal and physical abuse" and "will do I.P.O.S (Individual Plan of Service) revision for (patient #7's) false statement."
4. On 5/28/13 at 11 am physician #13 documented in patient #7's medical record:
"chest & Rt.(right) shoulder - red abrasions/Brussels on the Lt. (left) clavicle - about 6 cm x 1 cm... two other small bruises - reddish (about 2 cm each) on the Lt. (left) shoulder area. Rt. (right) forearm - 2 old bruises - faint bluish yellow - one is 3 cm x 1 cm, other is 2 cm. Rt. (right) upper back reddish discoloration. Rt (right) thigh mid posterior surface 4 cm x 2 cm bruise-old, reddish blue in color."
5. On 5/28/13 at 11:10 am physician #13 wrote an order for patient #7 for: "x-ray of upper and lower back (thoraco-lumber spine). Dx. (diagnosis) Back pain (upper & lower both)." No results or further documentation regarding this order were found.
6. On 9/11/13 from 2:40-3 PM review of the facility's investigation of patient #7's 5/28/13 abuse allegation revealed no documentation that patient #7 was asked to provide a verbal or written statement to the investigator (staff #6).
7. On 9/11/13 from 2:40-3 PM the facility's investigation of a neglect allegation, filed on behalf of patient #7 on 6/10/13, was reviewed. There was no documentation of an interview or written statement by patient #7 included in the investigation.

Interviews:
1. On 9/9/13 at 3:15 PM staff nurse #2 verified that there was no documentation of follow through on patient #7's 5/28/13 x-ray order. Nurse #2 stated that it is facility policy to follow through on physician's orders.
2. On 9/11/13 from 1:40-2 PM, staff #6, who investigated a 5/28/13 abuse allegation and a 6/10/13 neglect allegation for patient #7 stated that there were no notes documenting interviews or statements by patient #7 for either investigation.
3. On 9/11/13 at approximately 2 PM staff #6 stated that the Office of Recipient Rights is responsible for investigating all allegations of abuse and neglect and uses only Michigan Mental Health Code, not CMS (Centers for Medicare & Medicaid), definitions of abuse and neglect in determining whether abuse or neglect has occurred.
4. On 9/11/13 from 1:40-2 PM staff #6 stated that the facility's failure to obtain an x-ray for patient #7, ordered for injuries allegedly sustained as a result of alleged staff abuse, "is not something that I would identify as abuse or neglect or investigate." Staff #6 stated that he was unaware of any facility policies or procedures identifying this omission as neglect.
5. On 9/11/13 at approximately 3:10 PM, staff #14, an administration nurse, stated that there was no record of investigations of either of the above allegations being conducted by Nursing or another department.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on document review and interview facility nurses failed to follow physician's orders for 1 of 1 patients (#7) resulting in increased risk of care not being provided as ordered for all patients. Findings include:

Policy Review:
Transcription of Physician's Orders, 2/2010, states:
"The RN/Unit Clerk/LPN will check all charts daily to determine if new orders were written and transcribe the order to the appropriate form(s)."
"The RN on duty is to verify the completed transcription of the order for accuracy. A Registered Nurse must co-sign all orders transcribed."

Record Review:
Patient #7's medical record and Incident Reports were reviewed on 9/9/13 from 12:30 pm-1:30 pm revealing the following:
1. On 5/25/13 at 1:30 pm physician #12 documented that patient #7 had: "three linear ecchymoses at the left infraclavicular are- acute vs. subacute? No clear injury to patient..."
2. On 5/28/13 at 11 am physician #13 documented in patient #7's medical record:
"chest & Rt.(right) shoulder - red abrasions/Brussels on the Lt. (left) clavicle - about 6 cm x 1 cm... two other small bruises - reddish (about 2 cm each) on the Lt. (left) shoulder area. Rt. (right) forearm - 2 old bruises - faint bluish yellow - one is 3 cm x 1 cm, other is 2 cm. Rt. (right) upper back reddish discoloration. Rt (right) thigh mid posterior surface 4 cm x 2 cm bruise-old, reddish blue in color."
3. On 5/28/13 at 11:10 am physician #13 wrote an order for patient #7 for: "x-ray of upper and lower back (thoraco-lumber spine). Dx. (diagnosis) Back pain (upper & lower both)." No results or further documentation regarding this order were found.

Interview:
On 9/9/13 at 3:15 PM staff nurse #2 verified that there was no documentation of follow through on patient #7's 5/28/13 x-ray order. Nurse #2 stated that it is facility policy to follow through on physician's orders.