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THE BEHAVIORAL CENTER OF MICHIGAN 4050 E 12 MILE R0AD WARREN, MI April 14, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, policy review, observation and interview, it was determined the facility failed to protect patients rights to ensure that they would a) be free from abuse and neglect and b) be free from unnecessary restraint and seclusion. See tags A118, A145, A161, A166, and A179.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on focused record review and interview the facility failed to ensure that 1 of 1 patient allegations of sexual abuse (patient #3) was treated as a grievance.

Patient Findings:

On 4/14/11 at approximately 0930 a Recipient Rights Officer (staff #6) was interviewed regarding the facility's handling of patient #3's allegation of sexual abuse, filed with the Recipient Rights Officer on 2/11/11. The Investigative Report, was dated 3/17/11, more than a month after the allegation was made. Staff #6 stated that complaints by recipients are handled through the facility's Recipient Rights Process and that there is no other grievance process available to patients.

On 4/14/11 at approximately 1000, a Recipient Rights Officer (staff#11) was interviewed regarding patient #3's allegation of sexual abuse by a staff member. Per the RRO's Investigative Report, dated 3/17/11: "On Friday, February 11, 2011, the office of Recipeint Rights received a phone call from recipient (patient #3) alleging that she has been sexually abused..." Patient #3 was an inpatient at the facility on that date. During review on 4/14/11, the following sections of the report were incomplete: Findings, Conclusion, Recommendations, Documents Reviewed, and Persons Interviewed."

Staff #11 stated that she had investigated the allegation and done some interviews before she and the CEO concluded that the allegation was unsubstantiated. Staff #11 verified that she did not receive a written statement from the accused or document asking him specifically about the abuse allegation. Staff #11 stated that she did not document the conversation with the CEO or document her conclusions in any form.

Staff #11 stated that on 2/11/11 she and the CEO agreed that the accused staff (#14) would not work on the same unit as the patient. A facility "Patient's Concerns Summary Report" lists this allegation as resolved with the following action taken: "(accused) staff was transferred to another unit."Review of daily staffing sheets indicated that staff #14 continued to work on the patient's unit (2nd Floor) on 2/12, 2/14, 2/16, 2/17, 2/21 and 2/22/11. These findings were verified with staff #6 on 4/14/11.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview the facility failed to ensure that 1 of 1 patients (#3) was free of abuse by failing to conduct a timely investigation of an allegation of sexual abuse.

Document Review:

1. Policy MH-05-, Identifying Abuse and Neglect, updated 4/11/11 states: "It is the policy of (facility) to identify and report recipient abuse...and to act upon this information. The reporting of abuse will be in accordance with (Michigan) Public Act 290 of 1995."

Michigan Mental Health Code (R 330.7035) states: "A provider shall...provide for a prompt and thorough review of charges of abuse that is fair to both the recipient alleged to have been abused and the charged employee."

2.) Policy RR8.0/HR- 8.0, dated 4/13/1, titled "Suspension of Staff During Recipient Rights Investigation" affords no guarantee of protection to patients while allegations of staff to patient abuse are being investigated. The policy purpose ("to ensure patient safety during a Recipient Rights investigation") is at odds with the procedure which states that measures to protect a resident from staff accused of abuse "may" (or may not) immediately following the abuse allegation.

Patient Findings:

On 4/14/11 at approximately 1000, a Recipient Rights Officer (staff#11) was interviewed regarding patient #3's allegation of sexual abuse by a staff member. Per the RRO's Investigative Report, dated 3/17/11: "On Friday, February 11, 2011, the office of Recipeint Rights received a phone call from recipient (patient #3) alleging that she has been sexually abused..." Patient #3 was an inpatient at the facility on that date. During review on 4/14/11, the following sections of the report were incomplete: Findings, Conclusion, Recommendations, Documents Reviewed, and Persons Interviewed."

Staff #11 stated that she had done some investigative interviews and that she and the CEO concluded that the allegation was unsubstantiated. Staff #11 verified that she did not receive a written statement from the accused or document asking him specifically about the abuse allegation. Staff #11 stated that she did not document her conclusions in any form.

Staff #11 stated that on 2/11/11 she and the CEO agreed that the accused staff (#14) would not work on the same unit as the patient. A facility "Patient's Concerns Summary Report" lists this allegation as resolved with the following action taken: "(accused) staff was transferred to another unit."Review of daily staffing sheets indicated that staff #14 continued to work on the patient's unit (2nd Floor) 2/12, 2/14, 2/16, 2/17, 2/21 and 2/22/11. These findings were verified with staff #6 on 4/14/11.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0161
Based on observation, interview and record review, the facility failed to ensure that manual holds were treated as physical restraints and assessed and documented per policies for 3 of 3 patients (#6, #7, and #8). Failure to complete required documentation for manual restraint violates the patients' rights to free from restraint except to prevent immediate physical harm to self or others.

Document Review:

On 4/13/11 from 1100-1300, review of facility policy 2.4, "Restraints", dated 2/1/11 revealed:

1.)The following definition of physical management: "Physically holding a patient during a forced psychotropic medication procedure is considered a restraint."

2.) "When restraints is used for the management of violent or self destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or other, a physician or a RN ora PA trained in accordance with the requirements of this policy must see the patient face to face within one hour after the initiation of the intervention. This practitioner must evaluate and document immediate reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint or seclusion."

3.) "Face to Face Assessment: If the face to face examination if conducted by a trained RN, the RN must consult the attending physician who is responsible for the care of the patient as soon as possible after the completion of the face to face evaluation.

Patient Specific Findings:

During a tour of the facility on 4/13/11, at from 0900-1100, review of Restraint Logs on Floors 1, 2 and 3 revealed that 3 patients (#6, #7, and #8) were documented as having been physically restrained following episodes of agitated behavior.

1.) Floor 3- Review of the "Seclusion/Restraint Documentation Form" for patient #7 revealed 1 restraint application on 4/7/11. The form states that patient #7 was physically restrained for 3 minutes at 0843 hours to prevent an elopement attempt. The form also notes that patient #7 was given an injection of Haldol and Ativan. No documentation indicating what behaviors justified the use of physical management during the injection were noted. A Physician did not document a one hour face to face assessment afterwards. A Nurse (staff #12) completed the "Physician Assessment (Face to Face)" section of the "Seclusion/Restraint Documentation Form." The completion time noted the same time as the restraint initiation time (0843).

On 4/13/11 at 0945 staff #10, a Mental Health Technician, stated that he assisted in restraining patient #7 twice on 4/7/11, first when he attempted to elope through an exit door and afterwards when a nurse administered an injection. In the 1 hour assessment portion of the form, timed 0843, Nurse #12 states only that: "patient continued to be "defiant/resistant prior to PRN Ativan and Haldol IM" (by intramuscular administration.) No explanation of specific behaviors constituting a harm risk are provided to explain the need for the IM injection.

2.) Floor 2- Review of the for patient #8 revealed that application of a physical restraint on 3/28/11 at 1840 hours. No documentation of a 1-hour face to face assessment was noted. On 4/13/11 at 1015 hours the nurse (staff #13) who completed the "Seclusion/Restraint Documentation Form" was interviewed by phone. Nurse #13 was asked if a nurse or physician did a one-hour face to face following the application of physical restraints. Nurse #1 stated that the facility does not require one unless a patient is restrained for a full hour.

3) Floor 1- Review of the for patient #8 revealed that application of a physical restraint on 4/13/11 at 0205 hours. No documentation of specific behavior justifying the use of physical holding for an injection was noted. No documentation of a 1-hour face to face assessment was noted. This finding was verified by the Director of Nursing.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on record review and interview 2 of 2 patients (#7 and #8) did not receive updates to their Master Treatment Plans following the application of physical restraints. Findings include:

Document Review:

1.) Floor 3- Review of the "Seclusion/Restraint Documentation Form" for patient #7 revealed 1 restraint application on 4/7/11. The form states that patient #7 was physically restrained for 3 minutes at 0843 hours to prevent an elopement attempt, No update to patient #7's Master Treatment Plan was noted following this episode. This finding was confirmed by the Director of Nursing on 4/13/11 at approximately 1000 hours.

2.) Floor 2- Review of the for patient #8 revealed that application of a physical restraint on 3/28/11 at 1840 hours. The Seclusion/Restraint Documentation Form" states that the patient was threatening to a peer and refused redirection from behind the Nursing Station desk. No update to patient #7's Master Treatment Plan was noted following this episode. This finding was confirmed by the Director of Nursing on 4/13/11 at approximately 1030 hours.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on interview and record review, 3 of 3 patients physically restrained (#6, #7, and #8) did not receive comprehensive one-hour patient assessments. Findings include:

Document Review:

On 4/13/11 from 1100-1300, review of facility policy 2.4, "Restraints", dated 2/1/11revealed:

1.) "When restraints is used for the management of violent or self destructive behavior...a physician or a RN or a PA trained in accordance with the requirements of this policy must see the patient face to face within one hour after the initiation of the intervention. This practitioner must evaluate and document immediate reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint or seclusion."

2.) "Face to Face Assessment: If the face to face examination if conducted by a trained RN, the RN must consult the attending physician who is responsible for the care of the patient as soon as possible after the completion of the face to face evaluation...The face to face assessment is performed even in those situations where the person is released (prior to one hour.)"

3.) "The evaluation incorporates the following:

Identifies the patient's specific behavioral/cognitive changes, including a complete review of systems assessment, behavioral assessment, as well as review and assessment of the patient's history, medications, most recent labs, etc. This comprehensive review of this patient's condition is to determine if other factors such as drugs or mediation interactions, electrolyte imbalance, or hypoxia are contributing to the patient's violent or self destructive behavior."

Patient Findings:

1.) Floor 3- Review of the "Seclusion/Restraint Documentation Form" for patient #7 revealed 1 restraint application on 4/7/11. The form states that patient #7 was physically restrained for 3 minutes at 0843 hours to prevent an elopement attempt, The form also notes that patient #7 was given an injection of Haldol and Ativan. Afterwards, no document of a comprehensive 1-hour face to face assessment was noted.

On 4/13/11 at 0945 staff #10, a Mental Health Technician, stated that he assisted in restraining patient #7 twice on 4/7/11, when he attempted to elope and afterwards on his bed while a nurse administered an injection. In the assessment portion of the form, Nurse #12 states only that: "patient continued to be "defiant/resistant prior to PRN Ativan and Haldol IM" (by intramuscular administration.) Nurse #12 timed this note as 0843 as well. These findings were confirmed by the Director of Nursing (DON) on 4/13/11 at approximately 1000 hours.

2.) Floor 2- Review of the for patient #8 revealed that application of a physical restraint on 3/28/11 at 1840 hours. No documentation of a 1-hour face to face assessment was noted. On 4/13/11 at 1015 hours the nurse (staff #13) who completed the "Seclusion/Restraint Documentation Form" was interviewed by phone. Nurse #13 was asked if a nurse or physician did a one-hour face to face following the application of physical restraints. Nurse #1 stated that the facility does not require one unless a patient is restrained for a full hour. These findings were confirmed by the Director of Nursing (DON) on 4/13/11 at approximately 1030 hours.

3.) Floor 1- Review of the for patient #8 revealed that application of a physical restraint on 4/13/11 at 0205 hours. No documentation of specific behavior justifying the use of physical holding for an injection was noted. No documentation of a 1-hour face to face assessment was noted. This finding was verified by the Director of Nursing on 4/13/11 at approximately 1050.