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.

Based on observation and interview the facility failed to ensure that patients were provided with contact information needed to file a complaint with the State agency, limiting all patient's right to file complaints. Findings include:

All seven units were toured on March 28, 2013, from approximately 10 am - 12 noon. Contact information for the State of Michigan Complaint Hotline was not posted on any unit nor provided in printed materials provided to patients. This finding was verified by the Acting Director of Nursing during this tour.
Based on policy and record review, observation and interview, the facility failed to provide 1 of 1 current patient's (#2) with a prompt, through investigation of an abuse allegation and to protect patients from abuse during abuse investigations, increasing the risk of abuse for all patients. Findings include:

Policy Review:

"Abuse and Neglect Reporting,Investigation, and Review," 7/1/10, states:

3. "It is the policy of the Center for Forensic Psychiatry to prohibit all acts of commission or omission which are abusive or neglectful of CFP patients and to assure that all incidents of abuse or neglect are reported, reviewed, and investigated in a timely manner."
4.3 "Abuse Class III: The use of language or other means of communication by staff to degrade, threaten or sexually harass patient."

"Michigan Department of Community Health, Supervisor Handbook," 2013, states:

"There are occasions when a serious event occurs that dictates that an employee should be "suspended pending investigation." This is normally only used when an employee is a potential threat in the work place or, is suspected of serious abuse/neglect of mental health recipients or, is an immediate serious disruptive presence in the work place or, may be involved in criminal activity."

If it becomes necessary to suspend an employee pending investigation, the employee must be so advised, in writing...An Employee Departure Report form normally is given to the employee identifying suspension pending investigation...The issuance of this form...will be handled by the human resources officer."

Record Review:

1. From March 28-29, 2013 review of Incident Report, investigation notes and video regarding the 2/13/13 abuse allegation revealed:

---An Incident Report dated 2/13/13 contained a statement by Forensic Security Assistant (FSA) #5, that FSA #1 cursed at and threatened patient #2 on 2/13/13, at approximately 8:10 pm. FSA #5 named 3 witnesses (FSAs #2, #3 and #4).
---FSA #2 stated that he heard FSA #1 curse at patient #2 during the 2/13/13 incident. There was no documentation indicating that FSA #2 was asked whether FSA #1 also threatened patient #2.
---FSA #3 had not been interviewed yet.
---FSA #4 was assigned to 2:1 coverage (with FSA #1) of patient #7, in another part of the unit, at the time of the incident. It was unclear from video review, on 3/28/13 at approximately 3:30 pm, whether FSA #1 was present during the entire incident. This observation was verified by Security Officer #1 during video review.
---FSA #6's (undated) statement noted "loud noises" and "(patient #2) and (FSA #1)"going back and forth."
---Patient #2's statement regarding the incident was taken on 2/26/13, 13 days post-incident. The note does not state whether patient #2 was asked if staff had cursed at or threatened him.

2. On March 29 at approximately 9:15 am the Assistant Human Resources Director (AHRD) stated that FSA #1 was not suspended and continued to work after the 2/13/13 incident but was assigned to work on another unit. The AHRD stated that the HR Office typically takes no personnel actions until the Rights Office completes their investigation and that it was not a breach of policy or protocol to allow FSA #1 to work while this abuse allegation was under investigation.

3. On March 29 at approximately 9:30 am patient #2's clinical record was reviewed, revealing no documentation of the 2/13/13 incident or provision of follow-up support.


1. On March 29, 2013 at approximately 9:30 am patient #2 was interviewed on E4. Patient #2 stated that staff "did not treat me right" on his former unit (South 1 at the time of the incident.) Patient #2 stated that he could not name staff that treated him poorly on 1 South.
2. On March 29, 2013 at approximately 11:15 am Recipient Rights Advisor (RRA) #1 stated that the Rights Office is responsible for investigating this abuse allegation. RRA #1 verified that two witnesses (FSA #2 and FSA #5) made statements indicating that FSA #1 cursed at patient #2 and that one witness (FSA #3) has not been interviewed yet.
3. On March 29, 2013 at approximately 11:15 am RRA #1 stated that swearing at a patient constitutes verbal abuse but is not sufficient reason to suspend a staff member during the investigation.
4. On March 29, 2013 RRA #1 stated that FSA #1 had been transferred to work on another unit, pending the results of this investigation. RRA #1 stated that this is facility protocol during most abuse/neglect investigations.
5. On March 29 at approximately 11:30 am the Acting Director of Nursing (ADON) stated that it is facility protocol to transfer staff during abuse and neglect investigations, rather than suspend them. The ADON verified that the Nursing Supervisor did not initiate an investigation on 2/13/13 since it is protocol to wait for the Recipient Rights Advisor to investigate. (Recipient Rights Advisors are unavailable evenings, weekends and holidays.)