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HENRY FORD KINGSWOOD HOSPITAL 10300 W EIGHT MILE ROAD FERNDALE, MI 48220 Aug. 6, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review, the facility failed to protect the rights of patients for 2 (#10, #11) of 11 patients reviewed requiring a safe environment, resulting in the potential of patients losing their rights. Findings include:

1. The facility failed to provide a safe environment for 2 (#10, #11) of 11 patients requiring 15-minute safety checks, resulting in patients #10 and #11 not being monitored for extended periods of time with the potential for unsafe behaviors. (See A-144)
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to provide a safe environment for 2 (#10, #11) of 11 patients requiring 15-minute safety checks, resulting in patients #10 and #11 not being monitored for extended periods of time with the potential for unsafe behaviors. Findings include:

On 8/5/19 at approximately 1400, interview with the Registered Nurse L, (Child/Adolescent Psychiatric Nurse) taking care of both [AGE]-year-old patients on 7/8/19, revealed that patient #11 claimed he was sexually abused by patient #10 on the day of discharge (7/8/19) and the day before. The Nurse asked the patient, "When?" and the patient got upset stating, "I knew you wouldn't believe me." Nurse L further explained that the two [AGE]-year-old boys were roommates and he and the mental health assistants checked on them every 15 minutes or so during the day, and saw no rushed movements or distress by either boys.

On 8/5/19 at approximately 1530, interview with the Administrator revealed that she had reviewed the video surveillance for a time period of 7/8/19 (1451 - 1523) and a spot check of a time period on 7/7/19 (1800 - 1933) and did not determine any concerns. The Administrator further explained that the facility had done an investigation and there was a police investigation in progress.

On 8/6/19 at 0900, medical record review revealed that Patient #10 was a [AGE]-year-old male admitted to the Child/Adolescent Psychiatric Unit at the facility (6/25/19 - 7/9/19) and presented with suicidal ideation, an attempt to strangulate himself using a shower curtain, and previous attempt with cord around his neck. The patient was to be monitored every 15 minutes per policy. Additionally, medical record review revealed that Patient #11 was also a [AGE]-year-old male admitted to the Child/Adolescent Psychiatric Unit at the facility (6/25/19 - 7/8/19) and presented with suicidal ideation, history of cutting himself, and angry outbursts. There was a recent history of sexual abuse by a peer in school and past physical abuse by his biological father. The patient was to be monitored every 15 minutes per policy.

On 8/5/19 at approximately 1530 - 1700, video surveillance review with the Administrator revealed that the two boys had not had every 15 minute safety checks done by the Registered Nurse (RN) or Mental Health Assistant (MHA), between 7/7/19 0000 and 7/8/19 0703.

-On 7/7/19 at 2359 the RN went in the bedroom to check the patients.
-On 7/8/19 at 0057 the MHA checked the patients. (58 minutes)
-On 7/8/19 at 0118 the MHA checked the patients.
-On 7/8/19 at 0135 the MHA checked the patients.
-On 7/8/19 at 0201 the MHA checked the patients. (26 minutes)
-On 7/8/19 at 0215 the MHA checked the patients.
-On 7/8/19 at 0242 the MHA checked the patients. (27 minutes)
-On 7/8/19 at 0315 the MHA checked the patients. (33 minutes)
-On 7/8/19 at 0329 the MHA checked the patients.
-On 7/8/19 at 0411 the MHA checked the patients. (42 minutes)
-On 7/8/19 at 0456 the RN checked the patients. (45 minutes)
-On 7/8/19 at 0514 the MHA checked the patients.
-On 7/8/19 at 0557 the MHA checked the patients. (43 minutes)
-On 7/8/19 at 0703 the MHA checked the patients. (66 minutes)

Interview with the Administrator on 8/5/19 at approximately 1600 verified that the expectation was that the patients were to be monitored every 15 minutes (plus/minus five minutes). The Administrator verified that the census for the unit was five patients, and there was one Registered Nurse (RN) and two Mental Health Assistants (MHA) on the Child/Adolescent Unit. On 8/6/19 at 0945, phone interview with the RN O in charge on the Child/Adolescent Unit that midnight shift, revealed that she was not aware that the patients had not been monitored every 15-20 minutes.

On 8/6/19 at 1430, review of the facility policy/procedure titled "Safety Rounds New" dated effective 2/2017, documented "Patient safety is a priority in a psychiatric setting; hence frequent monitoring will be conducted. To mitigate safety risk on the units, patients are monitored at 15 minute increments with a variance of +/- 5 minutes and their location indicated by code found in EPIC ...On midnight shifts, rounders are expected to observe each sleeping patient for the presence of respirations which are confirmed by visual observation of rise and fall of chest at any time the patient is lying down. Staff must enter the patient room to confirm this but are not to linger in the room ..."