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.

DETROIT RECEIVING HOSPITAL 4201 ST ANTOINE ST - 2C DETROIT, MI 48201 June 24, 2020
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review, the facility failed to follow their policy and procedures for complaints and grievances for 1 (#1) of 2 patients resulting in the potential to have unresolved grievances/unmet patient rights. Findings include:
See specific tags:

A-122
Failure to review, investigate and resolve patient's grievances in a timely manner.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on document review and interview, the facility failed to follow their complaint and grievance policy and procedure for one (#1) of two patients whose grievances were reviewed, resulting in the potential to have unresolved grievances/unmet patient rights. Findings include:

On 6/24/2020 at 1330 a review of the facility's complaints and grievances logs were reviewed with Staff C. It was confirmed at that time by Staff C that there were no entries logged for patient #1.

On 6/24/2020 at 1430 an interview and record review was conducted with Customer Service and Patient Relations Staff R and the following was revealed:

Staff R said she had spoken on the phone with the patient's daughter on 5/27/2020. She said the patient's daughter reported that she "felt (name of physician) was not serious about the patient's (#1's) care."

Staff R provided a letter dated 5/27/2020 that was addressed to patient (#1). Staff R confirmed that was the only letter that she mailed out in response to the patient's daughter's grievance. Review of the letter at that time acknowledged receipt of her (#1's) daughter's grievance regarding the patient's care during his April 26, 2020 hospital admission on 5-Q at (name of facility).
The letter documented: "The appropriate administrator will investigate your dissatisfaction. I will contact you on or before June 27, 2020 with a status of your complaint."

There was no evidence in the letter dated 5/27/2020 that documented the patient's grievance had been reviewed or investigated. There was no evidence in the letter that documented the grievance was complicated and that it would require an extensive investigation. There was no evidence in the letter that documented the facility was still working to resolve the grievance.

Staff R was asked to explain why the complaint/grievance concerning patient #1 was not documented on the facility's log. Staff R said that she did not know.

Staff R said she had no further information regarding the status of the investigation. Staff R said the patient's daughter had recently called to request a meeting with the Chief Medical Officer.

An interview was conducted with the Chief Medical Officer (CMO) on 6/24/2020 at 1500. He said he was currently the interim CMO and had been in that position for approximately one year. He was asked if he was aware of a complaint/grievance involving patient #1. He said it had been brought to his attention just a few days ago. He said he was originally suppose to meet with the patient's daughter on 6/23/2020 but the meeting was rescheduled for today and he was planning on meeting with her regarding her concerns.

On 6/26/2020 at 0933 Staff C sent an unsolicited copy of the facility's complaint and grievance log via email to the surveyor. The grievance for patient #1 was logged. The grievance did not list the identified physician (Staff P) with whom Staff R referenced during the interview on 6/24/2020 at 1430. There was no update on the status of grievance. Additionally, there was no evidence on the log that documented the date that a response letter had been mailed out concerning the grievance.

A review of the facility's "Patient and Family Complaints and Grievances" policy No: CLN 033 (CO 2.004 Tenet Model Policy) with an effective date of 5/12/2020 documented as follows:
C: Patient Grievance
3. The seriousness of the grievance drives the response time.
Grievances should be resolved and the patient notified of the response in 7 days.
If resolution of the grievance is determined to take longer than seven days, the Grievance Committee or designee sends a response to the patient informing him/her that Hospital is still working to resolve the grievance and that the Hospital will follow-up with a written response within a stated number of days (a "Deferral Letter")
No more than seven days elapses before a response is sent to the patient...
6. The Patient Guest Relations department maintains a log that provided response to the patient.
Minimum elements include: Date of complaint/grievance
Tracking number or identification
Type of complaint/grievance
Location/Department
Person assigned to investigate
Dates response letters sent (7 days and 30 days as appropriate)
Comments.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review, the facility failed to follow policy and procedure for wound care orders, documentation for pressure injury and failure to update the plan of care for skin integrity for one (#1) of 2 patients reviewed for pressure injury resulting in the increased potential for adverse outcomes for one patient (#1) out of 10 patients reviewed. Findings include:

See specific Tags:
A-0395: Based on interview and record review the facility failed to ensure that a Registered Nurse initiated wound care / orders for newly acquired pressure injury.

A- 0396 : Failure to ensure nursing staff updated the plan of care for pressure injury for one (#1) of ten patient's reviewed for care plans.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed implement their policy and procedure for initiating wound care orders for a hospital acquired pressure injury and failed to consistently evaluate wound healing for wounds that were present on admission per policy and procedure for one (#1) of two patients reviewed for impaired skin integrity, resulting in unmet care needs.

On 6/24/2020 at 1230 review of the medical record revealed the following:
Patient #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus, Hypertension, multiple CVA's (cardiovascular accidents), quadriplegia, chronic trach PEG (percutaneous endoscopic gastrostomy tube), suprapubic catheter and multiple pressure injuries (trunk and lower extremities) that were present upon his admission.

Review of "Wound Care Consultation" notes dated 4/29/2020 and 5/21/2020 revealed the patient had multiple wounds on his trunk and lower extremities. There were wound measurements and treatment orders noted on each of the consultations.

Review of the skin assessments dated 6/12/2020 through 6/24/2020 revealed the patient acquired a Stage II pressure injury to his posterior head on 6/12/2020.
However, there were no orders for wound care to for the patient's posterior head wound documented in the medical record.

An interview and record review was conducted with Critical Care Coordinator Staff K on 6/24/2020 at 1300. At that time he confirmed there were no orders for the patient's posterior head wound. Further review of the patient's skin assessments dated 5/22/2020 through 6/24/2020 revealed there were no further wound care measurements nor evaluations of the patients community acquired pressure injuries documented in the chart after 5/21/2020.

At that time, Staff K said confirmed that it was feasible that wound care measurements should have been documented more frequently.

Review of the facility's "Skin and Wound Care" policy No. 2 PC 5200, dated April 10, 2018
documented as follows:
III. Policy:
A. The RN is responsible for the assessment, planning, evaluation and documentation of skin and wound care. Wounds are assessed with each dressing change and characteristics documented in the medical record...I. RN staff members initiate EMR orders for pressure injury prevention and management based on patient risk assessment and/or presence of pressure injury (injuries).

Wound assessment and Documentation:
Careful initial and repeated assessment, documentation of the patient and the wound will help the clinician in selecting treatment modalities as well as evaluating progress. The assessment includes identifying wound location, dimensions, wound bed, surrounding skin and analysis of any odor or exudate that may be present.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to consistently follow the plan of for impaired skin integrity and update the nursing plan of care for skin integrity for a hospital acquired pressure injury for 1 (#1) of 10 patients reviewed for care plans, resulting in the potential for less than optimal outcomes. Findings include:

On 6/24/2020 at 1400 medical record review revealed the following:
The patient of concern (#1) was a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus, Hypertension, multiple CVA's (cardiovascular accidents), quadriplegia, chronic trach PEG (percutaneous endoscopic gastrostomy tube), suprapubic catheter and multiple pressure injuries (trunk and lower extremities) that were present upon his admission.

Review of "Impaired tissue Integrity" Plan of care dated 5/11/2020 documented the following:
"Pt has multiple wounds throughout body documented in flowsheet, pt on Clinitron sand bed due to multiple pressure injuries, heel lift boots on, skin assessments every shift, daily bath."

Review of Skin Assessments revealed the following:
On 6/12/2020 at 1800 a new pressure injury located on the patient of concern (#1's) posterior head. The wound was described as a stage II that was cleaned and a silicon dressing was applied. However, there were no measurements documented.
On 6/13/2020, at 1500 the wound was described as a stage II that was cleaned and a silicon dressing was applied. However, there were no measurements documented.
Additionally, there was no assessment of the patient's posterior head wound for 21 hours.
On 6/13/2020 at 1900, the dressing to the patient's posterior head was assessed.
On 6/14/2020 between the hours of 0001 am and 1159 pm there were no skin assessments or skin treatments documented as performed for any of the patient's pressure injuries.
On 6/15/2020 at 0400 and at 1900 the nurses documented the dressings were assessed and clean to the patient's pressure injuries. However, there was no evidence that the dressings were changed.
On 6/16/2020 between the hours of 0001 am and 1159 pm the patients posterior head wound was not addressed.
On 6/17/2020 between the hours of 0001 am and 1159 pm the patients posterior head wound was not addressed.
On 6/18/2020 between the hours of 0001 am and 1159 pm the patients posterior head wound was not addressed.
On 6/19/2020 between the hours of 0001 am and 1159 pm the patients posterior head wound was not addressed.
On 6/20/2020 between the hours of 0001 am and 1159 pm the patients posterior head wound was not addressed.
On 6/21/2020 between the hours of 0001 am and 1159 pm the patients posterior head wound was not addressed.
On 6/22/2020 at 0700 and at 2200 the patients posterior head wound was assessed. It was noted that the dressing was clean. However, there was no evidence that the dressing was changed to the patient's posterior head wound.
On 6/23/2020 between the hours of 0001 am and 1159 pm there was no evidence that documented the patients posterior head wound dressing was assessed, cleaned or changed.
On 6/24/2020 between the hours of 0001 am and 1259 the patient's posterior head wound was not addressed.

A review of the facility's "Patient Assessment and Documentation" policy dated effective 11/15/2019 documented as follows:
III. Policy:
C: The RN documents admission and on-going focused assessments, patient/family teaching, plan of care, interventions and patient response in the medical record...
F. The RN interacts with patient, family and significant others to establish goals and formulates plan of care.