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.

ASCENSION MACOMB OAKLAND HOSP-WARREN CAMPUS 11800 EAST TWELVE MILE ROAD WARREN, MI 48093 Sept. 23, 2020
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure timely reporting of an allegation of staff to patient sexual abuse, and failed to document counseling of concerned staff members for failing to report an allegation of abuse and a threat of retaliation to a patient for reporting an allegation of abuse for one (#1) of one patients reviewed for abuse allegations out of a total of two complaints and grievances reviewed out of a total sample of 11, resulting in the potential for undetected, uncorrected patient abuse. Findings include:

On 9/18/20 at approximately 1430 the facility log of adverse events, the facility log of complaints/grievances and the facility log of abuse investigations from 6/1/20 through 9/17/20 were reviewed with the Risk Manager Staff AA. There was only one patient complaint/grievance related to abuse, one adverse event related to abuse and one abuse investigation documented during the 14 weeks reviewed and all were related to the same allegations of staff to patient abuse reported by Patient #1.

The facility adverse incident log from 6/1/20 through 9/17/20 documented that a "behavioral incident" regarding Patient #1 occurred on 8/15/20 and was reported on 8/19/20 (four days later).

On 9/18/20 at approximately 1435 The Risk Manager Staff AA was interviewed and reported that Patient #1's abuse allegation was one of several grievances he made to the Patient Relations Department. Staff AA said that the event allegedly occurred on 8/15/20 and was reported on 8/19/20 at 2007 (four days later). Staff AA said that Patient #1 was, "very delusional" and had a history of making sexual abuse allegations.

On 9/18/20 at approximately 1500 the facility abuse investigation file was reviewed with the facility Risk Manager Staff AA and the Director of Nursing Staff C. The following was revealed:

The facility Safety Event Manager (abuse investigation) time line noted that the facility became aware of Patient #1's allegation on 8/19/20 via an email from the Patient Relations Department regarding a grievance from Patient #1 alleging "inappropriate behavior" from Staff Nurse BB.

The Safety Event Manager Report (adverse incident report) for Patient #1's allegations of staff to resident abuse on 8/15/20 was dated 8/19/20 and documented that Patient #1, "alleged inappropriate behavior by the nurse." The report noted that the alleged event occurred on 8/15/20. The summary noted that the investigation concluded that Patient #1's allegation was unsubstantiated and was related to his "condition" (diagnoses of Paranoid Schizophrenia and Acute Psychosis). An abuse investigation rubric had the beginning date of the investigation hand written in as 8/17/20.

A "RL Datix Feedback Ticket" dated 8/17/20 at 1721 (patient complaints/grievances report) entered by Patient Relations Staff MM documented that Patient #1 made a complaint/grievance, "in person" that, "(Staff BB) rubbed his shoulders in a sexual way, as well as rubbed his penis on the crevice of his buttocks. He stated that he just rubbed his penis on him but did not take it out."

An email dated 8/17/20 at 1717 from Staff MM to Staff AA documented that the Unit Manager of Patient #1's unit Staff PP told her "earlier today" that Patient #1 accused Staff BB of "inappropriate touching". The email noted that Staff PP reported that Patient #1 said that Staff BB touched him on his shoulders and took his penis out and rubbed it on his back at around 1830 on 8/15/20. The email documented that Staff MM interviewed Patient #1 on 8/17/20 and noted that Patient #1 also reported paranoid allegations regarding the government poisoning him and probing him with electromagnetic devices.

A letter to the Patient Relations department from Patient #1 dated 8/15/20 documented numerous complaints and grievances, including that he was being held against his will in the facility, was given unnecessary medications, and was being subjected to sexual trafficking in the facility.

There was no documentation to indicate that the Unit Manager Staff PP contacted a Nursing supervisor or Risk Management, or that she completed an Adverse Event Report. Staff AA and Staff C did not explain why Staff PP contacted the Patient Relations Officer instead of a Nursing Supervisor and Risk Management. AA and Staff C did not explain why Staff PP did not complete an adverse event report regarding Patient #1's allegation of staff to patient sexual abuse.

A Security Department Incident Report dated 8/15/20 at 1958 documented that security officers Staff GG and Staff QQ were called to talk with Patient #1 on 8/15/20 at 1945 because the patient wanted to call the police about a sexual assault complaint. Staff GG reported that he spoke with Patient #1 who stated that Staff BB started massaging his shoulders without permission after assisting him in the bathroom. Staff GG documented that Patient #1 said that he felt what he believed to be Staff BB's penis through his scrubs (nursing uniform) up against his buttocks. Staff GG documented that he interviewed Staff DD, Patient #1's one to one sitter who was present during the alleged event. Staff GG documented that Staff DD did observe Staff BB massaging Patient #1's shoulders near the bathroom. Staff GG documented that he interviewed Staff BB who denied massaging Patient #1's shoulders and said that he only, "grabbed him by the arm while escorting him from the bathroom to his bed." Staff GG documented that he , "debriefed" (informed) charge nurse Staff CC about the allegation and his interviews. Staff GG documented that Staff CC got very upset and said that she called Security for help to talk with the patient and all they did was to accuse Staff BB of sexual assault. Staff GG documented that Staff CC then said, "Well, I am not going to have my nurses help (Patient #1) if he falls to the floor." Staff GG documented that he witnessed Staff CC tell a nurse named, "Joe" that if (Patient #1's room number) falls, don't pick him up.

A Security Department Incident Report addendum dated 8/15/20 at 2200 by Staff QQ documented that he and Staff GG were called by Staff CC to respond to Patient #1's unit to calm Patient #1 down because he made a complaint that a staff member sexually assaulted him. Staff QQ 's documentation confirmed the same facts that Staff GG documented in his Security Incident Report with the added note that after repeated questioning by Staff GG, Staff BB retracted his previous denial that he massaged Patient #1's shoulders and admitted to, "massaging Patient #1's shoulders, but only to relax him." Staff QQ also documented that he heard Staff CC tell other RNs in the hallway that, "if the patient falls, do not touch the patient or put your hands on him."

There was no documentation to indicate that Staff QQ or Staff GG reported the abuse allegation immediately to the House Department Leader/Nursing Supervisor or Risk Management.

On 9/18/20 at approximately 1525 Staff AA and Staff C were asked about the delay in reporting an allegation of abuse and the discrepancy in the dates Patient #1's allegation of staff to patient abuse was reported, and were unable to provide a clear explanation.

On 9/18/20 at approximately 1530 Staff GG was interviewed. Staff GG stated that Staff BB initially denied massaging Patient #1's shoulders and neck but admitted to the massaging after he was confronted with Staff DD's statement that he did. Staff GG said that he did not report the allegation. because he could not substantiate that sexual assault occurred.

On 9/18/20 at approximately 1545 Staff CC was interviewed. Staff CC reported that on 8/15/20 Patient #1 called her to his room to report that Staff CC massaged his shoulders and rubbed himself against his backside. Staff CC reported that Patient #1 was agitated so she called Security. Staff CC said, "(Staff BB) said that he was rubbing his shoulders when he was trying to get him into bed. I'm assuming that he (Staff BB) denied it was a massage because he didn't consider it a massage." Staff CC did not explain why she did not complete an Adverse Event Report or notify her supervisor or Risk Management regarding Patient #1's allegation of abuse or why she told other nurses not to pick Patient #1 up if he fell , but said that she, "got upset because Security called (Staff BB) a liar."

On 9/18/20 at 1615 the Director of Security Staff H was interviewed and stated that his staff should have reported Patient #1's allegation of staff to patient abuse per facility policy.

On 9/23/20 at approximately 1045 the Patient Experience Manager Staff MM was interviewed and reported that the Unit Manager Staff PP reported Patient #1's allegation to her on 8/17/20. Staff MM stated that she reported the allegation of abuse to Risk Management immediately. Staff MM said, "Whoever finds out about abuse cases has to notify Risk Management."

On 9/23/20 at approximately 1100 The Director of Nursing Staff C was interviewed regarding Staff CC's failure to notify her supervisor or Risk Management of Patient #1's allegation of abuse and her failure to complete an Adverse Event Report for the incident. Staff C said, "I do not know why they did not report it. The Nurse should have filled out an incident report and reported it to the House Supervisor." Staff C said that she inserviced Staff BB about asking for permission before touching a patient and exercising caution before touching a behavioral health patient with fixations on sexual delusions. Staff BB was unable to provide documentation of this. Review of Staff BB's personnel record on 9/23/20 at approximately 1400 revealed no documentation of this. Staff C was unable to provide documentation to indicate that Staff CC's threats of staff retaliation ( two witnesses overheard her instructing nurses not to pick the patient up if he fell ) were addressed. Review of Staff CC's personnel file on 9/23/20 at approximately 1410 revealed no documentation that she was inserviced/counseled regarding her failure to report an allegation of abuse or complete an incident report on the event.

On 9/23/20 at approximately 1300 Staff DD, present at the time of allegation was interviewed via phone. Staff DD said that Staff BB did not massage Patient #1's neck but only touched him on one shoulder to guide him back away from the room doorway. Staff DD said that he couldn't see if Staff BB's body was touching Patient #1's back because of the angle of view. Staff DD said that Patient #1 immediately got agitated and started yelling at Staff BB to get out of his room and not come back. When asked what Patient #1 was wearing at the time of the incident, Staff DD said that Patient #1 was wearing an open back hospital gown with nothing on underneath. Staff DD was asked about his written interview statement (for the abuse investigation) that Staff BB touched Patient #1 on the neck and shoulders. Staff DD said that he meant that Staff BB touched him on the shoulder where his shoulder met his neck.

On 9/23/20 at approximately 0900 Patient #1's clinical record was reviewed and revealed the following:

Patient #1 was a [AGE] year old male who was brought to the Emergency Department by police for psychotic behavior on 8/8/20 with Probate court Petition and Certification for involuntary hospitalization for mental illness. Diagnoses included Acute Psychosis and Paranoid Schizophrenia. Patient #1 remained in the Emergency Department (ED) awaiting Community Mental Health Authorization for inpatient admission until 8/10/20.

ED Physician documentation dated 8/8/20 at 1712 noted that Patient #1 had a long history of mental illness with multiple previous behavioral health hospitalization s. The physician documented that Patient #1 called the police to report that he was being anally probed and raped by aliens in the government. ED Physician and Nursing documentation noted that Patient #1 was violently agitated, refused medications and remained in four point cuffed physical restraints the entire time he was in the ED.

Patient #1 was diagnosed with Rhabdomyolysis (muscle destruction) on 8/10/20 and was admitted to a medical unit with plans to transfer him to an inpatient psychiatric unit after the Rhabdomyolysis resolved.

Nursing and Psychiatrist documentation for Patient #1 from 8/10/20 until his transfer to the Behavioral Health Unit on 8/19/20 documented that Patient #1 was agitated, frequently combative, often appeared to be having conversations with unseen/imaginary persons and verbalized paranoid delusions of rape by aliens and probes by government electromagnetic devices.

There was no documentation in the clinical record that Patient #1 made any allegations regarding staff on 8/15/20. There was no documentation of any incident on 8/15/20 in the clinical record. There was no documentation by Staff BB in Patient #1's clinical record on 8/15/20. There was no documentation in the clinical record to indicate that Patient #1's psychiatrist or attending physician noted his allegation of staff to patient abuse on 8/15/20.

On 9/22/20 at approximately 1600 review of the facility policy entitled, "Abuse and Neglect: Report", revised 8/2017 revealed the following statements:

"Any associate who witnesses or receives a report of alleged abuse or neglect from a patient/family, other patient, staff member, visitors or other person should immediately notify the on duty department leader, and Risk Management should be contacted immediately."

"An Event Reporting System (ERS) report should be completed."

"Human Resources should be notified to coordinate the investigation of allegations against an employee, and documents the investigation in accordance with the grievance process."
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview and record review the facility failed to adhere to nationally recognized practices for prevention and control of Covid-19 infection, resulting in the potential spread of infection. See specific tags:

A 749: Based on observation, interview and record review the facility failed to ensure that visitors and staff were screened for signs and symptoms of Covid-19 disease, information for staff and visitors regarding signs and symptoms of Covid-19 infection was updated to reflect current knowledge, patients were screened for signs and symptoms of Covid 19 infection after admission and staff and patients observed recommended source control methods, resulting in the potential for uncontrolled spread of infection to all patients and staff in the facility.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed to ensure that nationally recognized guidelines and standards of practice to prevent the spread of Covid-19 were consistently implemented to ensure that visitors and staff were screened for signs and symptoms of Covid-19 disease, information for staff and visitors regarding signs and symptoms of Covid-19 infection were updated to reflect current knowledge, and staff and patients consistently wore masks for source control and observed social distancing, resulting in the potential for uncontrolled spread of infection to all patients and staff in the facility. Findings include:

On 9/18/20 at approximately 0855 a sign posted at the entrance to the hospital warning staff and visitors not to visit if they had signs and symptoms of Covid 19 disease was observed. The sign did not list all the major currently known symptoms of Covid 19 illness and only advised staff and visitors that the signs and symptoms of Covid 19 disease were fever and/or symptoms of a lower respiratory illness,cough, difficulty breathing, or if someone in your household tested positive for Covid 19 disease, or if you have recent travel outside the area.

On 9/18/20 at approximately 0900 Staff A was observed screening visitors and staff at the facility entrance. One staff physician and two visitors were observed as they entered the facility. Staff A took each person's temperature but did not ask any screening questions to check if these people entering the facility had any symptoms of Covid-19.

On 9/18/20 at 1000 the Director of Nursing Staff C was asked about screening of staff and visitors as they entered the facility and said that the screener should be asking standard questions about symptoms using a facility screening tool. Staff C reported that there were 10 Covid-19 positive patients currently admitted in the facility.

On 9/18/20 at approximately 1020 Staff A was interviewed with Staff C. Staff C told Staff A that she was supposed to be asking everyone who entered the facility if they had symptoms of Covid-19 illness using the facility screening tool. Staff A reported that she did not know where the screening tool was. Staff C located the screening tool in a binder in a shelf in the table where Staff A was sitting. Review of the facility screening tool revealed that it was last revised on 4/20/20 and did not include the majority of currently known symptoms of Covid-19 illness, and contained only the same symptoms of Covid-19 illness posted on the entrance to the facility.

On 9/18/20 at approximately 1020 the facility Emergency Department (ED) was toured. Three community Emergency Medical System Technicians (EMS) were observed standing close together in a charting room near the ambulance entrance without protective face masks. The door to the room was open directly to the hallway where patients and staff were. EMS Staff I was standing at the room doorway and said he and the other EMS technicians in the room weren't wearing masks because they knew that they didn't have Covid-19. Staff C was asked about this at this time and said that the facility did ask that people wear masks and social distance. The facility Infection Preventionist Staff D was also interviewed at that time and noted that the state was under a Governor's emergency mandate for universal protective face mask wearing inside of public buildings.

On 9/18/20 at approximately 1040 ED staff nurse L was observed walking down the hallway from the nursing station to to the hall restroom without a protective face mask (no source control). At approximately 1045 Staff L was observed as she left the restroom and walked into the staff locker room without a face mask. At approximately 1050 Staff L was observed as she walked out of the staff locker room, down the ED hallway, past several patient rooms with open doors, past the nursing station and out of the building without a mask. Staff L declined interview.

On 9/18/20 at approximately 1041 Staff C was interviewed regarding Staff L's failure to comply with source control/face mask wearing inside the facility (in patient care areas) and said, "She's a midnights nurse. She was probably tired from her shift. We tell people that they have to wear masks. It is facility policy that all staff wear hospital grade masks in the building."

On 9/18/20 at 1042 Three unidentified staff members who were not wearing face masks were observed as they gave Patient #3 a chest X-ray. Patient #3 was not wearing a face mask. Review of Patient #3's clinical record at this time revealed that Patient #3 was an [AGE] year old female who (MDS) dated [DATE] for a fall and weakness. Staff C was interviewed at this time and said that both the patient and the staff should have been wearing masks per facility policy for Covid -19 prevention.

On 9/18/20 at approximately 1100 Linen Department Staff O was observed pushing a linen cart down the hallway of the 3rd floor with his protective mask around his chin and not covering his mouth or nose. When Queried, Staff O said, "I need to breathe."

On 9/18/20 at approximately 1115 during a tour of the staff/visitor cafeteria, chef Staff P was observed with her protective face mask covering her mouth but not her nose. When interviewed at that time, Staff P said, "I didn't know it was all the way down."

On 9/18/20 at approximately 1120 Dietary Aide Staff Q was observed as she served food from the steam table to staff and visitors. Staff Q had her protective face mask down around her neck and not covering either her nose or mouth. Staff Q was interviewed at that time and said that she was training her new co-worker and took her mask off to show him something.

On 9/18/20 at approximately 1130 the endoscopy unit was toured. Three resident physicians/Endoscopy fell ows and one Endoscopy technician were observed less than six feet apart from each other in a charting room with the door open to the hallway. None were wearing protective face masks. When interviewed at this time, the physicians stated that they didn't need to wear protective masks or social distance from each other because they all lived together.

On 9/18/20 at approximately 1200 Housekeeper Staff W was interviewed regarding symptoms of Covid-19 infection which would require her to stay home from work and call Employee health. Staff W reported that these symptoms were fever, cough and difficulty breathing or exposure to someone who tested positive for Covid-19. Staff W reported no knowlege of expanded currently known symptoms of Covid-19

On 9/18/20 at approximately 1424 the staff time clock was observed with Staff C. A sign posted by the time clock advised staff that by punching in they attested that they had no symptoms of Covid-19 infection, which were listed as, fever and or signs of lower respiratory illness, cough or shortness of breath, or exposure to someone who tested positive for Covid-19.

On 9/18/20 at 1430 an unidentified staff member was observed at the screening station at the entrance to the facility. The screener did not ask visitors whether they had any signs and symptoms of Covid-19 illness but only took each entering person's temperature. Staff C who was present was interviewed regarding this at this time and said that the staff member was relieving Staff A for lunch and normally works as a patient transporter.

On 9/18/20 at approximately 1520 the facility Chief Nursing Officer Staff B provided a screening tool for Covid-19 dated 6/4/20 that listed the currently known major symptoms of Covid-19 illness. Staff B said that the facility parent corporation provided the updated screening tool to the facility, but did not provide a clear answer when asked why the updated tool from the parent corporation was not in current use at the facility.

On 9/18/20 tapproximately 1530 the facility Infection Preventionist was interviewed during a review of the facility Infection Control Program and reported that the program was based on guidelines and recommendations of the Center for disease control (CDC).

On 9/23/20 at approximately 0945 Staff Nurse JJ was observed as she pushed Patient #8 down the hallway from his room to the elevator with his belongings in his lap. Patient #8 was not wearing a protective facemask. On 9/23/20 at approximately 0930 review of Patient #8's clinical record revealed he was a [AGE] year old male who was admitted on [DATE] for hernia repair surgery and was discharged from the facility on 9/23/20.

The facility policies on source control/personal protective equipment for Covid-19 prevention were requested but not provided.

On 9/18/20 at approximately 1200 the Infection Preventionist was interviewed during a review of the facility Infection Prevention program for Covid-19 and reported that the facility Infection Prevention Program was based on CDC guidelines.

On 9/23/20 at approximately 1500 review of the CDC guidelines for Covid-19 prevention in Healthcare facilities, updated 6/28/20 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-hcf.html) revealed the following guidelines,

" To prevent SARS-CoV-2 transmission by symptomatic and pre-symptomatic persons, healthcare facilities should use source control for all persons entering a healthcare facility (e.g., staff, patients, visitors).
Source control helps prevent transmission from infected individuals who may or may not have symptoms of COVID-19.
Cloth face coverings are not considered personal protective equipment (PPE); they are source control. "

On 9/23/20 at 1520 review of the CDC guidelines for prevention of Covid 19 in health care facilities entitled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", updated 7/15/20 (https://www.cdc.gov/Coronavirus/2019-ncov/hcp/infection-control-recommendations.html) revealed the following guidelinesfor acute care facilities:

"Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection and ensure they are practicing source control." and

"While screening should be performed upon entry to the facility, it should also be incorporated into daily assessments of all admitted patients".

On 9/4/20 at 1350 review of the CDC information on symptoms of Covid 19 entitled, "Symptoms of Coronavirus" updated 5/13/20 (https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html) revealed the following:

"People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19."