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.
|HAVENWYCK HOSPITAL||1525 UNIVERSITY DRIVE AUBURN HILLS, MI 48326||Sept. 30, 2015|
|VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT||Tag No: A0145|
|Based on interview and document review the facility failed to report allegations/incidents of abuse to the appropriate agencies in accordance with State and Federal Laws resulting in the potential for ongoing and uninvestigated abuse. Findings include:
On 09/28/2015 at 0830 during review of the complaint and grievance log a entry for 9/18/2015 recorded the "Nature of complaint/grievance: Abuse." Further comments documented: "a male staff member used unnecessary force in a physical management. Interviewed one patient, two RN's, four PCSs (patient care specialist), one scheduling coordinator. Additionally, video surveillance was reviewed. Allegation substantiated. Disciplinary action."
Further review of documents provided by the recipients rights officer/risk manager, staff H on 09/29/2015 at 1000 included eyewitness statements and documentation of the video footage for the incident on 09/18/2015. The eyewitness accounts documented, "Staff H was asked if the incident was reported to the local law enforcement or the Department of Human Services, Child and Adult Protective Services, he stated, "no."
On 9/29/2015 at 1400 the complete investigative file, medical record for patient #28, and the employee file for staff Q was reviewed. Based on documentation in the investigative file, staff Q "lifted patient #28 by the neck and threw him down face first into the bed with excessive force." The patient, #28 "complained of pain in his face." In the employee file the document titled, "Disciplinary action" dated 09/22/2015 revealed that staff Q was "terminated" based on the results of the investigation."
On 8/27/2015 at 0900 during review of the document titled, "Identifying and Reporting Abuse and Neglect" #RR-I006/ADM-I-003 revision date 12/14 on page 3 of 10, "III. Reporting Procedures:..O. The following action is taken if any staff member, by verbal allegation or personal observation, identifies or suspects patient abuse, neglect, or exploitation: .......4. The staff makes a verbal report to local law enforcement and the department of human services, child and protective services........, within 24 hours when there is reasonable allegation of criminal abuse."
|VIOLATION: MEDICAL RECORD SERVICES||Tag No: A0450|
|Based on document review and interview, the facility failed to ensure that the medical record was legible, complete, dated and timed for 3 of 7 patients' medical records reviewed (#9, #30, & #32 ) resulting in the potential for unmet patient needs. Findings include:
On 09/28/2015 at 1100 during the tour of the facility, the medical record for patient #9 revealed that the psychiatrist progress notes for 9/25/15 & 9/26/15 did not include a time when the document was signed (a line is provided on the bottom of the document for signature, date & time).
On 09/28/2015 at 1115 staff F was interviewed about psychiatrist progress notes being untimed, she stated, "I can see that they forgot to time their notes."
On 09/29/2015 at 1400 the policy titled, "Documentation Standards" #HIS-VI-001 dated revised 12/96 on page 1 of 2 stated, "III...B. All entries shall contain the date and time recorded."
On 9/29/15 at 1304 review of patient #30's medical record revealed 19/22 psychiatrist's progress notes did not include a time when the document was signed (a line is provided on the bottom of the document for signature, date & time).
On 9/2915 at 1400 review of patient #32's medical record revealed 5/13 psychiatrist's progress notes did not include a time when the document was signed.
On 9/30/15 at 1045 during an interview with staff A and O these findings were confirmed. Staff A stated, "Yes, this is something we have discussed with medical staff and are making changes going forward."
|VIOLATION: ORDERS DATED AND SIGNED||Tag No: A0454|
|Based on document review and interview, the facility failed to ensure that all orders in the medical record were legible, complete, dated and timed for 3 of 8 patients reviewed (#27, #30, & #32 ) resulting in the potential for unmet patient needs. Findings include:
On 9/28/15 at 1130 review of patient #27's medical record revealed five telephone orders dated between 9/18/15 and 9/21/15 that did not have a time documented in the designated space provided for the authenticating physician. On 9/28/15 at 1130 staff M confirmed these findings and she was queried as to the facility's policy on telephone orders. Staff M stated, "They (telephone orders) should be signed, dated, and timed within 48 hours."
On 9/29/15 at 1304 review of patient #30's medical record revealed two telephone orders dated 6/4/15 that did not have a time documented in the designated space provided for the authenticating physician.
On 9/29/15 at 1400 review of patient #32's medical record revealed one telephone order dated 6/30/15 that did not have a legible time documented in the designated space provided for the authenticating physician.
On 9/30/15 at 0830 review of the document titled, "Policy: NSG-V-031, Transcribing and Noting Physician Orders" revision date 9/09 revealed on page 1 "1. Physician orders: a. will be dated, timed, and signed by the physician; b. will be legibly written; c. given verbally or by telephone to a Registered Nurse or Pharmacist and be signed by the physician within 48 hours..."
On 9/30/15 at 1045 during an interview with staff A and O regarding the findings for patients #30 & #32 were confirmed. Staff A stated, "Yes, this is something we have discussed with medical staff and are making changes going forward."
|VIOLATION: PHYSICAL ENVIRONMENT||Tag No: A0700|
|Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include
See the individually and below cited K-tags dated September 30, 2015.
|VIOLATION: MAINTENANCE OF PHYSICAL PLANT||Tag No: A0701|
|Based upon observation and interview the facility failed to maintain the hospital environment to ensure a safe and sanitary environment resulting in the potential for transmission of infectious agents to all patients served by the facility.
On 9/28/15 at approximately 1045, the drain line for the kitchen walk-in cooler condenser was observed below the rim of the receiving drain, without the required air gap of at least 1 inch of unobstructed space.
On 9/28/15 at approximately 1130, the housekeeping closet near the entrance was observed to have a Y-valve with shut offs connected to the mop sink faucet. These shut offs are located downstream from the built in atmospheric vacuum breaker (AVB), subjecting the AVB to constant pressure, which it is not approved for.
On 9/28/15 at approximately 1155 the janitor's closet within the A Unit (adjacent to room 116) was observed to have a chemical dispensing system properly connected to the mop sink faucet via a wasting tee (aka "Side Kick") however, the built in AVB and cold water line and handle were warm to the touch, indicating the AVB had already failed and was permitting hot water to leach into the cold water loop.
On 9/28/15 between approximately 1030 and 1300, the following areas were observed with dust accumulation: sloped tops of cabinets in all patient rooms, clean utility rooms, day rooms and pantries throughout the facility, and tops of cabinets in the Pharmacy.
|VIOLATION: INFECTION CONTROL||Tag No: A0747|
|Based upon observation and interview the facility failed to provide a sanitary environment in the kitchen and in patient care units in a manner to prevent the transmission of foodborne and vectorborne communicable diseases. This deficient practice could potentially effect all inpatients, partial hospital program patients, and staff or visitors that consume food prepared from the kitchen.
On 9/28/15 at approximately 1050, the following potentially hazardous food (PHF) items were observed in a 2-door reach in cooler without discard dates: a tray of sliced tomatoes, a prepared cold cut sandwich, spaghetti and meatballs and cottage cheese. Staff P was unaware of when these items had been prepared, and all items were discarded by Staff P at the time of the survey.
On 9/28/15 at approximately 1105, a dietary employee in the cafeteria area was observed handling soiled dishware, followed by a broom and dustpan while wearing single use gloves. The employee then discarded the gloves, and began donning a new pair of single use gloves without washing hands. Staff P confirmed that hands must be washed in between glove changes.
On 9/28/15 at approximately 1110, the slicer in the kitchen was observed not in use with an accumulation of dried food debris on the areas underneath the blade and protective cover. An employee stated that the slicer had last been used on Saturday (9/26/15). Staff P confirmed that the slicer was not properly cleaned.
On 9/28/15 at approximately 1200, whole fruit such as apples, oranges and bananas and pre-packaged single servings of crackers were observed stored in a cardboard box in a day room on the A unit. On 9/28/15 at approximately 1215 at the nurse station on the D Unit, whole fruit and crackers were observed stored in a wicker basket with a hard plastic lining with a rough cut edge and also whole fruits in a cardboard box for service to patients.
On 9/28/15 at approximately 1215, at the nurse station on the E Unit, an employee was observed dispensing ice from a beverage cooler for a patient. The cooler contained a Styrofoam cup to be used for dispensing the ice. The employee was observed to dispense the ice without performing hand hygiene prior to handling the cup.
On 9/28/15 at approximately 1220 a single serving carton of milk was observed in the cabinet beneath the handwash sink at the pantry area of the day room on the E Unit. This carton had been opened, and was observed to have a printed on manufacturer's discard date of 9/13/15. The container of milk was warm to the touch. Staff D confirmed these findings and stated that housekeeping staff is supposed to be cleaning in the cabinets daily.
On 9/28/15 at approximately 1220 a prepared cold cut sandwich was observed in the pantry refrigerator of the E Unit with no discard date. The temperature monitoring log at this refrigerator was observed to have a most recent entry date of 9/22/15.
On 9/28/15 at the times noted, drain flies (aka fruit flies) were observed in the following locations: kitchen dishwashing area (1100); cafeteria serving line adjacent to the handsink (1115); C-2 Unit nurse station (1130). Staff D witnessed these observations and stated that the facility has a pest control contract but was unaware of any treatment for drain or fruit flies.
On 9/28/15 between approximately 1030 and 1230, the following items were observed stored on the floor: patient belongings in the storage closet for beds 226-231 on C unit; boxes of paper products and Styrofoam cups in the D unit day room; box of Styrofoam cups in E unit pantry.
On 9/28/15 at approximately 1245, employee coats were observed stored on shelving above food items in the basement kitchen storage room.