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Based on record review, policy review, observation and interview, it was determined the facility failed to protect and promote the rights of patients as evidenced by: failure to inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights (A 117); failure to establish a process for prompt resolution of grievances and inform each patient with whom to file a grievance(A 118); failed to ensure that the grievance process included a mechanism for timely referrals of premature discharges to the Quality Improvement Organization (A 0120), failure to provide a safe setting for patients to receive care (A 144): failure to implement restraint with safe and appropriate techniques as determined by hospital policy (A 167) and failure to ensure safe implementation of restraint by trained staff (A 194).

Based on interview and record review, the facility failed to inform two of three Medicare patients (#1 and #2) of their rights as outlined in the "An Important Message from Medicare" letter. Findings include:

On 8/3/10 review of patient #1's record revealed that a copy of the "An Important Message from Medicare" letter, dated 7/28/10, was signed on admission. After her discharge on 8/4/10, review of her record revealed no documentation that she had received the second copy of the letter prior to discharge. The Medication Nurse (Employee E) verified this finding and stated that she was not aware of the requirement that a second notice of "An Important Message from Medicare" be delivered prior to discharge. Review of patient #2's chart revealed no copy of "An Important Message from Medicare" nor any documentation to explain it's absence. This finding was verified by the Unit Clerk on the Third Floor.

Based on interview, document review, and observation, the hospital failed to inform admitted patients whom to contact to file a grievance and failed to maintain data that demonstrated prompt resolution patient grievances. Findings include:

<1> Hospital recipient rights advisors, interviewed 8/3/10, was asked whether an admitted patient was provided a written notice of his or her right to file a complaint/grievance with the designated CMS Agency. The rights advisor stated that the patient admission packet provided to each admitted patient should include this information.

Three patient admission packets were reviewed on 8/4/10. The revived packets did not contain information regarding a patients right to file a grievance with CMS, the CMS complaint hot line number, address to which a complaint may be sent, or a fax number to which a complaint may be faxed.

<2> The hospital's recipient rights advisor, interviewed 8/3/10, was asked whether she submits grievance process resolution data to any hospital committee or responsible administrator that validates whether grievances were promptly resolved as required by hospital policy/procedure. The rights advisor stated that no such data is formally reported out to a hospital committee or responsible administrator. The submittal of grievance process data was also discussed with the hospital's Chief Executive Officer (CEO) who was interviewed on 8/4/10. The CEO was not able to demonstrate that the hospital had an established process that would validate whether patient grievances were resolved in a prompt manner.

Based on document review and interview, the hospital failed to ensure that the grievance process included a mechanism for timely referral of a Medicare beneficiaries concerns regarding quality of care to the appropriate Utilization and Quality Control Quality Improvement Organization. Findings include:

<1> Hospital recipient rights advisor, interviewed 8/3/10 was asked whether the Recipient rights Office advises a Medicare beneficiary of his/her right to have his/her complaint/grievance regarding a quality of care concern referred to the local Quality Improvement Organization. The rights advisor said that such a notice is not provided to a Medicare beneficiary when a complaint/grievance is received or when notice of the hospital's investigative findings or interventions are sent to patient

<2> On 8/4/10 the hospital's Complaint and Appeal Process policy (#(RR.01) was reviewed. Review revealed that the policy does not include any reference regarding the requirement that if a Medicare beneficiary patient has a quality of care concern, the patient has the right to request that the hospital refer the patient's quality of care concern to the Michigan Quality Improvement Organization (i.e. the Michigan Peer Review Organization).

Based upon observation, interview and policy review, the facility failed to ensure a safe setting for provision of patient care. Findings include:

On 8/4/10, at approximately 1130, hospital staff "H" verified that a patient who is placed in the seclusion room on the third floor can not be maintained in sight of staff at all times when the door is closed. It was further verified that audio is not available.

On 8/4/10, at approximately 1145, hospital staff "M" verified that a patient who is placed in the seclusion room on the first floor can not be maintained in sight of staff at all times when the door is closed. It was further verified that audio is not available.

On 8/4/10, at approximately 1200, hospital staff "O" verified that a patient who is placed in the seclusion room on the second floor can not be maintained in sight of staff at all times when the door is closed. It was further verified that audio is not available. It was also verified that there are areas in all three seclusion rooms of the hospital that are not currently able to be visualized through the video monitoring. system.

Hospital policy states that a patient who is placed in seclusion will be under constant visual observation of staff for the first hour (this is accomplished by looking through the glass portion of the locked door). Hospital policy also states that continuous audio monitoring will occur while a patient is in seclusion.



27065

The facility failed to ensure that two patients (#4 and #12) who received psychotropic medications had proper documentation to receive the medication, per physician orders and facility administration and documentation procedure. Findings include:

On 8/4/10 patient #12's clinical record was reviewed with the Director of Nursing (DON). The patient had an order for Haldol 5 mg. by mouth for mild agitation and one for 5 mg by injection for severe agitation. He also had orders for Ativan 1 mg. by mouth for mild agitation and one for 2 mg by injection for severe agitation. On 4/28/10 patient #12 received injections of Haldol 5 mg and Ativan 2 mg. This was documented on the "Integrated Progress Note" but not on the Medication Administration Record, as required by facility policy. There was no documentation to support that the patient was experiencing "severe agitation" as required by the physician's order. The DON confirmed these findings.

The Charge Nurse (employee R) stated that she was present when patient #4 received injections of Ativan and Haldol on 8/3/10 at approximately 2200. According to Integrated Progress Notes, patient #4 received Ativan and Haldol by mouth at 0530 on 8/3/10 but this was not documented on the Medication Administration record. Further review of patient #4's record revealed that she did not have physician's orders for either Ativan or Haldol. The Charge Nurse (employee R) stated that nurses do not need physician's orders to give these medications, per facility protocol. Per facility policy, physician's orders are required prior to the administration of medications. On 8/5/10 at approximately 0930, the Medical Director confirmed that nurses are required to get physician's orders prior to administering medications.

Based upon interview, policy review and medical record review, the facility failed to ensure that restraint use is implemented in a safe manner in accordance with hospital policy. Findings include:

Hospital policy "Restraints" states in Documentation Guidelines A.11, the physicians order for restraint will include: Time/date; rationale for use; Time limit; Clothing to be removed (to be specified in the order if any removed); Renewal at lest every four hours or as specified in the order; and Type of restraint to be used and placement of the restraint on the patient.

In 2 (Pt #14 and Pt #15) of 15 medical records reviewed, the physicians order did not comply with hospital policy. The physicians order for Pt #14 states: May restrain patient for two hours for combative, assaultive behavior. The physicians order for Pt #15 states: Restraints 4 pts. up to 4 hours. There are multiple criteria as described in the hospital policy that are not included in these orders as required.




27065

On 8/4/10 at approximately 1530 patient #4 reported that she had bruised from being restrained the previous evening. Bruises were visible on patient #4's upper arms and right forearm. A Mental Health Technician who the patient identified as having restrained her (employee O) stated that he held patient #4 to keep her from entering a patient room while verbalizing threats. Patient #4's record revealed no documentation of the physical hold or the bruises.

At approximately 1550 the Charge Nurse on duty when the physical hold occurred (employee R) stated that she was not aware that the patient had been physically restrained or of any bruises. Employee R stated that she had done a visual inspection of patient #4's body on 8/2/10 and did not note any bruises on her arms. Per the facility policy titled "Restraints" physical management of a patient is considered a temporary restraint and requires the use of restraint procedures outlined in the policy.

Based upon interview, policy review and training record review, the facility failed to ensure that staff are trained in the safe implementation of restraint or seclusion. Findings include:

On 8/4/10 at approximately 1400, Director of Nursing confirmed that all nursing staff are to receive training for proper implementation of restraint and seclusion on an annual basis. The CEO provided documentation which identified 15 of 39 nursing staff had not received the required training within the previous year.


13155

While conducting unit observations on the second floor unit on 8/3/10 at 0945 hours, it was observed that the unit's seclusion room ceiling had a gaping hole that was approximately 12 inches by 12 inches. The hole exposed support grids for the gypsum board ceiling and plumbing lines supplying water to the overhead sprinkler. The surveyor was informed by the hospital Director of Nursing that the observed damage to the ceiling occurred approximately 3 weeks ago when a patient who was in the seclusion room activated the overhead sprinkler which flooded the seclusion room and damaged the gypsum board ceiling. Reportedly the patient was able to accomplish this by standing on the seclusion room bed which enabled her to reach up and access sprinkler head. Review of incident report dated 7/12/10 revealed that "patient # 20 who was in the quiet room pulled sprinkler system down, flooding unit."