St Joe Mercy Hospital System Livonia

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47415 Based on record review and interview, the hospital failed to ensure staff followed facility policy, by not conducting a complete investigation for an alleged sexual assault. The facility failed to offer and/or document the offer of a physical examination for 1 of 1 patient reviewed, who alleged sexual assault while an inpatient at the facility. This failure has the potential to affect all patients alleging sexual assault by limiting access to appropriate medical, forensic, and supportive services. Findings include: Record review revealed an allegation of sexual assault was received on 01/30/2026, by the Office of Recipient Rights (ORR). P-1 a 23-year- old behavioral health inpatient alleged she was raped while in the seclusion room. Review of the investigation documentation by the ORR, revealed an immediate internal investigation was initiated. However, the investigation lacked documentation that a physical examination was done or offered and declined by the patient. On 07/16/26 at 10:00 AM, an interview with Provider Staff O was asked if a physical or SANE exam should be offered to a patient alleging sexual assault. Staff O responded it would be case dependent. On O7/16/26 at 10:30 AM, Risk Management Manager Staff B and Director of Quality Staff C confirmed that per policy, patients alleging sexual assault, will be offered a physical exam; and confirmed that P-1’s medical record did not contain documentation that a physical examination was done or offered and declined. Review of the facility policy titled “Allegations of Abuse and Neglect of a Patient by a Colleague”, review/revised date 05/15/2025, revealed: “All allegations of patient abuse or neglect...shall be acted on promptly upon notification ...For physical and sexual abuse allegations ...Offer physical exam; refusal of an exam should be documented in the medical record””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50585 Based on observation and record review, the facility failed to ensure the safe storage of 1 of 1 oxygen cylinders observed in a patient care area, resulting in the potential for harm for all patients in the patient care area. Findings include: On 9/24/2024 at 0925 during a tour of the facility’s Emergency Department (ED), an oxygen cylinder was observed stored in the corner of a triage room. The cylinder was not secured in any rack, holder, or transport cart. ED Nurse Manager Staff E confirmed the finding at the time of discovery. Upon review of the facility’s policy “Compressed Gases,” dated 2/2024, the policy revealed that “Cylinders and tanks must be properly secured at all times to prevent them from falling and “Assure that oxygen cylinders are properly secured in racks or holders or transport carts.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47415 Based on interview and document review, the facility staff failed to investigate a reported grievance of potential sexual abuse and failed to promptly notify the complainant with written results of an investigation, for 1 (P-3) of 1 patient alleging abuse, resulting in the potential for less-than-optimal outcomes. Findings include: See specific tags: A-118 Failure to promptly investigate a grievance A-123 Failure to provide written results of a grievance investigation”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 47415 Based on document review and interview, the facility failed to promptly investigate an allegation of sexual abuse for 1 (P-3) of 1 patient alleging abuse, resulting in the potential for less-than-optimal outcomes. Findings include: On 8/20/24 at 1330 review of the complaint and grievance log revealed an entry alleging sexual abuse and confinement to P-3 (called in by boyfriend), received on 6/18/24. On 8/20/24 at 1400 record review of nursing notes for P-3 of 6/17/24 at 1355 revealed, “Patient received in large dining room, with disorganized/ hyper verbal speech, Patient is easily directable, but is preoccupied with a “rapist being on the unit”. Patient has voiced to other employees on the unit, that she was raped by, the patient in 525-2. Patient did not voice this to me during my nursing assessment with her... Patient was asked to leave group this morning due to UPB, and provoking some her peers. Order was placed for Hallway/Group Restrictions” Interview on 8/20/24 at 1500 with Staff FF revealed the recipient rights office did receive notification of an alleged rape to P-3 (called in by boyfriend) on 6/18/24. Staff FF stated P-3 was immediately interviewed and denied that a rape occurred. Staff FF also stated that security was notified of “boyfriends” threats to come to hospital to harm staff and the alleged perpetrator; and that the Livonia police were involved and called the recipient rights office to see if any assistance was needed. No documentation of a complete investigation of alleged rape was provided during survey. Staff FF stated no investigative actions regarding rape (other than patient interview) conducted after P-3 stated no rape occurred, the allegation was not handled as a grievance. Review of policy titled “Patient Complaint and Grievance Policy”, dated 7/2/24, revealed: “A complaint is considered a grievance when it meets one of the following criteria...Any allegation of abuse, neglect, patient harm or compliance with CMS Conditions of Participation...Patient grievances involving allegation of abuse, neglect, or harm involving staff members must be reported immediately to Risk Management who will coordinate appropriate investigation and communication with Patient Relations. All grievances will be promptly investigated, including: A review of the patient’s or representative’s perceptions of the incident...A review of related records...Interviews with staff and caregivers involved in the incident or as described in the patient’s complaint... Identification of opportunities for improvement and actions taken if needed... Once the investigation is complete, a member of the Grievance Committee, the responsible manager or the Experience of Care/Patient Relations department will provide the patient/patient representative with written notice, including:...The name of the hospital department and contact number...The steps taken on behalf of the individual to investigate the complaint...The results of the process...The date of completion of the grievance process Throughout the investigation and resolution of the grievance, all documentation is recorded...””

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 47415 Based on document review and interview, the facility failed to provide the complainant with a written response of the facility’s investigation regarding a grievance alleging sexual abuse, for 1 (P-3) of 1 patient alleging abuse, resulting in the potential for less-than-optimal outcomes. Findings include: On 8/20/24 at 1330, review of the complaint and grievance log revealed an entry alleging sexual abuse and confinement of P-3 (called in by boyfriend), received on 6/18/24. On 8/20/24 at 1400 record review of nursing notes for P-3 of 6/17/24 at 1355 revealed, “Patient received in large dining room, with disorganized/ hyper verbal speech, Patient is easily directable, but is preoccupied with a “rapist being on the unit”. Patient has voiced to other employees on the unit, that she was raped by, the patient in 525-2. Patient did not voice this to me during my nursing assessment with her...Patient was asked to leave group this morning due to UPB, and provoking some her peers. Order was placed for Hallway/Group Restrictions” Nursing notes of 6/18/24 at 1337, revealed that P-3 boyfriend has been calling the recipient rights representative, threatening her, alleging a patient on the unit raped P-3, and he was coming to hospital to do bodily harm to the perpetrator alleged in the sexual assault. The note also documented notifications were made to unit manager, director, and security. Multiple subsequent notes in the record, between P-3 and providers revealed P-3 stated a sexual encounter between her and another peer, did not happen. Interview on 8/20/24 at 1500 with Staff FF revealed the recipient rights office did receive notification of an alleged rape to P-3 (called in by boyfriend) on 6/18/24. Staff FF stated P-3 was immediately interviewed and denied that a rape occurred. No documentation of a complete investigation provided during survey. Staff FF stated no investigative actions taken after P-3 stated no rape occurred, the allegation was not handled as a grievance. No resolutions letters were sent to the complainant. On 8/21/24 at 1000, an interview with Staff MM confirmed no security report was made and there was no other documentation regarding the allegation of sexual abuse to P-3 or boyfriends threat. Staff MM also confirmed video was not reviewed. Review of policy titled “Patient Complaint and Grievance Policy”, dated 7/2/24, revealed: “A complaint is considered a grievance when it meets one of the following criteria...Any allegation of abuse, neglect, patient harm or compliance with CMS Conditions of Participation...Patient grievances involving allegation of abuse, neglect, or harm involving staff members must be reported immediately to Risk Management who will coordinate appropriate investigation and communication with Patient Relations. All grievances will be promptly investigated, including: A review of the patient’s or representative’s perceptions of the incident...A review of related records...Interviews with staff and caregivers involved in the incident or as described in the patient’s complaint... Identification of opportunities for improvement and actions taken if needed... Once the investigation is complete, a member of the Grievance Committee, the responsible manager or the Experience of Care/Patient Relations department will provide the patient/patient representative with written notice, including:...The name of the hospital department and contact number...The steps taken on behalf of the individual to investigate the complaint...The results of the process...The date of completion of the grievance process Throughout the investigation and resolution of the grievance, all documentation is recorded...””