University of Michigan Health System

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to ensure the general consent for treatment was obtained from the patient’s legal guardian for 1 (P-2) of 5 patients reviewed for general consents resulting in the potential for the patient or legal guardian to be uninformed of their rights. Findings include: On 3/28/2025 at 0748, P-2, a 17 month old infant, was admitted to the facility and P-2’s General Consent for Treatment dated 3/28/2025 at 0846 revealed the following The section that included “My signature represents the following (check all that apply)” revealed that check marks were next to the following statements: - Acknowledgement of NPP (Notice of Privacy Practices) Notification, - General Consent to Receive Healthcare Services, and - Assignment of Medical Benefits agreement. The signature line revealed the documentation “no contacts” with a typewritten note “No contact on file/left copy” and documentation “Consent Obtained, Explained, and Electronically signed by: (Case Management Assistant Staff AA) on 03/28/2025 at 08:46 am,” On 2/19/2026 at 1324, Accreditation Coordinator Staff C was asked if Staff AA was available to be interviewed on 2/20/2026. On 2/20/2026 at 0850, Staff C revealed that Staff AA no longer worked at the facility. On 2/20/2026 at 1217, P-2’s grievance was reviewed with Clinical Risk Director Staff EE and Senior Manager, Patient Relations Staff FF. Staff EE revealed that P-2’s grievance was received on 7/14/2025 and the resolution letter was sent on 11/11/2025 that revealed P-2’s general consent was “completed by unit staff.” On 2/20/2026 at 1515, Associate Director of Case Management Staff BB was queried how the facility determined that the general consent for treatment was obtained for P-2, Staff BB revealed that “Supervisor (Staff GG) felt they followed the policy.” When queried if Staff GG was available to be interviewed, Staff BB revealed Staff GG was “off.” When queried Staff BB that, in summary, the facility’s investigation was based on Staff AA no longer worked at the facility and the IMM (Important Message from Medicare) policy was sent to complaint and grievance department, Staff BB stated “yes.” According to the facility’s policy “Care Management of Medicare Inpatient and Observation Notification Guideline,” otherwise known as the IMM policy, dated 4/24/2025 revealed the “applicability” for the policy included “ All beneficiaries with primary, secondary, or tertiary Medicare and/or Medicare Advantage admitted to (the facility). A review of P-2’s medical record revealed P-2 was not a medicare beneficiary. On 2/20/2026 at 1530, Associate Chief Nursing Officer Staff DD was queried if they expected staff to follow policies and procedures, Staff DD reveled “yes.” When queried what were their expectations for obtaining consent for P-2, Staff DD revealed “first 24 hours on admission” and the use of “no contacts” was “concerning” and “does not seem appropriate.” Staff DD also revealed “expect to get consent” for P-2. According the facility’s policy (Facility) Informed Consent for Provision of Health Care Services, 62-10-000, dated 12/12/2023, “Patients have the right to participate in decisions about their medical care, including the right to consent to, or refuse, treatment.” The policy also revealed “The “General Treatment for Consent for Healthcare Services and Important Patient Information - Adult or Child” will also be presented to the patient or their Legally Authorized Representative for signature for any Emergency Department or inpatient visit.” There was no evidence supporting why the general consent was not obtained.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 48772 Based on observation and interview, the facility failed to ensure that patients’ personal information was protected for 1 (P-1) of 20 patients reviewed, resulting in the disclosure of protected health information (PHI) and the loss of patient rights. Findings include: P-1’s mother was interviewed at his bedside in the NICU (neonatal intensive care unit) on 2/19/26 at 1145. She stated that on 1/15/26, her son’s identification card was found in another patient’s room. An interview was conducted with the nursing director (Staff M) on 2/19/26 at 1337. Staff M stated that an identification card that is used for emergency drug dosing was placed in the rooms of the babies with the same last name in error. Staff M stated a report for breach of PHI was entered via the compliance hotline. An interview was conducted with the Senior Director of Corporate Compliance (Staff WWW) and Senior Privacy Specialist (Staff XXX) on 2/20/26 at 1447. Staff XXX stated that the patient identifier card, contained P-1’s name, medical record number, and date of birth was found in the wrong patient room, and the family was sent the required PHI breach notice. A request was made to review staff involvement, level of breach, and corrective actions taken by the facility, and was informed by Staff XXX that the information regarding this breach has not yet been entered by the Vice President of Human Resources. Policy-19968883, Michigan Medicine Discipline for Violations of Privacy or Security of Protected Health Information (PHI) or Other Sensitive Information for All Michigan Medicine Workforce (Effective 7/1/2023). States, Level 1: Accidental or inadvertent violation This level of violation occurs when a workforce member unintentionally or carelessly, due to inattentiveness, lack of understanding, or other human error, leaves confidential information susceptible to being overheard, accessed, used by or disclosed to unauthorized individuals. Level 2: Failure to follow established policies and/or procedures This level of violation occurs when a workforce member fails to follow a privacy or information security procedure or policy, resulting in an unauthorized access, use or disclosure of PHI. The progression of and/or extent of discipline that should be taken in any individual situation depends on all of the facts and circumstances available at the time the decision is made. The relevant facts and circumstances include but are not limited to the: Nature of the misconduct; the employee’s past disciplinary record, if any; severity of the violation; frequency of the violation; whether the violation was deliberate or malicious; and the existence of any aggravating or mitigating factors. The minimum sanctions to be taken for each Level of Violation are outlined below: Level 1 for Non-Medical Staff- Verbal coaching, or verbal warning with documentation by the immediate supervisor, with copy forwarded to the Department Director. Level 2-verbal warning with documentation or written warning with documentation retained by individual’s internal departmental file and copy forwarded to Human Resources personnel file. In addition, for all workforce members: Re-education is required by completion of the eLearning HIPAA Basics for All Workforce Members training module (PRIV-10001) that covers the relevant federal regulations, and submission of course completion documentation to the human resources or Office of Clinical Affairs, as applicable to the workforce member.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48772 Based on interview and record review, the facility failed to follow policy for scanning breast milk for 1 (P-1) of 4 patients reviewed in the neonatal intensive care unit, resulting in the administration of breast milk to the wrong patient, and the potential for infectious disease. Findings include: P-1 was born at the facility on 11/20/25 at 1839 at 37 weeks, 2 days gestation. P-1 has multiple congenital anomalies which require surgical repair. P-1 was also treated for bronchiolitis related to RSV (Respiratory Syncytial Virus), urinary tract infections, and norovirus. P-1’s mother was interviewed at his bedside in the NICU (neonatal intensive care unit) on 2/19/26 at 1145. She stated that on 11/28/25, a nurse fed P-1 breast milk meant for another infant on the unit with the same last name. She stated that she was notified of the error by the nursing Director (Staff M) and that P-1 had to undergo testing for HIV, Hepatitis B and C, and CMV (cytomegalovirus), all of which resulted as negative thus far. An interview was conducted with the nursing director (Staff M) on 2/19/26 at 1337. Staff M stated that the breast milk was delivered to the wrong patient room for a patient with the same last name and was administered by the RN (Staff TTT) on 11/28/25 during the day shift. Staff M stated that P-1 received 9-30 ml of breast milk meant for another patient. Staff M stated that the error was identified by the oncoming night RN and disclosure was made with P-1’s family. Staff M stated that infection control recommendations were followed and the donor mother agreed to have blood borne pathogen testing completed, which was negative, and CMV testing which was positive. A phone interview was conducted with the RN (Staff TTT) on 2/20/26 at 1358. Staff TTT stated that she worked the day shift on 11/28/25 and had unintentionally given P-1 the breast milk meant for another baby with the same last name. She stated that she retrieved the milk from the refrigerator in the patient room and verified the last name but did not scan the milk prior to feeding. Staff TTT stated that after this incident, she received coaching, reviewed the policy, and received education on the expectation for scanning breast milk prior to administration. During a tour of the NICU on 2/19/26 at 1050, the nursing director (Staff M) stated breast milk is considered a food product and is entered into the patient’s electronic medical record (EMR) under intake. Staff M stated that there is currently no available report that could extract breast milk scanning data from the EMR. There was no evidence for ongoing monitoring of breast milk scanning prior to administration. Policy-18671961, UMH Nursing Human Milk: Expressed, Stored, and Administered Policy (Effective 11/24/25). States, “All human milk is bar code scanned prior to administration to ensure the right milk and formulation is administered to the right patient.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 29955 Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide a medical screening exam (MSE) for 1 (P-1) patient of 20 patients reviewed for medical screening exams, resulting in the potential for less than optimal outcomes for all patients seeking emergency care. Findings include: See tag 2406: Failure to provide a medical screening exam.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 29955 Based on record review and interview, the facility failed to provide a medical screening exam for one (P-1) of twenty patients reviewed for a medical screening exam resulting in the potential for less than optimal patient outcomes for all patients seeking emergent care. Findings include: On 2/3/2025 during record review of P-1’s medical record it was revealed that on 1/10/2025 P-1 was brought to the facility Emergency Department (ED) via ambulance at 1141. P-1 was seen by staff J, ED physician. According to the medical record staff J documented, “Patient well known to this emergency department with multiple visits for intoxication. Presents today belligerent and intoxicated. I was asked to come to triage to evaluate him. At that time, he was belligerent, shouting obscenities, but able to ambulate and in fact attempted to attack a patient in the waiting room. I asked security to escort him out. Diagnosis: Intoxication, Disposition: Discharge, I saw and evaluated this patient. Patient’s prior records were reviewed.” P-1 was discharged from the facility ED at 1153. On 2/4/2025 during continuation of record review of P-1’s medical record it was revealed that on 1/10/2025 at 1313, P-1 was brought back to the facility ED via police escort. P-1 was discharged from the facility on 1/10/2025 at 1349. A medical screening exam was not found for the second presentation to the facility ED. An interview was conducted with staff J on 2/6/2025 at 1000. Staff J was queried if a medical screening exam was done on P-1 on the second presentation of P-1 on 1/10/2025 at 1313. Staff J stated he had been informed that P-1 had returned to the ED facility by the triage nurse and was requested to go to the lobby to assess P-1. Staff J stated that security was asked to have additional staff present related to P-1’s previous behavior that day (1/10/2025 at 1141). Staff J stated that when he went to the lobby P-1 was sitting quietly and sleeping in a chair by the “glass house” (an area where security is located). Staff J stated he had trepidation of waking P-1 because P-1 was unpredictable and sometimes would play “possum.” Staff J stated with 2 security guards present he woke P-1. Staff J stated he asked P-1 several questions and asked P-1 to ambulate. Staff J stated P-1 was alert and oriented times three (person, place, and time) and could ambulate without difficulty. Staff J was again queried if a medical screening exam had been performed on P-1. Staff J stated, “Yes...I did not document it as I thought the note from earlier covered that visit as well.” On 2/4/2025 a review occurred of the policy titled, “Emergency Medical Treatment and Labor Act,” policy number 17038111, effective on 1/22/2025. According to the policy, “IV. Policy Standards, #A. Any (1) individual who comes to a (facility) ED and requests examination or treatment for any medical condition or (2) any individual on (facility) Property in need of or requesting emergency medical treatment is entitled to and will receive, regardless of diagnosis, race, religion, gender, ethnicity, national origin, age, disability, marital status, sexual orientation or source of payment for care, an appropriate MSE (Medical Screening Exam) by a QMP (Qualified Medical Professional) to determine if the individual has an EMC (see Addendum A: Medical Screening Examination). Triage is not equivalent to the MSE (see Addendum B: Triaging and Registering Patients).””