Corewell Health Wayne Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50585 Based on interview and record review, the facility failed to promptly report a grievance of potential sexual abuse and failed to promptly investigate or provide the complainant with written results of an investigation, for 1 (P-3) of 1 patient alleging sexual abuse, resulting in the potential for less-than-optimal patient care outcomes. Findings include: See specific tags: A-118 Failure to promptly report or investigate a grievance A-123 Failure to provide written results of an 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: 50585 Based on interview and record review, the facility failed to promptly report and/or investigate an allegation of sexual abuse for 1 (P-3) of 1 patient alleging sexual abuse, resulting in the potential for less-than-optimal patient outcomes. Findings include: On 2/18/2024 at 0636, the nurses note indicated that “P-3 holds her arms to her chest and will start kicking her legs when nurse or tech attempt to place blood pressure cuff. P-3 states she has been forcibly raped, and she is suing the hospital.” On 2/18/2024 at 0742, the nurses note revealed “Security to bedside with writer and tech. P-3 refusing to let writer and tech take her vitals, screaming “my arms are sore, I was raped last night, I wanna make a report.” On 2/18/2024 at 1302 the nurses note revealed that “P-3 refusing, screaming staff is trying to rape her. Security to beside. P-3 kicking, swinging, and screaming so much vital machine errors out.” On 2/18/2024 at 1755, the nurses note revealed that “P-3 up out of stretcher running through unit., Tech attempted to walk P-3 back to room with security at (sic). P-3 began trying to pull on securities arm and badge. P-3 started to wrestle staff not wanting to be taken back to her room, P-3 yelling “I’m being sexually assaulted.” P-3 attempted to kick tech, P-3 placed in 4 point restraints.” On 8/14/2004 at 1000 Staff B was queried regarding if there were any investigations about P-3’s alleged allegation that was documented in the medical record on 2/18/2024. Staff B stated that security was present and was at P-3’s beside. Staff B reported that P-3 was refusing vitals and P-3 did not claim sexual allegations occurred to the Security Officer. When queried what documentation would occur, Staff B stated that a Security report would be filed if a patient claimed sexual abuse occurred. When asked what his expectations if a patient reported sexual abuse and he said, “supervisor to get more information, notify Administrator-on-call and Security, remove staff from patient care, and if necessary, contact the police department.” Upon a review of the facility’s complaint and grievance logs from 11/13/2023 to 8/13/2024, there was no report documented on behalf of P-3 for sexual abuse that allegedly occurred on 3/17/2024 or 3/18/2024. Upon review of the facility’s event log from 11/1/2023 to 7/31/2024, there was no report documented on behalf of P-3 regarding the alleged sexual abuse that allegedly occurred on 3/17/2024 to 3/18/2024. A review of the facility’s policy titled “Patient Complaint and Grievance Resolution,” dated 1/17/2023, revlealed that “the following are always considered grievances: Any written complaint, All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with Centers for Medicare and Medicaid Services (CMS) requirements are considered grievances.” The policy also indicated that the Patient Family Experience representative “provides the complainant with written notice of investigation resolution and decision (closure letter) that contains the name of the hospital/site, 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.””

“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: 50585 Based on interview and record review, the facility staff failed to provide the third party (complainant) with a written response of the facility’s investigation regarding the patient’s grievance alleging sexual abuse, for 1 (P-3) of 1 patient alleging abuse, resulting in the potential for less-than-optimal patient care outcomes. Findings include: Upon review of the facility’s complaint log from 11/13/2023 to 8/13/2024, the facility received a complaint of an alleged sexual abuse on behalf of P-3 from the third party on 2/29/2024, completed an investigation, and closed the complaint on 3/1/2024. According to the facility’s grievance log from 11/13/2023 to 8/13/2024, there was no documented grievance alleging sexual abuse on behalf of P-3. On 8/14/2024 at 0950 CNO Staff B was interviewed about the 2/23/2024 alleged incident of sexual abuse. Staff B stated that he was the Administrator-on-Call on 2/23/2024 and received a call from the Nurse House Supervisor in the evening on 2/23/2024. P-3 did not provide any description of sexual assault when P-3 was queried by the Nursing House Supervisor and Security. P-3 stated the incident occurred on “10th or 11th of the month.” Asked if Staff B received or read the information from the third party regarding the alleged sexual abuse he said “no.” On 8/14/2024 at 1330, Patient Relations Staff N was interviewed about the grievance submitted by a third party on behalf of P-3. Staff N acknowledged that the issue was resolved since the facility investigated the incident. Staff N acknowledged that the alleged grievance was documented by the facility as a complaint and there was no acknowledgement letter sent back to the third party. A review of the facility’s policy “Patient Complaint and Grievance Resolution,” dated 1/17/2023, revealed that “the following are always considered grievances: Any written complaint, All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with Centers for Medicare and Medicaid Services (CMS) requirements are considered grievances.” The policy also indicated that the Patient Family Experience representative “provides the complainant with written notice of investigation resolution and decision (closure letter) that contains the name of the hospital/site, 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.””

“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: 45245 Based on interview and record review, the facility failed to ensure that nursing staff documented the intake for one patient (P-1) of 10 patient charts reviewed, resulting in the potential for less than optimal outcomes for all patients in restraints at the facility. Findings include: Record review revealed P-1 was admitted to the Emergency Department (ED) on 08/13/2023 at 1348 for alcohol intoxication and placed in non-violent restraints at 2314. Review of “ED Care Timeline” on 12/05/23 at 1400 demonstrated that P-1 was ordered an “adult diet” by treating physician Staff M at 1634 on 08/13/23. Review of the medical record revealed no documentation of food being provided to P-1. Additionally, a single reference was located in the “ED Notes”, dated 08/13/23 at 2138 indicating the presence of a water cup, stating, “Pt kicked her water cup with the free leg...” A chart review was conducted on 12/05/23 at approximately 1000 with ED manager Staff O. Staff O was requested to search for documentation of food or water being provided to P-1, Staff O replied, “There is none.” An interview was conducted with Staff N on 12/04/23 at 1300. Staff N was questioned how she knows if a patient has been eating or not? Staff N stated that patients are continuously monitored, and un-eaten trays would be questioned. Staff N related that additional food is available in the unit pantry. Staff N was questioned if patient meals are documented? Staff N stated that “Intake and Output” should be documented, but that an aide or tech may have delivered food to a patient without documenting that.””