Henry Ford Health St John Hospital

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 50585 Based on observation, interview, and record review, the facility staff failed to document a nursing assessment in the medical record for 1 (P-2) of 13 patients reviewed, resulting in less than-optimal outcomes for the patient. Findings include: On 12/5/2024 at 1330, P-2’s incident report filed on 4/3/2024 was reviewed with Risk Manager Staff DD. According to ED Nurse Staff N’s note, Staff N revealed “The prior nurse told me that the patient was restrained (on 4/3/2024 at 2145) but did not mention that the patient said he was injured. When I talked to the patient, he told me one side of his face hurt from having his head pushed down when he was restrained. His cheek was slightly red, but I honestly probably would not have noticed if the patient did point it out to me. There was no laceration or swelling that I remember. I told him that this can happened if he was resistive while being restrained but he keeps saying “I was assaulted and I want to talk to you manager.” Charge RN Staff II was contacted. The Charge RN Staff II note revealed “Following 0700 (on 4/4/2024) RN shift changed, writer (Staff II) was informed that this patient had swelling and bruising present on the right side of his face. The patient stated to the new RN that the injury occurred at the time restraints were applied. The patient believed he received the injury from a security officer.” According to P-2’s medical record, Staff N documented in the medical record activity of daily living activities notes for P-2 on 4/4/2024 at 0723, 0753, 0832, 0946, 1036, 1134, 1247, the ED Patient Transfer note at 1118, and the Discharge Summary ED note at 1307 and there was no documentation of any skin redness or bruising in P-2’s medical record as reported by P-2 and the incident report. On 12/5/2024 at 1100, ED Nurse Manager Staff J was asked if they expected Staff N to document in the medical record the reported bruising that P-2 told them, and they said “yes.” When asked if that would initiate a follow-up assessment from a Physician or Advanced Practice Provider and they said “yes.” According to the facility’s policy “Nursing Ongoing Assessment,” dated 3/2024, the policy revealed that a “Focused Assessment” was an “Assessment of specific body system related to the patient diagnosis or complaint” and “A focused Assessment is completed and documented with any of the following: Patients course of treatment.” According to the facility’s policy “Event/Incident Reporting - Patients, Visitors, Volunteers, and Non-Employed Staff,” dated 1/2024, the policy revealed that under the “Patient Event or Injury” section, “Document the factual circumstances of the event in the medical record.””

“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: 45245 Based on interview and record review, the facility failed to identify grievances for two (P-1, P-2) of ten patients reviewed for patient rights, resulting in the loss of the right to have a grievance filed on behalf of a patient. Review of medical record for P-1 under “History of Present Illness,” dated12/17/23 revealed, “P-1 is a 70-year-old female under the care of a guardian. Additional documentation revealed the guardian was not notified of patient’s discharge, and the patient was discharged to unauthorized shelter via Lyft transportation service. The guardian called and informed the facility that the patient did not arrive at her designated living facility and was missing. Review of medical record “History of Present Illness (HPI),” dated 11/23/23 revealed that P-2 is a 74-year-old male with multiple comorbidities and a complicated hospital course including on-going and complicated wound care, feeding needs, and discharge planning. Interview with P-2’s daughter on 02/06/2024 at 1639 revealed the family attempted to file a grievance regarding P-2’s ongoing wound care and feeding needs on 01/03/2024 and felt the facility had not addressed their concerns. On 02/06/2024 at 1223 during an interview with unit manager Staff T, Staff T was asked what ‘concerns’ were shared by P-2’s family? Staff T stated, “There was a couple of different days we talked. They called and wanted a second opinion, from an outside perspective, for Neurosurgery. His (P-2’s) arms stopped moving after the surgery, and that was new. He developed worsening sacral ulcers and heel wounds while he was here. I was involved after the patient advocate, patient experience, and staff on 7 North had intervened. I attended ‘Huddle’ (morning briefing) and this just kept coming up.” Staff T was queried if there were any other concerns? Staff T stated, “She (daughter) wanted rehab, but didn’t want to release the financial information required. So, we waited for that. In the meantime, he (P-2) develops fevers and ‘Cauti’ (catheter associated urinary tract infection), because he is a chronic Foley patient. She (daughter) works here, so I called and asked for us to meet. We met 4-5 times. She wanted him to go to (redacted) rehab hospital. That was her first of her top five rehab picks. She was in process to receive Medicaid, and after that went through, P-2 was accepted to sub-acute rehab.” Staff T was asked if P-2’s family was satisfied with the outcome? Staff T replied, “They seemed happy with the outcome. They did say they were reporting it to the state also.” During review of facility’s internal log for complaints and grievances, it was discovered that the family for P-2 placed a call to the complaint & grievance line on January 3 at 1115. On 02/07/24 at 1115, during interview with VP Staff C, Staff C was asked if P-2’s family should have received an acknowledgement letter, after calling to report allegations of on-going inadequate care? Staff C stated, “A letter should be there, if the call was accepted.” A copy of the acknowledgement letter was requested but not provided before survey exit. Staff C was further questioned regarding documentation of guardian contact or filing a grievance on behalf of the guardian after P-1 was discharged from the facility and identified as missing. Staff C stated, ‘They’re lost.’ On 02/27/2024 at 1134, Staff V was asked, ‘Was this a grievance after a formal phone call was made?’ Staff V stated, “If called by family we turn it over to leadership. If it can’t be rectified in the moment, then it’s a grievance.” Staff V was asked if P-2’s family received any acknowledgement of the concern, any findings of the investigation, or any written resolution or closure of the concern? Staff V replied, “I don’t know. Not that I can see.” Staff V was next questioned how the facility knows that the family’s concerns were ‘satisfied’? Staff V replied, “Leadership decided in real-time if the concern is resolved to the family’s satisfaction. I’m not sure if there is any documentation of their satisfaction. We trust that the manager will resolve it.” Staff V was next questioned if she is confident that the consumer’s concerns were satisfied by the manager? Staff V stated, “I don’t know if they were.” On 02/07/2024 at 1023 Staff C was asked why P-1 or P-2 had no complaints or grievances filed on their behalf? Staff C replied, “Anyone can put it in Salesforce (internal complaint process)”. Typically, complaints and grievances are the second step if the manager can’t fix the problem at the bedside. There is a ‘hotline’ complaint number posted in the patient’s room. They (the family) need to file the complaint or grievance, by calling the hotline and stating that they want to file a ‘formal’ complaint or ‘formal grievance’. (Staff V) will accept the call. They (Staff V) will call, find the details out and put the whole complaint in Salesforce. Then the manager will follow-up. If a family or guardian called, it would go into ‘salesforce’ and there would be a documentation trail. Review of policy titled, “Patient - Family Complaint And Grievance Process,” # 9667177, rev.05/2021, states under ‘DEFINITION’, (A.) Patient Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care when the complaint is not resolved at the time of the complaint by staff present, abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations as defined in 42 CFR 489 (Public Health Code, Provider and Supplier Agreement). 1. If a patient care complaint cannot be resolved at the time of the complaint by staff present or is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf ... 4. Patient complaints that are considered grievances also include situations where a patient or a patient’s representative telephones the hospital with a complaint regarding the patient’s care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more CoPs, or other CMS requirements. Those post-hospital verbal communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the visit are not required to be defined as a grievance.” The facility failed to identify and document the missing person report by P-1’s guardian as a grievance. The guardian’s complaint could not be resolved at the time of care or at the time of the report to the facility. The facility failed to identify and document the ongoing care issues that could not be immediately resolved at the bedside for P-2 as a grievance. No corrective actions were implemented after either complainants’ allegations of inadequate care.”

“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: 45245 Based on interview and record review, the facility failed to provide a safe care setting for one (P-1) of four patients sampled for Patient Rights, out of a total sample of ten, resulting in the potential for poor outcomes. Review of medical record “History of Present Illness,” dated12/17/23 revealed, “P-1 is a 70-year-old female with past medical history of schizophrenia, asthma, peripheral vascular disease, and high blood pressure. P-1 presented to the facility’s Emergency Department (ED) on 12/17/23 with complaints of chest pain. P- was admitted to ED observation for cardiac evaluation the following morning. After evaluation by the Cardiology department the following day, P-1 was ‘cleared’ and prepared for discharge to home. P-1 provided an address to the ‘discharge’ nurse and a ‘Lyft’ (private transport service) was called to transport P-1 to an address in east Detroit. P-1’s guardian called the facility later that day, looking for P-1. Review of P-1’s medical record titled, “Face sheet,” dated 12/17/23 at 0542 confirmed that P-1 had a guardian, stating, “Patient Information-Primary contact: Michigan Guardian Services (Guardian).” Review of document ‘Emergency Triage Documentation” dated 12/17/23 at 0555 demonstrated that the facility documented “No Guardian” 3 minutes later. P-2 was admitted to ‘ED Observation’ on 12/17/23 at 1247. Document ‘Admission Assessment Adult’ was entered on 12/17/23 at 1433 and again stated, “Guardian-ED Legal Guardian-No”. Review of ‘Nursing Discharge Summary” authored by unit assistant clinical manager Staff P on 12/18/23 at 1011, states ‘ED Legal Guardian’-No.” ‘Discharge disposition’ is documented as ‘home by private car’. Review of P-1’s medical record with Staff I and M on 02/06/24 at approximately 1115, revealed no documentation of guardian notification prior to P-1’s discharge. During interview on 02/07/24 at 1305, Staff W was questioned if the facility had documented any correspondence with P-1’s guardian, prior to discharge or after discharge? Staff W replied, “We had contact after he (P-1’s guardian) called the adult foster care (AFC) home and she (P-1) was not there. The AFC filed a missing person’s report. We’ve had no written contact with the family after she (P-1) was returned to the AFC.” A copy of the missing person and police reports were requested and presented a short time later. Review of document “Reporting Officer Narrative” dated 12/18/23 at 1543 confirmed that P-1 was located at an unapproved address after discharge and was transported back to her AFC. On 02/07/24 at 1305, an interview was conducted with Clinical Decision Unit (CDU) manager Staff U and Risk Manager Staff W. Staff U stated that she reported the event in the ERS (event reporting system) on 12/18/23. The investigation, follow up and ‘sharing with Leadership’, was also conducted by Staff U. At that time, a copy of the report was requested from Risk Manager, Staff W. Staff W returned a short time later with a single page titled, “Legal Copy.” The document only provided opening and closing dates as well as a case number. Interview on 02/06/24 at 1130 with Stepdown unit manager Staff I, Staff I was questioned how the nurses know if a patient has a guardian? Staff I replied that ‘There used to be a green shield icon on the tracking board, but it was removed about a month ago, during some upgrade. We hope it comes back. Right now, we are notified by verbal report or RN discovery in the chart. No visual cues, it’s all nurse to nurse based.” An interview was conducted with Medical Director Staff B and Vice-President Staff C on 02/06/24 at approximately 1300. Staff B and C were questioned if the facility has implemented any changes since P-1 was improperly discharged? Staff B replied, “We are sharing this in ‘huddles, with leadership, and safety huddles. The ‘IT’ (information technology) fix will take some time. We want to make that information highly visible. For now, we are increasing communication. We’ve implemented a physician advisor to assist with communication.””