Kalamazoo Regional Psychiatric Hospital

“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: 29955 Based on interview and record review, the facility failed to maintain 180 of 413 cameras used for safety monitoring and investigations, resulting in the potential for unsafe conditions for all 113 patients currently receiving care at the facility. Findings include: During an interview on 5/3/2024 at 1330 with staff B, the Quality Compliance Director it was revealed that the facility could not produce video for an occurrence that occurred on 4/22/2024 in the dayroom of the Schrier unit. The incident was of an alleged physical altercation between P-3 and P-4. Record review of P-3 medical record occurred on 5/3/2024. According to the most recent psychiatric evaluation, P-3 psychiatric evaluation stated the following, “Charged with homicide for pushing his mother down stairs. He pushed peer at (facility) causing death...” A record review of the psychiatric evaluation for P-4 on 8/14/2023 stated, “According to patient’s own report that he submitted to the NGRI (Not Guilty by Reason of Insanity) community, he indicated that he has experienced psychotic symptoms since at least 2013. These include having ’ spiritual delusions that God was speaking to me and working through me, I use my grandfather’s credit card excessively and missed return flight home from Australia.” He indicated that he had stabbed his stepmother’s cat because he believed the cat was attacking him.” P-4 is identified as a NGRI legal status by order of the probate court. Both P-3 and P-4 are housed in the Schrier unit. The Schrier unit is an all male unit that houses a high percentage of forensic patients. Forensic patients are either at the facility for being deemed NGRI (not guilty by reason of insanity) or ICST (incompetent to stand trial). Staff B was queried why video was not accessible for review. Staff B stated that the facility was having difficulty with some of the cameras in the facility. When queried about the length of the problem with video surveillance, staff B stated it would be best to speak to the Administrative Services Director, staff Q. An interview was conducted with staff H, the Officer of Recipient Rights on 5/3/2024 at 1300. Staff H was queried if he knew about cameras being non-functioning. Staff H stated, Yes ... It is quite difficult to conduct investigations without having video to look at in order to substantiate claims ... Often I piece together hallway activity, but it makes things much easier when all the cameras are functioning. Staff H was then queried how long the facility had been without all cameras functioning. Staff H stated, “for a very long time.” Staff H was queried if he had reviewed the incident of 4/4/2024. Staff H stated that he had pieced together video from working cameras. Staff H was then queried if he always received submissions on the day that the patients submit their grievance to Office of Recipient Rights. Staff H stated, “No...submissions are made at all hours and days of the week...that is the issue. ORR is not here in the evenings or on the weekends. If I cannot look at an occurrence where the patient is stating something happened, then I cannot substantiate or unsubstantiate the claim.” Staff H was then asked how many allegations of physical harm were received by ORR (Office of Recipient Rights). Staff H stated, “a lot.” Staff H also stated that P-1 makes daily submissions and complaints to ORR, the state agency, the insurance company, and federal agencies with allegations of sexual abuse (rape) and physical abuse by staff. Staff H stated, “You (surveyor) are well aware of the multiple complaints submitted by (P-1 - a patient housed on the Schrier unit) to the state agency with allegations of sexual and physical harm... It is difficult to investigate the claims without video footage to track patient movement.” A review of complaint submissions for the facility to the state agency showed fourteen complaint submissions have been filed by P-1 or have P-1 as the patient of the complaint. Seven of the fourteen complaints contain allegations of sexual or physical abuse of P-1 from 8/2023 to 5/2024. On 5/3/2024 a record review of P-1 psychiatric evaluation conducted on 02/09/2023 stated the following, “Over the past year the patient has continued to exhibit significant mood, anxiety, and psychotic symptoms as well as severe behavioral problems including being disrespectful, verbally aggressive, disruptive, destructive, intrusive, hard to redirect, overly demanding, blaming others for his actions (or blaming his medications, especially Invega, for “making me angry”), attention seeking, feeling entitled.” The evaluation also stated, “He spends most of his time writing grievances and talking for hours on the phone, calling the police, and other agencies, accusing staff and patients of abusing him and states ’ I was raped when I first admitted to the unit. ’ According to the evaluation, P-1 was documented as severly physically harming a physician during a hospital stay at another facility. On 5/3/2024 an interview occured with P-1 about an incident he had submitted to the ORR on 4/22/2024. During the interview P-1 was asked if he had any injuries. P-1 stated, “(Staff L, RCA) stepped on my foot and broke it... I have a hard time walking on it.” P-1 was asked to provide a date of when his foot was broken. P-1 stated, “I’m not sure.” P-1 then went on to add, “I’m just going to kill someone... I can do that... why not just kill someone?” An interview was conducted with staff Q, the Administrative Services Director on 5/3/2024 at 1415. Staff Q was asked how long video surveillance had been inactive in the facility. Staff Q stated that the problem had been ongoing since early fall. Staff Q was then asked how many cameras were not functioning in the facility. Staff Q confirmed that 180 of the 413 monitoring devices were not working. Staff Q was asked if there had been arrangements made for the repair of the cameras. Staff Q presented an estimate of the cost of repair but was unable to state if there were any plans moving forward to have the cameras repaired. The estimate expiration date was June 6, 2024 if no commitment was made by the facility to accept the estimated cost of repair. On 5/3/2024 at 1400 an interview was conducted with staff S, a fire safety officer. Staff S was queried how long the facility had not had full functioning video surveillance. Staff S stated, “August 4 of last year (2023) ... I was working the day the contractor wiped everything out ... it has been a fix here and there, but it is a problem because every time they service the cameras something is wiped out ... and we have been without almost half of the cameras.” Staff S was then asked how he utilized video cameras as part of his job for safety measures. Staff S replied, “I use video cameras for seventy percent of my job ... I use them to monitor the units, to monitor the corridors, and to monitor the (facility) grounds. It is a problem that we (safety officers) do not have access to all areas that we used to ... I mean the video system would sometimes skip 7 to 12 seconds but nothing like this ... we (safety officers) were able to go back and see what had happened if a patient or staff member was attacked ... or when ORR (Office of Recipient Rights) needed to look at video to conduct and investigation ... Now areas like the dayroom can not be viewed.” Staff S was queried if he was able to use video previously in order to help protect units. Staff S stated, “Yes ... I could view what was going on and if something didn ’ t look right, I could call the unit. Especially when another officer was out doing rounds (security checks).” Staff S was queried if any additional positions were added for security. Staff S stated, “No. We have 2 security officers on during a shift.” On 5/3/2024 a record review of the document titled, “Position description, Fire Safety Officer,” dated 11/2013. According to the document it states under, “Duty 2, General Summary of Duty 2, % of Time 40, Security of Facility ...Review video and create timelines of events for authorized staff, as requested.” On 5/3/2024 a record review occurred of the document titled, “APF 141, Fingerprinting, photographing, audio-recording ADN viewing recipients through one-way glass,” policy number APB 2015-003, dated 10/1/2015. According to the document it states, under the subtitle “standards,” page 3, number 12, “Video-monitoring may be done for purposes of safety and security in common areas of MDHHS (Michigan Department of Health and Human Services) hospitals and centers with written notice to recipients upon admission. Documentation of the recipient ’ s receipt of the written notice shall be maintained in the recipient’s record. Each hospital and center shall establish written policies and procedures that address, at a minimum .... Archived footage of video surveillance recordings for up to 30 days in situations where the incident requires investigation by the department’s office of recipient rights, law enforcement, hospital or center administration and the U.S. Department of Health and Human Services Center for Medicaid and Medicare Services (CMS).” On 5/3/2024 record review occurred of the document titled, “Your rights when receiving mental health services in Michigan,” section 1: General Rights, under the subtitle, “Fingerprinting, Photographing, Audio and Video Recording, and Use of One-Way Glass,” page 4, reference Mental Health Code Section 724. It states the following, “ video surveillance may be conducted in a psychiatric hospital for purposes of safety, security, and quality improvement. Video surveillance may only be conducted in common areas such as hallways, nursing station areas, and social activity areas within the psychiatric unit. Video surveillance recordings taken in common areas shall not be used for treatment or therapeutic purposes...”