Bronson Behavioral Health Hospital

“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 obtain consent for psychotropic medications according to facility policy for 1 (P-4) of 16 patients reviewed resulting in the potential loss of making informed decisions regarding care. Findings include: On 08/05/2026 at 1:55 PM, Chief Medical Officer Staff S was queried would the medication guanfacine require a medication consent, Staff S said “yes”. Staff S was queried whether it was appropriate that P-4 received guanfacine before signing their medication consent, Staff S revealed that was a “nursing thing”. On 08/05/2026 at 1:45 PM, P-4’s medical record was reviewed. On 07/31/2025 at 8:20 PM, P-4’s medication administration record (MAR) revealed that P-4 received guanfacine 1 mg by mouth for generalized anxiety disorder. On 08/01/2025 at 9:43 AM, P-4’s MAR revealed that P-4 received guanfacine 2 mg by mouth for generalized anxiety disorder. On 08/01/2025 at 11:16 AM, P-4’s medication consent was signed by P-4, and the consent included the medication guanfacine. The consent was signed over 14 hours after P-4 received their first dose of guanfacine. According to the facility’s policy, “INFORMED CONSENT, MEDICATIONS,” dated 11/2024, “Medications must be administered in accordance with the recipient’s or legally responsible adult’s right to informed consent. Before initiating a course of psychotropic drug therapy to a recipient: (refer to Michigan Mental Health Code (MMHC) 330.1718 and 330.1719). A) The attending physician or a licensed health professional acting under the delegated authority of the prescriber shall inform the recipient or legally responsible adult of the need to administer medications. During the initial psychiatric evaluation and as needed thereafter, the physician shall explain the nature of his/her proposed treatment/s to the recipient or legally responsible adult; giving special attention to medications B) The prescriber/physician, or a licensed health professional acting under the delegated authority of the prescriber shall do the following before medication therapy can be initiated: 1) Obtain medication consent from ADULT recipients or legal guardian. 2) Explain and provide a written summary of risks, benefits, alternatives, common adverse effects, and food and drug interactions of the medication. 3) Sign, date, and time the medication consent form OR obtain phone/verbal consent that is also witnessed and signed by a Registered Nurse. If the initial consent is obtained by a licensed health professional other than the prescriber/physician, the prescriber/physician will finalize the consent with an endorsing signature at the earliest opportunity. A legal guardian of an adult must sign consent on the next visitation in the case of out of state (faxed consents).””

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 48030 Based on interview and record review, the facility failed to provide a safe discharge plan for 1 (P-1) of 15 patients reviewed for Discharge Planning, resulting in poor health outcomes and subsequent readmission. Findings include: Record review was conducted for P-1 on 08/04/2026 at 11:38 AM and revealed he was a 32-year-old who was admitted to the facility on 03/01/2026 for bipolar disorder, severe manic with psychotic features who was a danger to himself and others. Review of the Discharge Care Plan and Home Medications document dated 03/09/2026 reveals P-1 was given Benadryl 50 mg orally and intramuscular injections, Ativan 2 mg orally and intramuscular injections and Zyprexa 5 mg orally for severe anxiety and drug-induced extrapyramidal reactions. P-1 was also given Invega 6 mg by mouth for bipolar disorder. At the time of discharge to the Adult Foster Care (AFC) home where P-1 was residing prior to the admission on 03/09/2026, discharge instructions included a repeat Invega intramuscular injection on 04/09/2026 with no other medications prescribed. Record review reveals P-1 became aggressive at the AFC, was sent back to the Emergency Department and was re-admitted to the facility on 03/12/2026. During the second admission on 03/12/2026, P-1 required multiple doses of Zyprexa 5 mg, Ativan 1-2 mg intramuscular injections for aggressive behaviors and acute psychosis. P-1’s medications were changed on 3/13/2026 to Depakote 500 mg orally, Thorazine 25-50 mg oral and Thorazine 50 mg intramuscular injections, Invega was prescribed on 03/16/22026 and given for severe psychosis. Discharge documentation from 03/12/2026 through 03/20/2026 admission reveals Thorazine and Depakote were prescribed at discharge, but it is unclear if the AFC received the medications prior to P-1’s arrival. An interview with the Discharge Planner Social Worker (Staff Y) was conducted on 08/05/2026 at 11:29 AM and revealed she does not remember P-1 but did review the note from his discharge. Staff Y explained that the Supervisor from the Adult Foster Care (AFC) called the facility on 03/09/2026 requesting oral medications for P-1 and none were prescribed. When queried how the facility makes sure AFC facilities have medications available for patients upon discharge, Staff Y revealed “we don’t like same day discharges, we don’t always have enough time to get everything done”. Staff Y continued, “sometimes pharmacies do not have enough time to get prescriptions filled fast enough.” When queried if patients that required medications to help with agitation and aggressive behaviors while in the facility should have them available at the AFC prior to discharge, Staff Y agreed the facilities need these medications for patients to have a safe discharge if they continue to display aggressive behaviors. On 08/05/2026 at 11:55 AM an interview with the Director of Clinical Services (Staff B) was conducted. When queried how the discharge planning staff validates that patients have their medications at home prior to discharge, Staff B revealed, the Discharge Planners do not know when the providers call the prescriptions in or when they will be available to the patients. Staff B added that this can be more complicated if a patient has a short discharge turnaround time (same day discharge). When queried if prescribed medications for aggressive behaviors and acute psychosis are an important part of a safe discharge, Staff B agreed it was important to have these medications for a safe discharge and believes there is an opportunity for improvement. During an interview with the Medical Director (Staff S) on 08/05/2026 at 1:44 PM it was revealed he had reviewed P-1’s record and shared that after the first admission from 03/01/2026 through 03/09/2026 no medications were prescribed, other than the Invega injection on 04/09/2026. Staff S revealed that this was an oversight and P-1 should have been weaned off the Ativan during the first admission and because this did not happen, this may have led to his aggressive behaviors and the need for readmission on 03/12/2026. Staff S revealed that P-1 was prescribed Thorazine and Depakote following his second admission and these medications should have been called into the pharmacy prior to discharge and available to the staff at the Adult Foster Care (AFC) facility upon his arrival. When queried if the facility validates medications have been received by the facility prior to discharge, Staff S explained he was not sure if anyone was making sure the medications make it to the facility before the patient and added, “this patient should have had his medications available at discharge and we need to validate they are there for a safe discharge.” Review of facility policy titled, “Discharge Planning”, policy #AHC 4.2020, last revised 11/2024, in the section titled, “Procedure - Hospital discharge planning is a process that involves determining the appropriate post-hospital discharge destination for a patient; identifying what the patient requires for a smooth and safe transition from the hospital to his/her discharge destination; and beginning the process of meeting the patient’s identified post-discharge needs.””

“On May 21 - 22, 2024, a Life Safety Initial Certification Survey was conducted by the Michigan Department of Licensing and Regulatory Affairs, Bureau of Survey and Certification. At the survey, Bronson Behavioral Health Hospital was found in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41(b), Life Safety from Fire and the applicable provisions of the 2012 Edition of the National Fire Protection Agency (NFPA) 101, Life Safety Code and the 2012 Edition of NFPA 99, Health Care Facilities Code. The facility is a one story building of type II (000) construction, built in 2023. The building is complete supervised and monitored fire alarm system and is fully sprinklered. The facility has 83 certified beds. At the time of the survey the census was 45.”