PRINTED: 11/19/2024

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 000 INITIAL COMMENTS A 000

Facility ID: 630110

Census: 106

The purpose of this unannounced survey at this

non-deemed facility was for investigation of
complaint #MI00144210, #MI00144365, and
#MI00144569. The Department of Licensing &
Regulatory Affairs has evaluated this facility and
determined that it was not in compliance on the
date(s) indicated.

An Immediate Jeopardy (IJ) was determined to

exist on 5/21/2024 at 0900, under 42 CFR
482.13(c)2 due to the facility's failure to follow
nationally recognized American Heart Association
(AHA) guidelines and the facility's policy for
providing Basic Life Support (BLS) resulting in
poor outcomes for P-1. The Chief Operating
Officer (Staff A), the Director of Quality (staff B),
and the Chief Nursing Officer (Staff D) were
informed of the immediate jeopardy on
5/21/2024, at 1015. An acceptable Plan of
Correction was submitted, and the immediate
jeopardy was removed on 5/22/2024 at 1408.
A 115 PATIENT RIGHTS A 115
CFR(s): 482.13

A hospital must protect and promote each

patient's rights.

This CONDITION is not met as evidenced by:

Based on observation, interview, and record
review, the facility failed to protect the patients'
rights to informed consent for 1 of 4 patients
(P-2), failed to follow facility policy and nationally
recognized standards of practice for emergency
care for one of one patients (P-1), failed to

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 1 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 115 Continued From page 1 A 115

protect all 9 of 9 patients on the Developmentally
Delayed unit from accessing harmful items, failed
to protect two of two patients (P-15 and P-16)
reviewed for abuse free from abuse by staff, and
failed to report the death of a patient in restraints
in one of one patients (P-1) to CMS (Centers for
Medicare and Medicaid) resulting in the potential
for poor patient outcomes to all patients served
by the facility. Findings include:

Please see tags:

A-0131 - Failure to obtain informed consent.
A-0144 - Failure to provide care in a safe setting.
A-0145 - Failure to protect patients from abuse.
A-0213 - Failure to recognize and report death in
restraints.
A 131 PATIENT RIGHTS: INFORMED CONSENT A 131
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:

Based on record review and interview, the facility
failed to gain informed consent from the guardian
of one of four patients (P-2) resulting in the
potential of uniformed consent for all patients with
a guardian. Findings include:

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 2 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 131 Continued From page 2 A 131

On 5/20/2024 a record review of P-2's medical
record was conducted. A document in the
medical record titled, "Guardian Verification,"
stated under subtitle "Guardianship Status,
patient does not have a guardian." Review of the
document titled, "Consent to share your health
information," dated 5/1/2024 at 1400, listed two
family members but failed to list a guardian. The
document was noted to signed by the patient with
the wrong last name. Additional documents
signed by the patient included, "General Consent
for treatment, the Important Message from
Medicare, Primary Care Physician Notification,
Notice of Privacy Practices Acknowledgement,
Receipt of Adult Formal Voluntary Admission
Application, Mental Health Codes Confidentiality
and Privileges Communication, Patient Rights
Booklet / Unit booklet, Unit Rules & Expectations,
and Smoking Restriction."

On 5/9/2024 at 1650 a general consent by the

guardian was taken over the phone. The guardian
was not identified by name, but two witnesses
signed that consent was obtained from the
guardian. All documents signed by P-2 were
resigned by consent obtained from the guardian
on 5/9/2024 via a phone conversation with
nursing.

On 5/20/2024 during an interview with staff D, the

Director of Nursing, it was asked if a person with
severe dementia could sign documents if they
had cognitive issues that interfered with
understanding what they were signing. Staff D
stated, "No." Staff D was then queried how the
facility would know if a patient had a guardian.
Staff D stated two employees access a program
on the county website to run a query if a patient
has filed guardianship papers. Staff D stated,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 3 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 131 Continued From page 3 A 131

"Sometimes if the patient is coming from a care
facility a phone call is placed to where they
reside." Documentation failed to show that a
query had been made for P-2 guardianship, and
failed to include where contact had been made to
the care facility where P-2 resides."

On 5/21/2024 record review occurred of the

document titled, "Consent: Informed Consent for
Treatment," policy number BMD-C-7, with a
revision date of 6/14/2023. According to the
document under the subtitle "Definitions" it stated
under "5. Comprehension, An individual must be
able to understand what the personal implications
of providing consent will be based upon the
information provided under subdivision (b) of this
subrule...Definitions, 2. Competency: An
individual shall be presumed to be legally
competent. This presumption may be rebutted
only by a court appointment of an guardian or
exercise by a court of guardianship powers and
only to the extent of the scope and duration of the
guardianship. An individual shall be presumed
legally competent regarding matters that are not
within the scope and authority of the
guardianship...Procedure: 4. Recipient or his/her
Legal guardian shall be informed that consent
can be withdrawn for participation or any activity
at any time and that this can be done without any
prejudice towards the Recipient."
A 144 PATIENT RIGHTS: CARE IN SAFE SETTING A 144
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:
Based on record review and interview, the facility
failed to follow policy and nationally recognized

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 4 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 4 A 144

standards of practice while providing CPR
(Cardiopulmonary Resuscitation) for one of one
patients (P-1), and failed to provide a secure
environment, resulting in the potential for poor
outcomes for all patients. Findings include:

A record review of P-1 medical record occurred

on 5/20/2024 at 1600. According to the medical
record P-1 was documented by staff K, registered
nurse as, "Male, 41-years-old, brought in by law
enforcement, no listed guardian, no advance
directive, Vital Signs Height 75 in. (6'3"), Weight
394 lbs., Temperature 97.7 degrees Fahrenheit,
Pulse 102, BP (blood pressure) 132/73, pain not
addressed, BMI (body mass index) 49." The chief
complaint stated, "Pt (patient) denies any pain,
but appears very labile. Pt balled his fist up and
jerked towards nurse during assessment. Pt
presents altered mental status; Pt states he feels
overwhelmed due to loss of employment. Pt has
tangential speech."

Further nursing mental health assessment states,

"consciousness: alert, confused, speech: garbled,
rambling, patient medically stable: yes, ... Mental
status exam, cooperation: poor, motor activity:
normal, eye contact: fair, speech rate: hesitant,
comfort style: guarded, mood: labile, impulsive,
appearance/hygiene: disheveled, clothing:
layered in clothes, affect: labile, oriented to:
person, sensorium: alert, thought process: flight
of ideas, hallucinations: denies, detail what
patient sees, hears, feels, etc.: Pt denies seeing
or hearing anything but rumbles random words /
outburst." Information continued, "delusions:
paranoid, detail delusions: blank, thought content:
paranoia, detail: blank, homicidal: denies
homicidal ideation, insight: poor, judgement: poor,
impulse control: poor."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 5 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 5 A 144

Physical assessment stated, "Nutritional risk

screen appetite: good, EENT - assess eyes, ears,
nose, and throat for abnormalities denies,
respiration - assess chest configuration,
respiration rate, rhythm, depth, pattern, breath
sounds, comfort: Denies. (no documentation
found for assessment of respiratory system).
Cardiovascular - assess heart sounds, rate,
rhythm, pulse, blood pressure, circulation, fluid
retention, comfort. Denies (no documentation
found for assessment of cardiovascular system).

P-1 did not have a psychiatric evaluation prior to

the code event.

On 5/20/2024 at 1400 record review occurred of

video documentation of 4/4/2024 at 0627 on the
5S all male unit. P-1 was viewed as coming out of
his patient room. P-1 was observed rubbing his
eyes. P-1 room door was shut from 062900 to
062920 by MHT, staff H. Staff H released the
patient room door at 062921 at which time P-1
came out of the room and began swinging at staff
H and staff E, MHT. Staff F, RN charge nurse,
staff H, and staff E were observed struggling to
physically restrain P-1 in order to gain control of
P-1 at 063059. P-1 was observed falling prone to
the floor at 063102. P-1 was observed to be
maintained in a prone position by staff H
straddling P-1 and using his right knee to keep
P-1's left thigh to the ground and using his right
elbow in the center of P-1 scapulae holding P-1
down. Staff H was then viewed at 063133 placing
his chest on P-1 upper back as P-1 remained in a
prone position. Staff P-1 continued to struggle
until 063206 when P-1 stopped moving. At
063225 staff E was viewed providing a bath
blanket to staff H to cover P-1 as his lower body
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 6 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 6 A 144

and buttocks were in full view. P-1 remained in a
prone position. Staff F remained to the right of
P-1 upper body near P-1 head. Staff E was
observed going into P-1 patient room at 063237.
Staff K, RN was observed placing her right hand
next to P-1 neck at 063247 to check P-1 pulse. At
063313 staff K rechecked P-1 pulse. At 063335
P-1 was rolled supine. Staff E was observed
placing a pillow underneath P-1 head. Staff F
remained at the right side of P-1. At 063336 Staff
K was observed standing above P-1 doing
compressions on P-1 chest. At 063350 staff K
was observed stopping compressions to check
pulse. Compressions were restarted at 063407 by
staff F. The crash cart was observed being
removed by staff at 063407 from the medication
room but was not brought to the patient. Resident
staff M was observed next to P-1 at 063407. Staff
J, attending psychiatrist was noted to be present
at 063416. Resident staff M took over
compressions at 063424. Multiple staff were
noted in the immediate area without participation
in the code. Compression rate was
approximately 60 per minute. Compression rate
less than 100 per minute. Resident staff N was
noted to be making a phone call at 063520 (Call
by staff N was being placed to staff G, medical
director - attending medical physician. As
confirmed by staff G interview.) Compressions
were changed over to staff F. Compression rate
was 60 per minute. Oxygen administration began
at 063616. At 063623 Staff L, LPN was noted to
go to the crash cart. At 063623 Resident staff M
took over compressions. 063729 Staff F was
noted to be drawing medication. At 063805
compressions were taken over by staff N. During
this time the defibrillator remained on the crash
cart. At 063822 compressions were taken over by
unknown resident. At 063911 compression were
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 7 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 7 A 144

once again switched out (staff N). Staff L was
noted at 063933 to have a syringe in his right
hand to administer to P-1. At 063925 staff F
resumed compressions. Compression rate
remained at 60 per minute. Staff L performed IM
(intramuscular) injection to P-1 at 063937 in lower
extremity. At 064040 compressions were
switched out again to unknown resident.
Compression rate was 100 per minute.
Compressions were taken over by staff F at
064123. Compression rate was 60 per minute.
Compressions were taken over by staff N at
064208. A second crash cart arrived on scene at
064302. Staff F took over compressions at
064255. Staff L was noted drawing medication
into a syringe at 064307. At 064316 staff L
administered medication to P-1. At 064501 the
defibrillator was taken off the second crash cart
by staff N. The defibrillator was placed next to P-1
at 064542. Defibrillator pads were placed on P-1
at 064642. At 064648 staff L was noted drawing
medication. At 064702 EMS personnel arrive on
scene. At 064718 Police authorities arrive on
scene. At 064730 compressions were stopped to
place EMS blanket under P-1. At 064800
compressions by unknown resident were started
again on P-1. Compressions were switched again
at 064844. At 065048 Compressions and
ambu-bag resuscitation were stopped to check
the EMS defibrillator. Compressions were
restarted at 065104 by resident staff N. EMS
personnel were seen establishing an IO
(Intraosseous access) at 065350. Compressions
were stopped at 065400. Compressions resumed
at 065500. P-1 was transferred to EMS stretcher
at 065549 with a stop in compressions until
065603. Compressions ceased at 065618 and
resumed again at 065622. P-1 was transported
by EMS off the unit at 065657.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 8 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 8 A 144

Employee files for staff involved in the Code blue

event performed on P-1 on 4/4/2024 were
reviewed. All staff were found to have current
BLS certification. Review of staff F (registered
nurse) file revealed a signed document dated
10/5/2023 that stated, "I, (staff F) by signing this
acknowledgement, agree that I have been
educated on the following elements of patient
care ... I will never place a patient face down
during restraints ..."

Record review of P-1 medical record from the

receiving facility took place on 5/22/2024.
Documentation by the Emergency Room
physician stated the following, "Patient (P-1) is a
41-year-old male presenting to the ED for
evaluation via EMS from (facility) as a CPR in
progress. History was obtained from EMS. Per
EMS report patient was being treated for excited
delirium and became unresponsive. On arrival
here, patient remained pulseless and appears
cyanotic. Patient was placed on a cardiac monitor
and CPR was continued. There was no airway
established. Used bag mask for ventilation until
8-0 ETT (endotracheal tube) placed. Prior to
arrival, EMS performed CPR and administered 2
doses of epinephrine. They were able to establish
IO (Intraosseous) access. Here in the ED, with
continued CPR, patient was administered 5 more
doses of epinephrine through continued CPR. At
pulse check, cardiac monitor showed V-fib
(Ventricular fibrillation) and shocked at 200 J
(Joules). CPR was then continued and a sixth
dose of epinephrine was administered (8 doses
of epinephrine in total). At subsequent pulse
check, patient was found to be in asystole. Time
of death was pronounced at 0722. Next of kin
was notified. Attending physician, (name) at
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 9 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 9 A 144

bedside during CPR. Medical examiner requests
examination."

On 5/22/2024 a record review occurred of the

policy titled, "Code Blue," with a revision date of
3/19/2024. The policy it states under the subtitle,
"Scope of Application," The medical staff, patient
care staff, and other direct/indirect healthcare
professionals within the scope of his or her
practice at (facility). The document stated the
following,

"Policy:

The Code Blue alert will provide timely and

effective assessments and interventions to
patients ....who experience cardiopulmonary
arrest within and outside the direct patient care
units of (facility). The term "Code Blue" will be
used to summon a team of trained medical
personnel to undertake cardiopulmonary
resuscitation. Cardiopulmonary resuscitation
implies but is not limited to the use of approved
techniques for:
1. Oxygenation, 2. Airway management, 3.
Cardiac arrhythmia recognition, cardiac
defibrillation, and pharmacological interventions
of perfusion in an orderly attempt to achieve a
return of spontaneous circulation, and 4. External
cardiac massage.

Procedure
Initiation of a Code Blue
A. Any personnel that identify a person in
suspected or actual cardiopulmonary arrest may
initiate a Code Blue. This person will:
1. Stay with the patient, visitor, or hospital staff
and begin Basic Life Support (BLS) interventions,
if certified.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 10 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 10 A 144

2. Simultaneously beginning the process of
notification for assistance (yelling out to additional
staff members.)
B. The first staff that receives notification of
needed assistance with Code Blue will:
1. Activate Code blue by pressing the labeled
speed dial button on the Charge Nurse phone.
2. Code and location will be automatically
announced three times via the overhead public
paging system.
3. If, for any reason, the overhead paging system
does not operate appropriately, staff will use the
two-way radio to activate code blue alert.
4. Retrieve the Crash Cart and bring it to the
location.
C. CODE BLUE STAFF MEMBERS MAY
INCLUDE:
* Attending physician and/or Resident doctor
* Anesthesiologist/CRNA if available
* Registered Nurses
* Licensed Practical Nurses
* Certified Nursing Assistants
* Mental Health Technicians
* Any other staff certified and deemed necessary
to perform BLS.
Departmental and Hospital Staff Responsibilities
A. Each identified department is responsible for
ensuring that competently trained staff will be
designated to respond to all Code Blue events
each shift.
Chain of Command During Code Blue
A. Management of the patient will be assumed by
the first physician or Resident Doctor to arrive on
scene of the Code Blue. This management will
continue until a higher priority physician
(Attending Physician / Physician on call) is
contacted and advice received, as defined below,
arrive to the scene.
B. In the event a physician or resident doctor is
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 11 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 11 A 144

not present the first Registered Nurse to respond
will assume responsibility for the Code Blue
Management.
C. A registered nurse will be identified as Code
Leader and is responsible for directing additional
personnel during the Code Blue.
Responsibilities of Nursing Staff in Patient Care
Areas
A. All Nursing Staff at (facility) are required to
have BLS Health Care Provider certification. They
are responsible for knowing the location of the
Crash Cart and/or additional emergency
equipment on their unit.
B. Upon hearing the page of a Code Blue
announcement over the paging system, the unit
nurse and other patient care staff assigned to the
unit will proceed immediately to the Code Blue
location. The first arriving qualified staff will
initiate BLS interventions and perform automatic
external defibrillation (if indicated).
C. The RN delegates responsibility to Code Blue
responders to assist with resuscitation efforts
including, but not limited to:
1. Monitoring the patient's vital signs
2. Attach electrodes and lead to the patient
3. Identify and document the patient's cardiac
rhythm if able.
4. Securing necessary equipment/medications
from the Crash Cart.
5. Establish or assist the resident doctor with the
establishment of IV/IO access.
6. Administering emergency medications as
ordered by the physician leader.
7. Continuously observing the patient and
providing documentation for the medical record.
8. Ensuring security is notified if traffic control is
needed.
9. Facilitating the notification of family, guardian,
and/or patient advocate for support as necessary.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 12 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 12 A 144

10. Providing a report to the receiving unit/facility
if the patient is transferred.
D. The Crash Cart from the unit will remain with
the coding patient until the final disposition of the
patient. After the final disposition of the patient is
complete, the Crash Cart (including all exposed
equipment, e.g. defibrillator) will be cleaned,
restocked, and appropriately documented in the
Crash Cart Log by the Charge nurse and then
returned to its origin.
E. The nurse will complete the Code Blue
Debriefing with the clinical team.
Responsibilities of the Medical Resident or
Attending Physician
A. Respond to all Code Blue pages.
B. Assume command of the Code Blue event
upon arrival; Direct resuscitation efforts and
dismiss staff not required for the resuscitation
efforts ....
C. Promptly provide a narrative of the events and
actions taken in the patient's progress note and
notify the attending physician (if not present
during the code).
D. Transfer the patient to ER if required.
Responsibilities of Security
A. Establish and maintains a perimeter around
the patient and the staff responding to the code
blue.
B. Re-direct non-essential persons/family away
from the scene.
Responsibilities for Crash Cart monitoring and
maintenance
A. Crash Carts are checked by designated staff
on patient care units every 24 hours on the 7P -
7A shift to verify it is unopened. The designated
staff will verify that the Crash Cart has not been
opened by confirming the Crash Cart lock tag is
intact with the unique lock tag numbers
corresponding with those documented in the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 13 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 13 A 144

Crash Cart Log. All individual equipment and
individual medications expiration dates will be
documented on the Crash Cart Inventory on the
first day of each month and each time the Crash
Cart lock tag is broken. At this time, any expired
equipment and/or medications will be removed
and replaced following the process as indicated
below. Any items replaced in the Crash Cart after
a Code Blue or due to expiration will be
documented on the Crash Cart Inventory.
B. If the lock is not intact or the expiration date is
exceeded:
1. The nurse manager/supervisor on duty
must be notified immediately.
2. Crash Cart medication trays are
immediately returned and exchanged in the
Pharmacy.
C. Departments that are not open
around-the-clock will have the Crash Cart Log
and Equipment Logs completed daily during
routine operational hours by designated staff.
Departments will assign staff to complete logs in
areas that are closed due to low census.
D. Defibrillators are and logged by the designated
staff every 24 hours on the 7P - 7A shift (or during
routine operational hours) for charging capability
per manufacturer's guidelines through successful
completion of self-test. Following the check,
defibrillators should be plugged into red
emergency outlets where available."

On 5/22/2024 an interview was conducted with

staff D, the Director of Nursing. Staff D was
queried if she had conducted a review of the
events on 4/04/2024. Staff D stated, "Yes." Staff
D was queried if a Code Sheet had been
completed for the code event. Staff D stated,
"No." Staff D was then asked if she had
conducted a debriefing of staff that were involved
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 14 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 14 A 144

in the code. Staff D stated that she had talked
with everyone involved in the code event. Staff D
was then asked if she had identified any
opportunities for improvement for future codes.
Staff D stated that she and staff R, Nurse
Educator and BLS (Basic Life Safety) Instructor
had identified that the defibrillator was not used.
Staff D was queried why the defibrillator had not
been used. Staff D stated that staff thought the
defibrillator was inoperable. Staff D was asked to
review the documentation on the Crash Cart
checklist from the morning of 4/4/2024 at 0300.
Staff D was then asked if the defibrillator was
checked to assess operational status. Staff D
stated that it was checked. Staff D was then
asked if the oxygen tank was noted to be empty
on 4/4/2024 at 0300. Staff D stated, "Yes ...but I
think it was full." Staff D was then shown where
the oxygen tank had been marked as not
available until 4/5/2024 where it stated the oxygen
tank had been replaced. Staff D was asked if a
code sheet had been used to record the code
event. Staff D stated, "No." Staff D was then
queried if a list of all personnel involved in the
code on 4/4/2024 was available. Staff D stated,
"No but we can review the video and make a list."
Staff D was queried if a debriefing had taken
place with staff involved. Staff D stated, "not
anything formal but we did ask staff what
happened." Staff D was asked if staff not involved
in the code should have been removed from the
area. Staff D stated, "Yes." Staff D was then
asked if the Code Blue on 4/4/2024 had followed
policy. Staff D stated, "We have identified areas
of opportunity."

On 5/22/2024 an interview was conducted with

staff R, Nurse Educator and BLS Instructor.
During the interview with staff R, it was asked
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 15 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 15 A 144

what professional organization standards were
used for BLS. Staff R responded, "American
Heart Association." Staff R was queried if she had
reviewed the video documentation of the code
conducted with P-1. Staff R stated, "Yes." Staff R
was then queried if she had identified any issues
with the code. Staff R stated, "We (staff D and
staff R) noticed the defibrillator was not used from
the first cart as staff thought it was not working."
Staff R was asked if compressions were done at
an appropriate rate. Staff R stated, "They
(compressions) were done on the lower side of
acceptable." Staff R was then asked if she
thought the compressions were done at a rate of
100 per minute. Staff R stated, "Yes ... I think so."

On 5/21/2024 a record review occurred of the

document titled, "Highlights of the 2020 American
Heart Association Guidelines for CPR and
ECC,"p.8, published date 2020, electronic copy
found at
https://cpr.heart.org/en/resuscitation-science/cpr-
and-ecc-guidelines. According to the document
titled "Adult Cardiac Arrest Algorithm" it states the
following:

CPR Quality -
*Push hard (at least 2 inches [5 cm]) and fast
100-120/min), *Minimize interruptions in
compressions, *Avoid excessive ventilation,
*Change compressor every 2 minutes or sooner if
fatigued, *If no advanced airway, 30:2
compression - ventilation ratio, *Quantitative
waveform capnography - If PETCO2 is low or
decreasing reassess CPR quality,
Rhythm shockable?
Shock energy for Defibrillation -
*Biphasic: Manufacturer recommendation (e.g.
Initial dose of 120 - 200 J (Joules); if unknown,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 16 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 16 A 144

use maximum available. Second and subsequent
doses should be equivalent, and higher doses
may be considered,
*Monophasic: 360 J (Joules)
Drug Therapy -
Epinephrine IV/IO dose: *First dose: 1 mg every
3-5 minutes
*Amiodarone IV/IO dose: First dose: 300 mg
bolus, Second Dose: 150 mg or
Lidocaine IV/IO dose: First dose: 1-1.5 mg/kg,
Second Dose: 0.5-0.75 mg/kg
Advanced Airway -
*Endotracheal intubation or supraglottic advanced
airway,
*Waveform capnography or capnometry to
confirm and monitor ET (endotracheal) tube
placement,
*Once advanced airway in place, give 1 breath
every 6 seconds (10 breaths/min) with continuous
chest compressions
Return of Spontaneous Circulation (ROSC)
* Pulse and blood pressure
*Abrupt sustained increase in PETCO2 (typically
?40 mm Hg)
*Spontaneous arterial pressure waves with
intra-arterial monitoring
Reversible Causes
*Hypovolemia
*Hypoxia
*Hydrogen ion (acidosis)
*Hypo-/hyperkalemia
*Tension pneumothorax
*Tamponade, cardiac
*Toxins
*Thrombosis, pulmonary
*Thrombosis, coronary

1. Start CPR
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 17 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 17 A 144

*Give Oxygen
*Attach monitor/defibrillator
Rhythm Shockable?
#2 Ventricular Fibrillation/p Ventricular
Tachycardia
#3 Shock
Epinephrine ASAP
(see above Drug Therapy)
#4 CPR 2 minutes
Rhythm Shockable?
#5 Shock
*IV/IO access
# 6 CPR 2 minutes
*Epinephrine every 3-5 minutes
*Consider advanced airway, capnography
Rhythm Shockable? If Yes proceed to #7
#7 Shock
#8 CPR 2 minutes
#9 Asystole/Pulseless Electrical Activity
Epinephrine ASAP
(see above Drug Therapy)
#10 CPR 2 minutes
*IV/IO access
*Epinephrine every 3-5 minutes
*consider advanced airway, capnography
Rhythm Shockable?
#11 CPR 2 minutes
*Treat reversible causes
#12
* If no signs of return of spontaneous circulation
(ROSC), go to #10 or #11
*If ROSC, go to Post-Cardiac Arrest Care
*Consider appropriateness of continued
resuscitation
On May 20th, 2024, at 1040, during the initial tour
of 4 South Unit for developmentally delayed
patients with Staff D, the Director of Nursing, it
was observed the janitor's closet was unlocked
allowing access to patients who were freely
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 18 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 144 Continued From page 18 A 144

roaming the unit. Within the janitor's closet the
following was accessible, a spray container of
germicidal disinfectant, a television remote unit,
and a gallon of liquefying stripper solution. Staff D
confirmed all three hazardous substances were
accessible to all 9 patients on the unit. Staff D
confirmed the door to the janitor's closet should
remain locked and secured from all patients.

On May 20th, 2024, at 1057 the door to the

laundry room was unlocked allowing access to an
open box of powdered laundry detergent on the
table next to the washer. Staff D confirmed that
the door should remain locked and secured at all
times to patients.

On May 20th, 2024, at 1103, during the initial tour

of 5 South patient care area, with Staff D
present, it was observed a cloth underneath the
partially opened door to patient room 545
preventing the door from closing and opening.
Staff D confirmed the finding and stated that
doors were not to be propped open.

On May 20th, 2024, at 1140, during the initial tour

of the 5 South patient care area, patients were
observed walking the hallways. Room 553
designated for the storage of patient's
belongings, was noted to be unlocked allowing
access to patients' valuables. A bin located in the
room was noted to include tubes of paint and
other liquid art supplies on the lower back shelf.
A 145 PATIENT RIGHTS: FREE FROM A 145
ABUSE/HARASSMENT
CFR(s): 482.13(c)(3)

The patient has the right to be free from all forms

of abuse or harassment.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 19 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 145 Continued From page 19 A 145

This STANDARD is not met as evidenced by:

Based on record review and interview, the facility
failed to protect 2 of 2 patients (P-15 and P-16)
from abuse by staff resulting in harm. Findings
include:

On 5/21/2024 a record review occurred of an

adverse event where P-16 reported being abused
to multiple staff members including staff O, the
Officer of Recipient Rights and staff MM, Nursing
Supervisor. According to the adverse event P-16
was locked in the Quiet Room on the night of
4/17/2024 for an unknown extended period of
time. P-16 reported that he had been thrown to
the ground by staff NN, RN 4S Developmentally
Delayed unit, on 4/18/2024.

Record review of the medical record for P-16

stated the following, "The patient is a 34-year-old
Caucasian single male. The patient present from
his group home due to aggression, delusional
behavior, paranoia, and being internally
preoccupied. Upon arrival, the patient was noted
to be hyperglycemic, see medical note. The
patient believes that people are out to harm him.
The patient states that he has a fax machine that
has been hacked and he needs to fix it ....The
patient has an 8th grade education ...Orientation
is to person ...Intelligence is below average
....Justification for admission: danger to self,
danger to others, psychosis, and inability to
function." According to an order for admission it
states, "Patient acts like a child at times ...." P-16
was admitted to the Developmentally Delayed
unit on 12/22/2023 with the diagnosis of
schizophrenia and intellectual disability. There
was no documentation related to seclusion in the
patient's chart.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 20 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 145 Continued From page 20 A 145

On 5/22/2024 at 1245 a record review of video

documentation occurred of the incident on
4/18/2024 with P-16. According to the video
documentation on 4/18/2024 at 070514 P-16
could be seen in the doorway of the activity room
with staff NN, registered nurse of the 4 S. At
070516 Staff NN could be seen pushing P-16
through the doorway and continuing to push P-16
past tables and chairs. At 070519 Staff NN was
viewed pushing P-16 to the floor and grabbing
P-16 ballcap from him. Staff NN continued to
point his finger in P-16's face. At 070533 Staff NN
was viewed turning away from P-16 at which time
he continued to walk out the room. P-16 was
seen getting up from the floor and walking to
follow Staff NN. P-16 was seen going to the
nurse's station visibly upset. Additional staff are
viewed guiding P-16 into the activity room. At
0707, staff MM was viewed engaged in
interviewing P-16.

A psychiatry daily physician notes by staff OO,

psychiatrist on 4/18/2024 at 0625 stated, "Chief
Complaint: I was attacked ... Patient (P-16)
interviewed and chart was reviewed. Patient
presents anxious. Patient reports that allegedly a
staff member attacked him and per staff,
currently doing investigation with the patient and
guardian and RR (Recipient Rights) are notified.
Patient has reached his chronic baseline. Patient
has marginal hygiene and grooming. Patient is
seen engaged in conversation with the attending
psychiatrist. Will continue to monitor for safety
and follow up with social work regarding
placement."

According to a progress note dated 4/18/2024 at

1700 it stated, "Pt (P-16) was seen due to the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 21 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 145 Continued From page 21 A 145

complaint of altercation with staff from nursing
station. Pt reports that he was pushed by the
nurse. Pt denies any fall, injuries, trauma,
painfever [SIC], chills, nausea, vomiting and
headache at this time."

According to P-16 statement taken by staff MM,

Nursing supervisor the following was stated,
"Patient was standing at the nurses station
screaming and writer walked up to the patient and
asked him what was wrong, and patient stated he
is tired of being abused. Patient stated, "he
attacked me". Writer asked "Who" patient was
walked into the dining room and interviewed by
nurse supervisor and nurse educator. Patient
persisted to state he had got in trouble by night
shift nurse for stealing his phone, "it was on the
desk and I was jealous so I took it. So they locked
me in the quiet room all night and would not let
me out" Patient states "so when I did come out in
the morning I was standing at the desk and he
attacked me he threw me to the floor" Patient was
asked if he would like to file a police report and
patient states "No I don't want the police here"
Patient was then asked if he would like to file a
grievance and patient states no. (Physician)
notified, medical notified and Guardian contacted.
Guardian was asked if she would like to file a
police report and or a grievance report and she
stated that she would like to hold off for now."
Staff NN was no longer employed by the facility.
No other corrective actions occurred after this
incident.

On 5/22/2024 at 1057 during survey, a "Team

Strong" (Team Strong is a term used by the
facility when a patient altercation is ensuing and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 22 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 145 Continued From page 22 A 145

available staff are to go to assist with the patient )
was announced overhead throughout the hospital
to assist with an agitated patient.

On 5/22/2024 at 1320 during an interview with

staff A, Chief Operations Officer a request was
made to conduct record review of video footage
of the "Team Strong" incident.

On 5/22/2024 at 1425 a record review occurred of

video footage of the "Team Strong" incident. On
5/22/2024 at 1055 P-15 was viewed at the 5
South Nurse's Station where P-15 was engaged
in a verbal argument with Staff Q, Charge Nurse
of 5 South. At 1055 Staff W, Mental Health
Technician was seen approaching P-15. At
105517 Staff W was viewed in verbal exchange
with P-15. At 105521 P-15 became aggressive
and lunged at Staff W. Staff W and P-15 were
viewed physically fighting. At 105526 a Mental
Health Tech placed himself between staff W and
P-15. At 105528 P-15, staff W, and the additional
staff member fell to the floor. Staff W and the
additional staff member were observed to be on
top of P-15. Staff W was the first to stand up.
While the additional staff member (MHT) and
P-15 went to stand staff W drew back his right
arm and punched P-15 at 105537. The force of
staff W's punch propelled P-15 back to the
ground causing P-15 to hit his head. At 105543
P-15 returned to standing and was redirected
away from staff W. Staff W continued to follow
P-15 and required restraint from additional staff.

On 5/22/2024 at 1450 an interview was

conducted with staff Q. Staff Q was asked to
explain the incident. Staff Q stated that P-15 had
been monopolizing the phone and was asked to
step away from the phone. Staff Q stated P-15
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 23 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 145 Continued From page 23 A 145

was becoming belligerent and was told that he
needed to refrain from the use of foul language
and being disrespectful. Staff Q stated that P-15
continued with profanity and staff W came up to
the nurse's station. Staff Q stated P-15 looked at
staff W and stated, "so you want to continue from
this weekend?" Staff Q stated she did not know
what was meant by that comment. Staff Q then
stated that P-15 lunged at staff W and she called
a "Team Strong" over the announcement
system." Staff W was not available for interview
prior to the exit of survey.

On 5/22/2024 at 1505 an interview occurred with

P-15. P-15 was asked to explain the incident.
P-15 stated that staff W had targeted him during
the weekend and several times had pointed his
finger at him in a threatening manner. P-15 was
asked if he felt safe. P-15 stated he did feel safe
except for the mental health tech (name)(staff
W). P-15 was asked if he was physically harmed
during the incident. P-15 stated that his right hand
had skin missing in two places. P-15 bandage
was noted to be loose and not adhered to his
skin. P-15 pulled the bandage back and said,
"this is what happened," exposing the palm of his
right hand. Two areas were noted to have the top
layer of skin (epidermis) missing. P-15 was asked
if he had pain. P-15 stated his right shoulder and
face "hurt a little bit." P-15 was asked if anyone
had assessed him after the incident. P-15 stated
that staff G had "checked on me." P-15 was
asked if he hit his head during the incident. P-15
stated, "I don't know ... maybe because I have a
headache."

On 5/22/2024 at 1600 an interview was

conducted with staff G, the Medical Director. Staff
G was asked if he had seen P-15. Staff G stated,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 24 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 145 Continued From page 24 A 145

"Yes...I just saw him...He was in an altercation."
Staff G was queried if he had seen P-15 right
hand. Staff G stated, "Yes... I ordered the staff to
clean the wound with soap and water and to
place antibiotic cream on the wounds then to
apply a dressing." Staff G was then queried if he
had ordered alcohol to be used to wipe the
wound. Staff G stated, "No...that is not what I
ordered." Staff G was then queried if he was
aware that P-15 had hit his head in the
altercation. Staff G stated, "No. No one told me
that he had hit his head." Staff G stated that he
was going to reassess P-15 with new knowledge
that P-15 had struck his head during the
altercation.

A record review of the medical record for P-15

occurred on 5/22/2024. P-15 was petitioned for
mental health treatment on 5/10/2024 and was
admitted to the facility on 5/14/2024. P-15 signed
a "Formal Voluntary Admission," on 5/14/2024.
According to the "Family Medicine History and
Physical," by staff G, Medical Physician, P-15 is
described as, "a 19-year-old male with PMH (past
medical history) significant for Gonorrhea as per
chart. Pt (patient) was admitted to (facility) with
Psychosis, NOS (not otherwise specified). Pt at
this time denies any chronic and acute
complaints. Pt denies any history of HTN
(hypertension), Asthma, T2DM (Diabetes Mellitus
Type 2), Hypothyroidism, Seizure disorder,
stroke, heart attacks, blood or clotting disorders.
Patient denies cough, fever, chills, nausea,
vomiting, chest pain, shortness of breath,
abdominal pain, and changes in bowel and
bladder movements and lower extremity swelling
or calf tenderness at this time. All other pertinent
ROI (release of information) are negative except
mentioned above. Vital signs are WNL and pt is
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 25 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 145 Continued From page 25 A 145

medically stable at this time. Patient was cleared
medically by Sending Facility." P-15 vital signs at
the time of admission were listed as: Height 67 in
(5'7"), Weight 162.4 lbs, Temperature 97.7
degrees Fahrenheit, Pulse 69, Respirations 18,
Blood Pressure 140/94, Pain not documented,
BMI (Body Mass Index) 25.

According to the document "Psychiatric

Evaluation" dated 5/14/2024 stated, "The patient
(P-15) was transferred from (facility) per court
order and petitioned by mother. As per intake
records, the patient present on AOT (Assisted
Outpatient Treatment), has history of outpatient
treatment with auditory and visual hallucinations,
medication and treatment refusal, tangential,
disorganized thoughts and speech, aggression
paranoia, lack of frustration tolerance, and limited
insight and judgment. The patient has a prior
inpatient hospitalization ..." P-15 admitting
diagnoses were listed as, "1. Schizoaffective
Disorder, Bipolar Type, 2. Nicotine Use Disorder,
Moderate, 3. Cannabis Use Disorder, unknown
severity, and 4. Rule Out Schizophrenia."

According to the policy titled "Abuse and

Neglect," number BMD-A-1, revision date
12/14/2023 it states under subtitle "Abuse Class
II, (b) 'Abuse class II' means any of the following:
(i) A non-accidental act or provocation of another
to act by an employee, volunteer, or agent of a
provider that caused or contributed to non-serious
physical harm to a recipient. (I) 'Non-serious
physical harm' means physical damage or what
could be reasonably be construed as pain
suffered by a recipient that a physician or
registered nurse determines could not have
caused, or contributed to, the death of a recipient,
the permanent disfigurement of a recipient, or an
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 26 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 145 Continued From page 26 A 145

impairment of his or her bodily functions. (ii) the
use of unreasonable force on a recipient by an
employee, volunteer, or agent of a provider with
or without apparent harm. (iii) Any action or
provocation of another to act by an employee,
volunteer, or agent of a provider that causes or
contributes to emotional harm to a recipient. (iv)
An action taken on behalf of a recipient by a
provider who assumes the recipient is
incompetent despite the fact that a guardian has
not been appointed, that results in substantial
economic, material, or emotional harm to the
recipient. (m) 'Physical management' means a
technique used by staff as an emergency
intervention to restrict the movement of a
recipient by direct physical contact to prevent the
recipient from harming himself, herself, or others.
(v) Exploitation of a recipient by an employee,
volunteer, or agent of a provider. (z)
'Unreasonable force' means physical
management or force that is applied by an
employee, volunteer, or agent of a provider to a
recipient in one or more of the following
circumstances: (i) There is no imminent risk of
serious or non-serious physical harem to the
recipient, staff or others. (ii) The physical
management used is not in compliance with
techniques approved by the provider and the
responsible mental health agency. (iii) The
physical management used in not in compliance
with the emergency interventions authorized in
the recipient's individual plan of service. (iv) The
physical management or force is used when other
less restrictive measures were possible but not
attempted immediately before the use of physical
management or force."

The policy continues to define "Vulnerable Adults"

as "Those individuals who are unable to protect
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 27 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 145 Continued From page 27 A 145

themselves from Abuse, Neglect or exploitation
because of a mental or physical impairment or
because of advanced age."

Subtitle "Staff to Patient Allegations of Abuse or

Neglect" states, "Attending physicians are
contacted to provide evaluation of patient
condition inclusive of Psychiatry and Medical."
A 213 PATIENT RIGHTS:RESTRAINT/SECLUSION A 213
DEATH RPT
CFR(s): 482.13(g)(1) & (3)(i)

[Death Reporting Requirements: Hospitals must

report deaths associated with the use of seclusion
or restraint.]

(1) With the exception of deaths described under

paragraph (g)(2) of this section, the hospital must
report the following information to CMS by
telephone, facsimile, or electronically, as
determined by CMS, no later than the close of
business on the next business day following
knowledge of the patient's death:
(i) Each death that occurs while a patient is in
restraint or seclusion.
(ii) Each death that occurs within 24 hours
after the patient has been removed from restraint
or seclusion.
(iii) Each death known to the hospital that
occurs within 1 week after restraint or seclusion
where it is reasonable to assume that use of
restraint or placement in seclusion contributed
directly or indirectly to a patient's death,
regardless of the type(s) of restraint used on the
patient during this time."Reasonable to assume"
in this context includes, but is not limited to,
deaths related to restrictions of movement for
prolonged periods of time, or death related to

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 28 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 213 Continued From page 28 A 213

chest compression, restriction of breathing or
asphyxiation....

(3) The staff must document in the patient's

medical record the date and time the death was:
(i) Reported to CMS for deaths described in
paragraph (g)(1) of this section; or ....

This STANDARD is not met as evidenced by:

Based on interview and record review, the facility
failed to report the death of one of one patient's
(P-1) reviewed for death in restraints after being
physically restrained by manual hold on 4/4/2024
to the Regulatory Authority by the end of the next
business day 4/5/2024. Findings include:

On 5/20/2024 at 1155 during the opening

conference it was revealed that the facility had
failed to report the death of P-1 after being
physically restrained by manual hold to the
Regulatory Authority. Staff A, the Chief Operating
Officer was asked if there had been any patient
deaths related to restraint. Staff C, the Director of
Operations stated, "Yes and that was reported to
your office." Staff C was asked to provide
documentation that was provided to the
Regulatory Authority. Staff A stated, "We received
an email in response to a request from (name) in
your office...I can show it to you."

At 1400 on 5/20/2024, staff A provided an email

with instructions and a hyperlink to report death of
a patient related to restraint use. The hyperlink
was shown to navigate directly to the CMS site to
provide information from the reporting facility.
Staff A stated he had provided and forwarded the
information to staff C for reporting purposes.

At 1420 on 5/20/2024, staff C was asked if she

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 29 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 213 Continued From page 29 A 213

had used the information provided by staff A in
order to report the death of P-1 to the Regulatory
Authority. Staff C stated, "This doesn't look like
the site I went to... I actually Googled the form
and filled it out and sent it to ORR (Office of
Recipient Rights) for the State of Michigan and to
MDHHS (Michigan Department of Health and
Human Services). Staff C was queried if she had
followed up with the Regulatory Authority to
confirm receipt of the submission. Staff C stated,
"No... I didn't think it was necessary."

On 5/20/2024 at 1525 a record review occurred of

the policy titled, "Restraint/Seclusion -
Behavioral," Number BMD-R-5, last revised
06/15/2023. According to the policy under subtitle
Procedure, it states, "22. Any death of a
Recipient/patient that occurs while in restraints or
seclusion or where it is reasonable to assume the
death is a result of being in restraints or seclusion
shall be reported to the department manager.
The Recipient/patient's condition prior to death
and the category of restraints used within the last
7 days will be reported to the CMS regional office
by the next business day following the
Recipient/patient's death. Staff must document in
the Recipient/patient's medical record the date
and time the death was reported to CMS."

On 5/21/2024 at 0945 a record review occurred of

P-1 medical record. The medical record for P-1
failed to have documentation of reporting of the
death to CMS. Staff D, the Director of Nursing
confirmed the finding.
A 395 RN SUPERVISION OF NURSING CARE A 395
CFR(s): 482.23(b)(3)

A registered nurse must supervise and evaluate

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 30 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 395 Continued From page 30 A 395

the nursing care for each patient.

This STANDARD is not met as evidenced by:

Based on interview and observation, the facility
failed to follow standards of care for wound care,
and failed to follow a physician's verbal orders for
one of one patients (P-15) resulting in less than
optimal patient outcomes. Findings include:

On 5/22/2024 at 1500 during an interview with

P-15 it was revealed P-15 had two open wounds
approximately one half inch by one quarter inch
on the right palm of his hand. P-15 stated he
obtained the wounds during an altercation with a
staff member. P-15 dressing was not adhered to
the skin and stated, "It really hurt after they
cleaned it with alcohol." The wounds were
visualized and appeared the epidermal layer (top
layer of skin) was missing with the dermis (middle
layer of skin) exposed. P-15 was queried how
the wound was cleansed and he stated, "They
had me rinse it with water because it was
bleeding then they wiped it off with alcohol
pads...It really stung and hurt."

On 5/22/2024 at 1520 an interview was

conducted with staff Q, the charge nurse for the 5
South unit. Staff Q was queried if alcohol was
appropriated to clean out a wound. Staff Q stated,
"No." After the interview staff Q communicated to
staff BB, RN that P-15 dressing needed to be
changed. Staff BB went to the medication room
and returned with gloves and alcohol wipes. Staff
BB was queried what the alcohol wipes were
needed for in a dressing change. Staff BB stated,
"to clean the wound." Staff BB was then queried if
alcohol wipes were used for wound care. Staff BB
stated, "Yes."

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 31 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 395 Continued From page 31 A 395

On 5/22/2024 at 1525 an interview was
conducted with staff D, the Director of Nursing.
Staff D was asked if alcohol should be used for
wound care. Staff D stated, "No."

On 5/22/2024 at 1600 an interview was

conducted with staff G, the Medical Director. Staff
G was asked if he had seen P-15. Staff G stated,
"Yes...I just saw him...He was in an altercation."
Staff G was queried if he had seen P-15 right
hand. Staff G stated, "Yes... I ordered the staff to
clean the wound with soap and water and to
place antibiotic cream on the wounds then to
apply a dressing." Staff G was then queried if he
had ordered alcohol to be used to wipe the
wound. Staff G stated, "No...that is not what I
ordered."
A 750 INFECTION CONTROL SURVEILLANCE, A 750
PREVENTION
CFR(s): 482.42(a)(3)

The infection prevention and control program

includes surveillance, prevention, and control of
HAIs, including maintaining a clean and sanitary
environment to avoid sources and transmission of
infection, and addresses any infection control
issues identified by public health authorities; and
This STANDARD is not met as evidenced by:
Based on observation, interview, and record
review, the facility failed to keep medication
refrigerators clean, resulting in the potential of
contamination of medications and poor patient
outcomes for all patients requiring refrigerated
medications. Findings include:

On 05/20/2024 at 1125, during at a tour of 5

South patient care area, in the medication room
with Staff S, (pharmacy technician) present, the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 32 of 33
 PRINTED: 11/19/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
230013 B. WING _____________________________
05/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

461 W HURON ST
PONTIAC GENERAL HOSPITAL
PONTIAC, MI 48341

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

A 750 Continued From page 32 A 750

medication refrigerator contained brownish frozen
substance on the top shelf and scattered
throughout the refrigerator. On the refrigerator
shelf, there was an unlabeled plastic container
with a dark green substance inside. On the
bottom and walls of the refrigerator, multiple
brownish stains were present.

On 05/20/2024 during an interview with staff S at

1130, she stated the day before she took a
picture of a soda can that exploded on the
refrigerator door shelf, and she informed the
nurse.

On 5/21/2024 a record review occurred of the

policy titled, "Medication Storage," dated 10/2023.
According to the policy it states, "Drug Supplies
shall be stored under proper conditions of
sanitation, temperature, light, and humidity to
comply with the manufacturer's
recommendations." During an interview with staff
T, the Director of Pharmacy it was confirmed the
facility failed to follow the policy.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BHLY11 Facility ID: 630110 If continuation sheet Page 33 of 33