DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
231521 A. BUILDING __________
B. WING ______________ 		10/17/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
MCLAREN HOSPICE 1515 CAL DRIVE, DAVISON, MI, 48423
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
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 reverse for further 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
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0517      
37411 Based on record review and interview, it was determined that the agency failed to oversee the patients right to be free from physical abuse in 1 of 3 records reviewed (MR# 3), which resulted in potential harm by the agency staff. Findings include: **Agency policy, "Hospice Patient Bill of Rights 1-014.1 3/4/19 stated, " ...The Patient Bill of Rights statement that defines the right of the patient to: ...H. Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries from unknown source, and misappropriation of patient property." MR#3: The Start of Care (SOC) was dated 7/29/19. The Plan of Care (POC) identified terminal diagnoses of Alzheimer's. The patient resides at a skilled nursing facility (SNF). On 10/17/19 at 9:08 am, SNF Staff-J was interviewed by this surveyor regarding the allegation that Staff-I was abusive toward the patient. SNF Staff-J confirmed the prior statement and stated, "I was cleaning dishes off the tables when Staff-I walked into the dining area. I then heard the patient say, "give me that" which caught my attention and then I observed Staff-I trying to take the silverware from the patient. Staff-I then tossed the silverware and napkin towards the patient with the napkin hitting the patient in the face, then Staff-I quickly stormed out of the dining area. I then walked up to the patient who stated, "she threw that at me." I then informed SNF Admin-B, who was also in the dining area but was out of direct view of the incident, that it had occurred and pointed out Staff-I who was walking away down the hallway." It was inquired where the silverware went, SNF Staff-J replied, "It was still on the table." Admin-A was asked on 10/17/19 at 10:30 am if Hospice management were aware of this incident and she replied, "Yes and there is an internal investigation of the incident currently underway .....we have not yet reached a conclusion as to the degree of seriousness Staff I's actions represent." Staff-I provided a written statement of the allegation for an internal investigation of the allegation by the hospice agency of the Hospice aide on 10/3/19. The statement included the following, "I noticed that client did not have salad dressing on her salad, so I got salad dressing and put it on her salad. Client mixed salad with knife. I used a fork and offered client a bit of desert, client turned head. So I set the fork down back in the desert, I removed the knife from the client and placed a fork on her plate. Client became upset and threw fork. Stated, give that back." Turned and left dining room to deescalate situation." (sic) The hospice failed ensure the patient was free from mistreatment.