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Based on document review and interview, it was determined that the facility failed to ensure that the medical bylaws rules and regulations were implemented in one (1) of two (2) medical records (MR) of patients being transferred for evaluation at an acute care hospital (MR #28).

Findings include:

Reference: Facility Bylaws Rules and Regulations state, "... E. Admission of Patients ... 5. Patients returning from other facilities after receiving medical care other than planned consult) [sic] should be evaluated on arrival. A progress note should be entered and medication reconciliation done ... G. Patient Transfer 1. Each patient transferred to another facility shall have a physician's order and progress note detailing the transfer and purpose. This note should be entered before transfer."

1. Medical Record #28 was reviewed. Patient #28 was transferred to an acute care hospital on 10/12/18. A physician telephone/verbal order to transfer the patient was present in the medical record. The patient returned from the hospital on the evening of 10/14/18.

a. There was no evidence of a progress note by a physician or authorized prescriber detailing the transfer and purpose.

b. There was no evidence that the patient was evaluated on arrival from the acute care hospital. A progress note was entered in the medical record the next day, on 10/15/18. The medication reconciliation was completed via telephone/verbal order on 10/14/18.

c. The above was confirmed by Staff #4.

Based on facility document review and staff interview, it was determined that the facility failed to ensure it has a mechanism to evaluate the quality of each contracted service, and ensures that each contracted service is provided in a safe and effective manner.

Findings include:

1. On 12/13/18, the facility's QAPI (Quality Assessment and Performance Improvement) was reviewed in the presence of Staff #1 and Staff #7. Staff #1 stated he/she was unsure if the facility does QAPI activities on its contracted services.

a. Documented evidence in the QAPI meeting minutes reflect that the contracted services of laboratory and pharmaceutical services submit self analysis data for each service to the facility.

2. There was no evidence that the facility performs it's own analysis of each contracted service to ensure the services are provided in a safe and effective manner.

3. Staff #1 and Staff #7 confirmed the above.

Based on review of medical records, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure that all patient rights are protected and promoted.

Findings include:

1. The facility failed to ensure the notice of rights requirements are met. (Cross refer to Tag A 116, Tag A 118, Tag A 132)

2. The facility failed to ensure all patients are included in the development and implementation of his/her plan of care. (Cross refer to Tag A130)

3. The facility failed to ensure that patients had the right to receive care in a safe setting. (Cross refer to Tag A 144)

Based on observation and staff interview, it was determined that the facility failed to ensure a summary of the patients' rights is posted conspicuously in the patient's room and in public places throughout the hospital.

Findings include:

1. On 12/10/18, Unit 1 South was toured in the presence of Staff #8. A summary of the patients' rights was not posted in the patient rooms or conspicuously on the unit.

2. On 12/12/18, Unit 2 Center was toured in the presence of Staff #27. A summary of the patients' rights was not posted in the patient rooms or conspicuously on the unit.

a. Staff #27 confirmed the above.

A. Based on review of the facility's Patient Admission Handbook, it was determined that the summary of the patient's rights does not include the phone number and address for lodging a grievance with the State agency.

Findings include;

1. On 12/12/18 on Unit 2 Center, Staff #27 provided a copy of the Patient Admission Handbook that is given to patients. Review of the handbook lacked evidence of the phone number and address for lodging a grievance with the State agency.

B. Based on observation, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure that data collected regarding patient grievances and complaints is incorporated into the hospital's Quality Assessment and Performance Improvement Program (QAPI) program.

Findings include:

Reference: Facility Policy Number: 105.1, Subject: "Patient Complaints/Grievances" states, "... PROCEDURE ... 13. The Client Services Representative will document and maintain data regarding patient complaints and grievances. 14. The complaint and grievance data will be reported to the --[facility's initials]-- Divisional Quality Committee and Quality Council for review and incorporation into the Quality Assessment and Performance Improvement Program."

1. On 12/13/18, the facility's QAPI meeting minutes were reviewed. The meeting minutes lacked evidence of review and trending of grievances and complaints.

2. Staff #38 confirmed during interview that he/she does not report complaints and grievances into QAPI, and does not review them for trends.

A. Based on review of 4 of 4 medical records, it was determined that the facility failed to ensure that patient's have a right to be informed of, and participate in, decisions about their treatment.

Findings include:

Reference: Facility policy "Recovery Planning" states, "Policy Recovery planning is crucial to successful treatment. The recovery plan reflects the organization's treatment philosophy. All patients, and when appropriate patients' families, have a right to be informed of, and participate in, decisions about treatment ... Procedure: 1. Recovery planning identifies care and services appropriate to the individual's specific needs and the severity of condition, impairment, or disability."

1. Patient #26 was admitted to the facility on 10/23/18. The Comprehensive Team Recovery Plan Meeting initially met on 10/29/18 and subsequently met to update the patient's progress on 11/5/18, 11/13/18, 11/20/18, 11/26/18 and 12/3/18. There was no evidence that the patient was included, participated, refused or was unable to participate, or that he/she was informed of, if any, changes in the plan of care.

2. Patient #17 was admitted to the facility on 11/8/18. The Comprehensive Team Recovery Plan Meeting met on 11/9/18. Although the Comprehensive Treatment Plan form was signed by the patient, it lacked documentation of a plan of care, or whether a plan was verbally discussed with the patient or attempted or that the patient was unable to participate.

a. A Comprehensive Treatment Plan Revision was conducted on 11/14/18. There was no evidence that the patient was informed of any changes in the plan of care that he/she was a part of.

3. Patient #28 was admitted to the facility on 10/5/18. The Comprehensive Team Recovery Plan Meeting met on 10/8/18 and subsequently met to update the patient's progress on 10/12/18, and 10/26/18. There was no evidence that the patient was included, participated, refused or was unable to participate or that he/she was informed of, if any, changes in the plan of care.

4. Patient #20 was admitted on to the facility on 10/1/18. The Comprehensive Team Recovery Plan Meeting met on 10/8/18 and subsequently met to update the patient's progress on 10/15/18. There was no evidence that the patient was included, participated, refused or was unable to participate or that he/she was informed of, if any, changes in the plan of care.



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B. Based on review of the facility's Patient Admission Handbook, it was determined that the summary of the patient's rights does not include information regarding the patient's right to participate in the development of his/her discharge plan.

Findings include:

1. On 12/12/18 on Unit 2 Center, Staff #27 provided a copy of the Patient Admission Handbook that is given to patients. Review of the handbook lacked evidence of information related to the development and implementation of a discharge plan.

Based on review of the facility's Patient Admission Handbook, it was determined that the summary of the patient's rights does not include information regarding the patient's right to formulate an advance directive.

Findings include:

1. On 12/12/18 on Unit 2 Center, Staff #27 provided a copy of the Patient Admission Handbook that is given to patients. Review of the handbook lacked evidence of information related to advance directives or the facility's life-saving methods.

Based on observation and staff interview, it was determined that the facility failed to ensure patients receive care in a safe setting.

Findings include:

1. During a tour of the facility on 12/13/18, 10 out of 10 patient sleeping rooms on unit 1-North lacked tamper-resistant screws.

a. During an interview, Staff #39 confirmed most of the screws for the door hardware lacked tamper-resistant screws.

2. During a tour of Unit 1-North, hinged closet doors were still attached to built in closets which pose a ligature point.

3. During a tour of Unit 1-North, night stands next to patient beds had drawers that pull out and become a possible ligature point.

4. During interview, Staff #39 stated the hospital was in the process of removing hinged closet doors. No timeline was provided.


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5. During a tour of Unit 1 South on 12/10/18, it was noted that in several patient rooms, medical beds had electric cords and hardware which pose a ligature risk.

6. During a tour of Unit 1 North on 12/11/18, in the presence of Staff #16, in Room 167, a medical bed was noted to have electric cords and hardware which pose a ligature risk.

7. Staff #13 indicated that the hospital had ordered new beds.

Based on document review and interview, it was determined that the facility failed to ensure that the incident reporting policy is implemented.

Findings include:

Reference: Facility policy, "Incident Report" states, "Policy All incidents involving patients ... are to be reported on the Incident Report Form ... An incident includes the following: ...
(3) Any altercation between (among) patients and ... including abuse of of [sic] any kind ...
Procedure Patient Incident: ... 9. The completed report will be forwarded to BHS Administrative Director of Nursing Services within 24 hours of the incident."

1. On 12/11/18 and 12/12/18, Patient #18 reported to surveyors that on 12/5/18, he/she was "sexually assaulted." Patient #18 stated a male patient grabbed his/her buttocks three (3) times, then came to his/her room and asked him/her to service him/her.

a. Review of the medical record confirmed documentation of the inappropriate sexual behavior by a male patient.

b. Request for an incident report was made twice by the surveyor. Staff #3 and Staff #4 indicated that one had not been done.

Based on QAPI (Quality Assessment and Performance Improvement) program document review and staff interview, it was determined that the facility failed to ensure that interventions identified for improvement projects are evaluated for success in one (1) of three (3) quality improvement projects reviewed.

Findings include:

1. On 12/13/18, a facility quality improvement project to increase patient attendance at group therapy meetings was reviewed in the presence of Staff #1, Staff #7, and Staff #42. Interventions identified included serving coffee at the 2 PM group meeting, provision of certificates of attendance (Rock Star/Shining Star Certificates), and therapist one to one patient meetings for encouragement and education.

2. There was no evidence that each of the interventions was evaluated for success in increasing the patient attendance at group meetings.

a. Staff #42 confirmed that each intervention is not evaluated for success, and he/she could not be sure if any of the interventions has lead to an increase in patient attendance in group meetings. Staff #42 stated the attendance has been at a steady percentage rate.

Based on facility document review and staff interview, it was determined that the facility failed to ensure it implements preventive actions and mechanisms that include feedback and learning throughout the hospital, in two (2) out of three (3) QAPI (Quality Assessment and Performance Improvement) cases reviewed.

Findings include:

1. On 12/13/18, the facility's QAPI was reviewed. The facility could not provide evidence of implementation of two (2) action items as follows:

a. Review of Case #2 identified as an action item, revising and updating the close Observation form to capture that patients with walker or wheelchair assistive devices, have these assistive devices accounted for/ with the patient. There was no evidence provided to indicate the close Observation form was revised and/or updated.

(i) Staff #7 confirmed the above.

b. Review of Case #3 identified as an action item, to review with the medical providers the medications requiring therapeutic levels, and to reinforce the ordering of those levels at appropriate times. There was no documented evidence of this action item's completion.

(i) On 12/14/18 at 1:50 PM, Staff #7 stated during interview, that the Medical Director discussed this at a Department of Psychiatry meeting, but there were no meeting minutes recorded/documented.

Based on medical record review, staff and patient interview, and review of facility documentation, it was determined that the facility failed to have an organized nursing service.

Findings include:

1. The facility failed to ensure staffing for assistive personnel was in accordance with the facility staffing plan. (Cross refer to Tag A 392)

2. The facility failed to ensure that nursing staff are assessing, coordinating, documenting, and evaluating the care of each patient. (Cross refer Tag 395)

3. The facility failed to ensure that treatment plans are developed in an interdisciplinary manner. (Cross refer to Tag A 396)

4. The facility failed to ensure that medications are administered in accordance with prescriber's order and documented in accordance with facility policy. (Cross refer to Tag A 405)

Based on document review, it was determined that the facility failed to ensure that the staffing plan policy is implemented.

Findings include:

Reference: Facility policy "Staffing Plan" states, " ... Procedure ... a staffing plan has been established based upon census acuity and skill mix of the staff.
NBHH staffs all units at a 5:1 ratio on day and evening shift and 8:1 on night shift ...
Each unit is staffed with at least (2) Registered Nurses on Day Shift and Evening Shift and (1)-(2) Registered Nurses on Night Shift. Each unit is staffed by at least (3) PA [psychiatric assistants] staff on Day Shift and Evening Shift and (2) on Night Shift ... Staffing adjustments are made each day considering: 1 to 1 observation levels ..."

1. Review of the Direct Nursing Staffing Form from 11/25/18 to 12/8/18 revealed the following staffing shortage:

a. On 11/25/18, 11:00 PM to 7:00 AM shift, 1C unit, Census 25, 1 patient on 1:1. There was 1 Registered Nurse (RN), and 2 PAs. There should have been 3 PAs instead of 2.

b. On 11/25/18, 11:00 PM to 7:00 AM shift, 1N unit, Census 25. There was 1 RN and 1 PA. There should have been 2 PAs instead of 1.

c. On 11/25/18, 3:00 PM to 11:00 PM shift, 2C unit, Census 25, 1 patient on 1:1. There were 2.5 RNs and 2 PAs. There should have been 3.5 PAs instead of 2.

d. On 11/25/18, 11:00 PM to 7:00 AM shift, 2N unit, Census 25, 1 patient on 1:1. There were 1 RN and 2 PAs. There should have been 3 PAs instead of 2.

e. On 11/26/18, 7:00 AM to 3 PM shift, 1C unit, Census 25, 1 patient on 1:1. There were 2 RNs and 3 PAs. There should have been 4 PAs instead of 3.

f. On 11/26/18, 7:00 AM to 3 PM shift, 2C unit, Census 25, 1 patient on 1:1. There were 2 RNs and 3 PAs. There should have been 4 PAs instead of 3.

g. On 12/3/18, 3:00 PM to 11:00 PM shift, 2C unit, Census 25, 1 patient on 2:1 (2 staff members to 1 patient). There were 2 RNs, .5 LPN (licensed practical nurse) and 3.5 PAs. There should have been 5 PAs or other staff instead of 4.

h. On 12/6/18, 11:00 PM to 7:00 AM shift, 1N unit, Census 25. There were 1 RN and 1.5 PAs. There should have been 2 PAs instead of 1.5.

i. On 12/6/18, 7:00 AM to 3:00 PM shift, 2N unit, Census 25. There were 2 RNs and 2 PAs. There should have been 3 PAs instead of 2.

j. On 12/7/18, 7:00 AM to 3:00 PM shift, 2N unit, Census 25, 1 patient on 1:1. There were 2 RNs and 3 PAs. There should have been 4 PAs instead of 3.

A. Based on document review, it was determined that the facility failed to ensure that coordination of patient care and documentation is in accordance with the Nursing Observation Levels policy.

Findings include

Reference: Facility policy "Observation Levels" states, " ... Documentation for 1:1 [one-to-one] ...
2. Renewal orders for 1:1 observation shall be written at least every 24 hours by the attending Physician/APN after a face-to-face assessment of the patient ...
4. The treatment team shall meet within 24 hours of a patient being placed on 1:1 observation, although this may occur on the next working day if the patient is placed on 1:1 observation during a holiday or weekend. The treatment team shall write a team note and document the interventions being provided by each discipline in the patient's treatment plan. The interventions provided by each discipline must address goals and objectives that conform to the exit criteria for the discontinuation of 1:1.
5. ... Treatment teams shall address the behavior(s) that require ongoing 1:1 observation by reviewing and revising the treatment plan as needed and documenting the patient's response in a team note at least every 72 hours.
6. The RN must assess the patient at least every two hours, collaborating with the assigned staff, and monitoring the 15-minute observation recordings and signing off on the Special Observation Flow Sheet.
7. An order is required to discontinue, modify, or renew a Special Observation Status."

1. The medical record of Patient #17 indicated a physician order dated 11/11/18 for "1:1 Eye Contact at all times for sexually inappropriate behavior and aggressive behavior."

a. Upon review, the Special Observation Flow Sheet revealed that the patient was kept on 1:1 observation until 11/14/18 at 16:15 (4:15 PM) upon modification of the order. There was no evidence of a daily physician order renewal for a 1:1 observation for 11/12/18, 11/13/18 and 11/14/18.

b. Upon review, the Comprehensive Treatment Plan Revision form dated 11/12/18 lacked evidence of a team note and interventions being provided by each discipline in the patient's treatment plan related to the patient being placed on 1:1 observation on 11/11/18. There was no evidence of a 72 hours team note documenting the patient's response.

c. Upon review, the Special Observation Flow Sheet beginning 11/11/18 at 11:45 AM until 11/14/18 at 4:15 PM lacked evidence that the nurse assessed the patient at least every two hours.

B. Based on document review, it was determined that the facility failed to ensure that nursing staff assessed, evaluated and provided a full and accurate description of the care provided to the patient including an evaluation of the patient's response to treatment.

Findings include:

Reference: Facility policy, "Nursing Documentation Requirements" states, "... Procedure ... Incidents/Events:
Incidents and events will be recorded. Observation and assessment of patient's responses to treatment/interventions will be documented accurately and completely using the PIE format."

1. On 12/12/18, Medical Record #16 was reviewed and revealed the following:

a. On 12/2/18 at 1200, the Medication Administration Record (MAR) indicated that the patient was administered Epi Pen 1 dose. The Nursing Patient Notes at 1346 indicated that the patient reported mild signs/symptoms of an allergic reaction to fish, but no description of symptoms was documented to justify the administration of the Epi Pen. Although the note states that vital signs were taken, there was no evidence of documentation of any vital signs.

b. A telephone order dated 12/7/18 at 1300 stated, "Benadryl 50 mg. (milligrams) IM (intramuscular) allergic reaction. One time order Epinephrine Pen if symptoms persist."

(i) On 12/7/18 at 1500, the MAR (medication administration record) indicated that the patient was administered Benadryl 50 mg IM for an allergic reaction, two hours after the order was received. Furthermore, the administration of Benadryl was documented in the MAR under the order dated 11/29/18 for "Benadryl 50 mg. IM every six hours as needed for EPS [extra pyramidal syndrome]."

(ii) The nursing Patient Note at 1754 indicated the patient complained of an allergic reaction. There was no evidence of a description of the symptoms displayed by the patient or the time the reaction occurred.

(iii) The nursing Patient Note also included at 1754, the administration of an Epi Pen at 1715 because of the ineffectiveness of Benadryl. There was no evidence of a description of the symptoms displayed by the patient prior to the Epi Pen administration. There was no reassessment of the effectiveness of the Epi Pen.

c. The nursing Patient Note dated 12/7/18 at 2245 stated that Benadryl 50 mg. by mouth was administered for "c/o [complaint of] EPS [extra pyramidal syndrome], client had an allergic reaction earlier in the day. Client stated, "I feel better."

(i) There was no documentation in the nursing notes or on the medication administration record of the specific signs and/or symptoms exhibited by the patient necessitating the administration of the medication.

Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure all recovery plans are developed in an interdisciplinary manner in accordance with facility policy and procedure, in five (5) of seven (7) medical records reviewed for care planning (Medical Records #17, #20, #22, #23, #27).

Findings include:

Reference: Facility Policy Number: 135, Subject: "Recovery Planning" states, "... Procedure ... 4. Qualified and competent individuals plan and provide care and services specific to the individual's needs and, as appropriate to the care and services given, in a collaborative and interdisciplinary manner. At a minimum the recovery team consists of the physician, nurse, social worker, and adjunctive therapist. Other support services staff such as dietician, Physical Rehab Therapist, or Pharmacist attends recovery planning meetings at the discretion of the psychiatrist. ... 6. A Comprehensive Recovery Plan ... shall be completed within 5 days and no later than 7 days of admission. ..."

1. On 12/12/18, Two Center was toured in the presence of Staff #27. Staff #36 stated during interview that the interdisciplinary team meets everyday and determines which patients are newly admitted and which patients' care plan is due for completion. He/She stated the care plan is usually completed within 72 hours by the interdisciplinary team.

2. Medical Record #22 was reviewed. Patient #22 was admitted 11/12/18, and his/her initial comprehensive treatment plan was completed on 11/19/18. The treatment plan lacked evidence that the physician provider and the social worker were in attendance at the interdisciplinary meeting on 11/19/18 to develop the patient's treatment plan.

a. The physician provider signed the comprehensive treatment plan on 11/26/18, one week after the interdisciplinary team meeting was held.

b. The social worker signed the comprehensive treatment plan on 11/20/18, the day after the interdisciplinary team meeting was held.

3. Medical Record #23 was reviewed. Patient #23 was admitted 11/17/18, and his/her initial comprehensive treatment plan was completed on 11/22/18. The treatment plan lacked evidence that the physician provider was in attendance at the interdisciplinary meeting on 11/22/18 to develop the patient's treatment plan.

a. The physician provider signed the comprehensive treatment plan on 11/24/18, two (2) days after the interdisciplinary team meeting was held.

4. The above was reviewed with Staff #27.


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5. Medical Record #27 was reviewed. Patient #27 was admitted on 10/23/18, and his/her initial comprehensive treatment meeting plan was held on 10/29/18. The treatment plan lacked evidence that the physician provider and the social worker were in attendance at the interdisciplinary meeting on 10/29/18 to develop the patient's treatment plan.

a. The physician provider signed the comprehensive treatment plan on 10/30/18, the day after the interdisciplinary team meeting was held.

b. The social worker signed the comprehensive treatment plan on 10/31/18, two (2) days after the interdisciplinary team meeting was held.

6. Medical Record #20 was reviewed. Patient #20 was admitted on 10/1/18, and his/her initial comprehensive treatment meeting plan was held on 10/8/18. The treatment plan lacked evidence that the physician provider was in attendance at the interdisciplinary meeting on 10/8/18 to develop the patient's treatment plan.

a. The physician provider signed the comprehensive treatment plan on 10/10/18, two (2) days after the interdisciplinary team meeting was held.

7. Medical Record #17 was reviewed. Patient #17 was admitted on 11/8/18, and his/her initial comprehensive treatment meeting plan was held on 11/9/18. The treatment plan lacked evidence that the social worker was in attendance at the interdisciplinary meeting on 11/9/18 to develop the patient's treatment plan.

A. Based on document review and staff interview, it was determined that the facility failed to ensure that medications are administered in accordance with prescriber's order and documented.

Findings include:

Reference: Facility policy, "Medication Administration and Use: Medication Charting" states, "... Procedure:
General Information 1. The nurse administering a medication is responsible for charting the administration ...
Changing Medication Orders ...
2. Medication given on an "as needed" basis (PRN shall be recorded in the appropriate section of the MAR in the usual manner ... In addition ... the following should also be noted either in the nurse's notes or the appropriate section of the MAR: The patient's subjective complaints or symptoms ... The results of the administration of the medication."

1. On 12/11/18, the medical record of Patient #14 was reviewed and revealed the following:

a. A physician order, dated 11/23/18, stated to give Keflex 500 mg. (milligrams) 1st dose now by mouth every 6 hours for 7 days for cellulitis.

(i) The first now dose of Keflex 500 mg. was administered at 11:00 AM on 11/23/18, as per the medication administration record. The second dose was administered at 12:00 PM on 11/23/18. There was no evidence that the second dose of Keflex that was administered at 12:00 PM was cleared by the physician.

b. There was no evidence that at midnight and 6:00 AM on 11/24/18 and at midnight on 11/30/18, the patient was administered Keflex, as ordered.

c. As per nursing note documentation, on 12/4/18 at 1630, the patient was administered Benadryl 50 mg (milligrams) intramuscular (IM) and Thorazine 100 mg IM. Upon review, the medication administration record (MAR) lacked evidence of the medication administration.

d. The above was confirmed by Staff #13.

e. A PRN (as needed) medication in the MAR included an entry that the patient was administered Benadryl 50 mg. IM for EPS (extra pyramidal syndrome) on 12/4/18.

(i) There was no documentation in the nursing note or the MAR of the specific sign/symptoms exhibited by the patient necessitating the administration of the medication or its effectiveness.

2. Review of Medical Record #27 revealed the following:

a. A physician order dated 10/23/18 for Novolin R FSBS (finger stick blood sugar) twice daily with coverage, was not documented in the medication administration record (MAR) as being performed on 11/9/18 and 11/10/18 at 6:30 AM and on 11/9/18 and 11/19/18 at 4:00 PM. There was no evidence that the patient refused.

b. A physician order dated 10/23/18 for Atorvastatin 10 mg one table by mouth at bedtime was not documented in the MAR as being administered on 11/20/18, 11/26/18 and 12/6/18 at 2100 (9:00 PM). There was no evidence that the patient refused.

c. A physician order dated 10/23/18 for Cogentin 0.5 mg. 1 tablet by mouth at bedtime was not documented in the MAR as being administered on 11/20/18, 11/26/18, 11/30/18 and 12/16/18 at 2100 (9:00 PM). There was no evidence that the patient refused.

d. A PRN medication in the MAR included an entry that the patient was administered Cogentin 1 mg. for EPS (extra pyramidal syndrome) on 11/11/10 at 1620 (4:20 PM). The nursing Patient Notes indicated the reason: "Given with standing order of Haldol for EPS."

(i) There was no documentation in the nursing note or the MAR of the specific sign/symptoms exhibited by the patient necessitating the administration of the medication, or a verbal order by the physician.


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B. Based on staff interviews and document review, it was determined that the facility failed to ensure that orders for controlled substances are documented in the medical record.

Findings include:

1. On 12/12/18, review of Medical Record #10, contained a Pharmascript Pharmacy Control (CII through CV) Prescription Form that stated, "Oxycodone 30 mg tab (milligram tablet), 1 tab one dose only, STAT (immediately), Quantity 1 (one), Prescriber signature, Date: 12/10/18." On this form is was noted that it was faxed to the pharmacy on 12/10/18, with staff initials.

a. Review of the Physician's Order forms in Medical Record #10 indicated no evidence of documentation of a physician's order on 12/10/18 for one (1) dose of Oxycodone 30 mg.

b. Staff # 27 confirmed this finding.

Based on medical record review and review of facility policy, it was determined that the facility failed to ensure all verbal/telephone orders are countersigned in writing in accordance with facility policy, in five (5) of six (6) medical records reviewed (Medical Records #2, #3, #17, #27, #28).

Findings include:

Reference #1: Facility Policy Number: NCP 24, Subject: "Verbal or Telephone Orders," Policy "A licensed nurse accepts verbal/telephone orders. The Physician/Advanced Practice Nurse (APN) must countersign all orders within 24 hours of their issuance. ..."

Reference #2: The facility's Medical Staff Rules and Regulations state, "... L. MEDICAL RECORD ... 3. ... An order shall be considered to be in writing if dictated to a registered nurse via telephone. a. Orders dictated to a registered nurse over the telephone (i.e. telephone orders) shall be signed, dated and timed by the person to whom the the order was dictated and shall indicate in writing the authorized prescriber dictating the orders. Theses orders shall be signed, dated and timed by an authorized prescriber within twenty-four (24) hours of issuance. ..."

1. In Medical Record #28, a telephone order dated 10/21/18 at 2100 to increase Levemir Insulin to 35 units every morning was not countersigned by a physician or an authorized prescriber, as of 12/10/18.

2. In Medical Record #17, a telephone order dated 11/9/18 at 1745 to discontinue previous Lasix order and to start Lasix 20 mg [milligram] po [by mouth] daily was countersigned by someone [illegible] on 11/11/18 at 1:00 PM, two (2) days after the initial order.

3. In Medical Record #27, a telephone order dated 11/8/18 at 2300 for every 15 minute checks for aggressive behavior was countersigned by the physician on 11/14/18, six (6) days after the initial order.


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4. On 12/10/18 on Unit 1 South, the following verbal/telephone orders were evident:

a. In Medical Record #2, a telephone order dated 12/6/18 at 1640 to discontinue Clozaril and repeat a CBC [complete blood count] in the morning. There was no physician or APN (Advanced Practice Nurse) countersignature.

b. In Medical Record #3:

(i) A telephone order dated 11/14/18 at 0515 to administer Ativan 1 milligram (mg) Intramuscular (IM) now, and Thorazine 50 mg IM now for severe agitation. There was no physician or APN countersignature.

(ii) A verbal order dated 11/23/18 at 1030 to discontinue close observation and start unit privileges, was countersigned three (3) days after the initial order on 11/26/18 at 1020.

Based on observation, staff interview, and document review, it was determined that the facility failed to ensure that all information necessary to monitor the patient's condition is recorded in the medical record, according to practitioner's orders.

Findings include:

1. On 12/18/18, Medical Record #16 was reviewed and revealed the following:

a. The Physician's Admission Order Sheet states, "Vital signs (T [temperature], P [pulse], R [respirations], BP [blood pressure]) BID [twice daily]."

(i) Vital signs were not completed twice daily as ordered on the following dates: 12/2/18, 12/7/18, 12/8/18, and 12/10/18.

2. This finding was confirmed by Staff # 4.

Based on observation, staff interviews and document review, it was determined that the facility failed to ensure that vaccines are stored according to acceptable standards of practice.

Findings include:

Reference: The Centers for Disease Control Vaccine Storage and Handling Toolkit, January 2018, https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, states, "...Check and record storage unit minimum and maximum temperatures at the start of each workday... If your device does not display min/max temperatures, then check and record the current temperature a minimum of 2 times (at the start and end of the workday) This should be done even if there is a temperature alarm."

1. On 12/11/18, Flucelvax, influenza vaccine, was found stored in the medication refrigerators on units 1 South, 1 Center, 2 South, and 2 Center.

a. Upon interview Staff #5 and Staff #11 confirmed that the refrigerator temperatures were only monitored and recorded once daily. Proper storage conditions could not be assured.

Based on document review, a tour of the kitchen and lunch meal observations conducted in the presence of Staff #23 and Staff #24, it was determined that the food services department failed to ensure compliance with the New Jersey State Sanitation Code: "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines (Chapter 24)" of the NJ State Sanitary Code NJAC 8:24.

Findings include:

Reference #1: Chapter 24: 8:24-6.5(a) states, "The physical facilities shall be maintained in good repair."

Reference #2: The facility document titled, "Resident Tray Assessment" states, "...Standard of Food on Tray 20 minutes out..Entree 130 degrees Fahrenheit...Milk 41 degrees Fahrenheit..."

Reference #3: Chapter 24: 8:24-3.2(j) states, "Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants."

1. The ceiling in the ware washing area had six (6) tiles with visible grey black discoloration. (Refer to Reference #1)

2. During a lunch meal tray assessment, the following food items were out of facility policy range: (Refer to Reference #2)

a. Entree (Baked Fish) was measured at 156 degrees Fahrenheit on the tray line and 117 degrees Fahrenheit on the Unit once transported.

b. Milk was 49 degrees Fahrenheit on the Unit. Milk is kept on each individual unit, not transported.

3. During transport of the meal trays from the serving area, the following was observed: (Refer to Reference #3)

a. The tray transport cart failed to have insulated tray covers.

b. The apple crisp was served in and covered by a 4 ounce Styrofoam cup.

(i) The cup covering the apple crisp fell off the serving tray into the hallway during transport two times.

(ii) Staff #24 stated that the apple crisp should have been wrapped in plastic covering during transport.

4. The above findings were confirmed by Staff #23 and Staff #24.

Based on observation, document review and staff interview, it was determined that the facility failed to meet patient nutritional needs in accordance with recognized dietary practices.

Findings include:

1. Review of Medical Record #25 revealed that the patient was on a Carbohydrate Counting Diet.

a. A Psychiatry Progress note, dated 12/13/2018 at 1250 PM, states, "...Increased drinking orange ounce, FS [fasting sugar]=306, refusing to cease drinking juice, pt is diabetic + wound on abdomen. ...." [sic]

b. During interview, Staff #24 and Staff #29 stated that the diabetic patients have access to fruit juices on each unit available 24 hours, which causes non compliance with the Carbohydrate Counting Diet.

2. Review of Medical Records #4, #26, #27, #28, #29, #30, #31, and #32 showed that the patients were all on a Carbohydrate Counting Diet, with diagnosis of Diabetes.

a. Eight (8) out of eight (8) patients had access to fruit juices on their units for 24 hours.

b. The facility was unable to provide a method by which the patients total carbohydrate intake was monitored.

3. The above findings were confirmed with Staff #24, and Staff #29.

Based on observation, staff interviews, review of facility documents and manufacturer's instructions for use, it was determined that the facility failed to ensure the overall hospital environment is maintained to ensure the safety and well-being of the patients.

Findings include:

1. On 12/10/18, during a tour of facility, the following was observed:

a. On unit 1 South:

(i) Room M 150, the Soiled Room:

- There was visible build-up of dirt on the floors and on the joining fixture that meets the floor to the wall.

- The sink and the faucet had a visible build-up of residue.

(ii) Room M 108 A- The Pantry:

- The trash can had visible dirt and dried substances on all surfaces of the container and lid.

- There was visible build-up of dirt on the floors and on the joining fixture that meets the floor to the wall.

(iii) Room M 147 - The Medication Room:

- The sink and counter surface had visible dirt and debris on the faucet elements with residue build-up where the grout was missing.

- The floor was visibly dirty and had build-up residue.

b. On 1 Center:

(i) Room M 144 - Medication Room:

- The sink and counter surface had visible dirt and debris on the faucet elements with residue build-up where the grout was missing.

- The floor was visibly dirty and had build-up residue.

(ii) The Utility Room:

- Large amounts of debris and dirt build-up was visible on the floors and on various environmental cleaning equipment.

- The carpet attached to the lower portion of the walls down the units hallways had visible dust build-up.

(iii) Room M 178 - Day Room:

- Visible debris, food particles and dust were visible under the furniture.

- The vinyl-like material that covered the patient seating furniture had visible substance markings.

(iv) Room M 179 - Activity Room:

- The sink, walls and cabinets had build-up of substances on multiple surfaces.

(v) Room M 295 - Central Supply closet:

- There was visible debris on the floor.

c. On 2 South:

(i) In the Soiled Utility Room:

- A spray bottle of liquid air freshener was hanging on the flush-handle of the hopper.

- A filled plastic refill "Shampoo/Body Wash" bag for a patient dispenser was sitting on the inside ledge of the hopper.

(ii) Room M 208 A - The Pantry:

- The garbage can had visible dirt and dried substances on all surfaces of the container and lid.

(iii) Room M 248 - The Medication Room:

- Red/brownish drip-markings were found on the front of the sharps box that was attached to the wall.

Reference #1: EvenCare G2 Blood Glucose Monitoring System, instructions for use (IFUs) states, "Cleaning and Disinfecting Your EvenCare G2 Meter ... The following products are validated for disinfecting the EvenCare G2 Meter: Dispatch Hospital Cleaner Disinfectant Towels with Bleach ... Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning wipes with Alcohol ... Clorox Healthcare Bleach Germicidal and Disinfecting Wipes ... Medline Micro-Kill Bleach Germicidal Bleach Wipes ... Other EPA Registered wipes may be used for disinfecting the EvenCare G2 system, however, these wipes have not been validated and could affect the performance of the meter. ..."

1. On 1 South at 11:10 AM, in Room M 147, the Medication Room, Staff #41, a registered nurse (RN), when questioned, confirmed the glucometer was cleaned and disinfected using CaviWipes.

a. Upon request, the manufacturer's IFUs for the EvenCare G2 blood glucometer was obtained and reviewed in the presence of Staff #5, Staff #8 and Staff #41.

(i) Staff #41 presented the Medline Micro-Kill Bleach Germicidal Bleach Wipes from the overhead cabinet within the medication room and confirmed that the staff were instructed to use the CaviWipes and not the Medline Micro-Kill Bleach Germicidal Bleach Wipes, but was unsure of why.

(ii) Staff #5 confirmed all units in the facility use the same glucometer and therefore, are using the CaviWipes to clean and disinfect the meter.

Reference #2: OSHA 29 CFR Part 1910.1030 ... "Regulated Waste -- 1910.1030(d)(4)(iii)(A)(2)(iii) Replace routinely and not be allowed to overfill ..."

Reference #3: Facility policy titled, "Regulated Medical Waste-Transporter" states, "... Procedure - ... "Sharps Containers" When containers are no more than 2/3 full: 1. Nursing staff will contact Environmental Services for pick-up. ..."

1. On 2 South, in Room M 248, the Medication Room, the sharps container was found with the "Full" safety indicator engaged at the opening and there were no other sharps containers in the medication room available for the staff to use.

2. Staff #5 confirmed the above findings.


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3. During a tour of the facility on 12/12/18 at approximately 10:00 AM, in the presence of Staff #29, the following observations were made:

a. On the 1 North unit, the kitchen pantry drawer was broken. The pantry counter was visibly dirty with the corner and sides of the laminate peeling.

b. On the 1 South unit, the bottom portion of the pantry, used to store juice containers was eroded with visible spillage.

c. On the 2 Center unit pantry room, the baseboards were peeling with visible debris and a gray colored sticky substance on it in several areas.

4. The above findings were confirmed by Staff #14 and Staff #32.


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5. On the mid-morning of 12/11/18 during the tour of 1 North Unit, in the presence of Staff #13, the following was observed:

a. In Room 167, there was dirt on the floor behind the door.

b. In the patient Storage Room, there was visible dust on the floor.

c. In Room 163, the Dining Area, the wall behind the door had cracks in the lower half and was missing the floor molding.

6. The above findings were confirmed by Staff #13.

A. Based on patient interview and observation, it was determined that the facility failed to ensure a sanitary physical environment is maintained.

Findings include:

1. On 12/12/18 at 1:20 PM, Patient #18 asked to speak with this surveyor. Patient #18 reported the showers are filthy.

a. The shower room on Unit Two (2) Center was observed. The second interior shower curtains on all four (4) shower stalls had brownish and light black discoloration on their surfaces.

2. On 12/14/18, the shower room on Unit one (1) Center was observed. The second interior shower curtains on all four (4) shower stalls had brownish and light black discoloration on their surfaces.

a. Staff #1 and Staff #2 confirmed the above.


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B. Based on observation and staff interviews, it was determined that the facility failed to ensure that parenteral medications are prepared according to acceptable standards of practice.

Findings include:

Reference: APIC Position Paper, Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016) states, " ... Preparation of parenteral medications must be performed in a clean, dry work space that is free of clutter and obvious contamination sources (e.g., water, sinks)."

1. On 12/11/18, the medication preparation areas, located inside four (4) out of four (4) medication rooms surveyed on units 2 Center, 1 South, 1 Center, and 2 South, were each immediately adjacent to a sink.

2. On 12/11/18, the medication preparation areas, located inside three (3) out of four (4) medication rooms surveyed on units 1 South, 1 Center, and 2 South, had sticky residue on the surfaces and were cluttered with boxes and supplies.

3. These findings were confirmed by Staff #11.

Based on document review and interview, it was determined that the facility failed to ensure that written policies and procedures address all of the organ procurement responsibilities.

Findings include:

1. On 12/11/18, a Memorandum of Agreement with an OPO (Organ Procurement Organization) designated entity was provided. On 12/12/18, an Organ Tissue Donation policy was provided.

a. The Memorandum of Agreement with the OPO states, " ... Background The federal Conditions of Participation for Medicare and Medicaid Hospital ... mandate certain activities to promote and support organ and tissue donation and transplantation. These rules generally require hospital to have written protocols that (i) incorporate an agreement that the hospital has to refer all patient deaths ("Routine Referral") to its Organ Procurement Organization ('OPO") (ii) incorporate an agreement that the hospital has with at least one tissue and eye bank ... to facility donation and recovery, (iii) ensure that the OPO or a Designated Requestor advised the family of potential donors of the donor option, (iv) encourage sensitivity and discretion with respect to families of potential donors, and (v) ensure the hospital works cooperatively with its designated OPO and servicing organizations regarding education, medical record reviews, and other donor related issue."

b. Upon review, the Organ Tissue Donation policy provided indicated that upon admission, if the patient is already an organ and tissue donor, its status would be noted in the medical record, and contained a process in which the facility would provide the opportunity for all appropriate patients to be organ donors. In the event of a patient's death, only those patients who had executed an organ/tissue donor agreement would be referred. In addition, if a patient was transferred to another facility, the patient's organ/tissue donor agreement would be provided.

c. The above policy lacked the components referred in the Memorandum of Agreement.

d. The above was confirmed by Staff #4.

Based on medical record review, document review, interview, and observation, the facility failed to ensure:

I. The development of a treatment plan with all elements critical to effective treatment planning and implementation for one (1) of nine (9) active patients (Patient A2). The facility failed to address problems identified in the Clinical Assessments by the Psychiatrist, Advanced Practice Registered Nurse (APRN), and Social Worker in the Master Treatment Plan (MTP). The problems listed on the MTP did not address essential problems that were identified in the assessments. There were no goals or interventions in place to affect the treatment needed. This deficient practice has the potential to inhibit the patient's ability to progress toward discharge and may inhibit the patient's ability to accomplish the short-term goals listed on the treatment plan. (Refer to B118)

II. Active treatment measures, such as group and/or individual treatment, were provided for four (4) of nine (9) sample patients (A1, A6, A7, and A8) who were unwilling, unable, or not motivated, to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patients' lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125)

Based on medical record review, policy review, and interview, the facility failed to provide Psychosocial Assessments that met professional social work standards. These Assessments failed to include conclusions/formulations for the data documented in the Psychosocial Assessment and failed to include individualized treatment recommendations that described anticipated social work roles during inpatient treatment and discharge planning for nine (9) of nine (9), sample patients (A1, A2, A3, A4, A5, A6, A7, A8, and A9). These failures have the potential to result in a lack of professional social work treatment services and/or lack of input to the treatment team to assist in the care of the patient during hospitalization.

Findings Include:

A. Medical Records

Patient A1's Psychosocial Assessment dated 11/08/18; Patient A2's Psychosocial Assessment dated 11/29/18; Patient A3's Psychosocial Assessment dated 11/23/18; Patient A4's Psychosocial Assessment dated 11/29/18; Patient A5's Psychosocial Assessment dated 11/27/18; Patient A6's Psychosocial Assessment dated 11/30/18; Patient A7's Psychosocial Assessment dated 11/29/18; Patient A8's Psychosocial Assessment dated 11/23/18; and Patient A9's Psychosocial Assessment dated 11/30/18 all failed to list conclusions/formulations based on data obtained in the Assessments and did not indicate the anticipated social work treatment roles while the patient was in the hospital.

B. Policy Review

The hospital policy, "Behavioral Health Hospital Policy Number 5; Department of Origin : Social Services; Documentation; Revised 7/18," stated that the Psychosocial Assessments, "... are to be completed within 72 hours of admission and include reason of admission, family background, marital status, supportive relationships in the community, advance directives, status guardian & POA (Power of Attorney) status, housing, outpatient providers, substance abuse issues, legal Hx (history), veteran status, strengths, education, religious/spiritual needs, employment Hx and goals for treatment." The policy did not include a requirement for conclusions based on the data obtained and/or recommendations for in-patient treatment by the social worker.

C. Interview

During an interview on 12/11/18 at 11:45 a.m., the Director of Social Work indicated an understanding that the Psychosocial Assessment did not document conclusions and recommendations based on the social work assessments. She also acknowledged an understanding that the recommendations should include the role of the social worker in working with the patients, during hospitalization, to achieve patient-specific goals.

Based on medical record review, policy review, and interview the facility failed to provide Psychiatric Evaluations within 60 hours of admission for five (5) of nine (9) sample patients (Patients A2, A3, A4, A8, and A9). Failure to document a signed, authenticated Psychiatric Evaluation within 60 hours of admission has the potential to inhibit the treatment team's ability to initiate a timely Treatment Plan and can increase patients' length of stay in the hospital.

Findings Include:

A. Medical Records Review
1. Patient A2 was admitted on 11/28/18. Patient A2's Psychiatric Evaluation was not signed and authenticated until 12/03/18.

2. Patient A3 was admitted on 11/21/18. Patient A3's Psychiatric Evaluation was not signed and authenticated until 11/26/18.

3. Patient A4 was admitted on 11/28/18. Patient A4's Psychiatric Evaluation was not signed and authenticated until 12/03/18.

4. Patient A8 was admitted on 11/22/18. Patient A8's Psychiatric Evaluation was not signed and authenticated until 12/07/18.

5. Patient A9 was admitted on 11/29/18. Patient A9's Psychiatric Evaluation was not signed and authenticated until 12/03/18.

B. Policy Review

Hospital "Policy Number: 27 Department of Psychiatry, Subject Psychiatric Assessment and H & P (History and Physical) Revised 7/13/18," stated, "A complete initial psychiatric assessment and history and physical must be handwritten and dictated within 24 hours of admission. These assessments must be co-signed on the next working day after it is transcribed"

C. Interview

During an interview on 12/11/18 at 1:45 p.m., the Medical Director concurred that Psychiatric Assessments were not being authenticated within policy timeframes.

Based on medical record review, policy review, and interview, the facility failed to provide Psychiatric Evaluations that included the personal assets in descriptive, not interpretive fashion on which to base a meaningful treatment plan in nine (9) of nine (9) patient records (A1, A2, A3, A4, A5, A6, A7, A8 and A9). The failure to identify patient strengths has the potential to impair the treatment team's ability to choose treatment modalities which best utilize the patients' attributes in therapy.

Findings Include:

A. Medical Record Review

Patient A1's Psychiatric Evaluation signed 11/02/18, Patient A2's Psychiatric Evaluation signed 12/3/18, Patient A3's Psychiatric Evaluation signed 11/26/18, Patient A4's Psychiatric Evaluation signed 12/3/18, Patient A5's Psychiatric Evaluation signed 11/28/18, Patient A6's Psychiatric Evaluation signed 12/03/18, Patient A7's Psychiatric Evaluation signed 12/03/18, Patient A8's Psychiatric Evaluation signed 11/26/18, and Patient A9's Psychiatric Evaluation dated 12/03/18, all failed to identify assets/patient strengths that could be utilized in the development of a treatment plan.

B. Policy Review

Hospital "Policy Number: 27 Department of Psychiatry, Subject Psychiatric Assessment and
H & P (History and Physical) Revised 7/13/18," stated that the assessment should include "Patient assets".

C. Interview

During an interview on 12/11/18 at 1:45 p.m., the Medical Director concurred that assets were not present in the Psychiatric Assessments.

Based on medical record review, observation, and interview, the facility failed to develop a Treatment Plan with all elements critical to effective treatment planning and implementation for one (1) of nine (9) sample patients (Patient A2). The facility failed to address problems identified in the clinical assessments by the Psychiatrist, the Advanced Practice Registered Nurse (APRN), and the Social Worker in the Master Treatment Plan (MTP). The problems listed on the MTP for Patient A2 did not address essential problems that were identified in the assessments. There were no goals or interventions in place to affect the treatment needed. This deficient practice has the potential to inhibit the patient's ability to progress toward discharge and may inhibit the patient's ability to accomplish the short-term goals listed on the treatment plan.

Findings Include:

A. Medical Record Review

1. Patient A2's Psychiatric Evaluation, dated 12/03/18, documented the following: " ...with a diagnosis of schizoaffective disorder and neurocognitive impairment .... "[Patient] also presented as confused, disorganized, irritable, and angry ... reports issues with [his/her] memory ...." The Mental Status Examination section of the Psychiatric Evaluation documented, "[Patient] is oriented to person only. [His/her] memory is impaired. The patient recalls the current president as Trump and the previous president as Nixon. [S/he] has both long- and short-term memory are [sic] impaired. Insight and judgement are impaired." Diagnoses upon admission listed, "Schizoaffective disorder by history" and "Neurocognitive Impairment by history."

2. Patient A2's Psychosocial Assessment dated 11/30/18, described memory as "Poor Short-Term Memory; Poor Long Term [Memory]."

3. Patient A2's MTP, dated 11/30/18, listed only three (3) problems to be addressed from a preprinted list of eight (8) problems. The MTP listed corresponding goals and interventions that would be difficult for a patient with neurocognitive impairment to accomplish. For the Problem, "Medication/Tx (Treatment)", the listed Short-Term Goal was, "Identify at least (one) 1 benefit of adherence with medications and treatment." For the Problem, "Self-care", the listed Short-Term Goal was, "Demonstrate at least (two) 2 behaviors daily that indicate improvement in self-care." For the Problem, "Medical", there was no Short-Term Goal listed.

B. Observations

During an observation on12/10/18 at 1:30 p.m., Patient A2 was found resting in bed instead of attending the scheduled Spirituality for Wellness Group which was ongoing at that time.

C. Interviews

1. During an interview on 12/10/18 at 1:30 p.m., Patient A2 discussed with the surveyor (his/her) inability to participate in groups. (S/he) indicated that (s/he) would not know what to say in the group. (S/he) was confused regarding date, year, reason for being in the hospital, and did not appear to be able to meaningfully participate in scheduled activities.

2. During an interview on 12/10/18 at 1:45 p.m., RN1 indicated that Patient A2 does not go to group and further indicated that all the patient does is seclude (him/herself) in the bedroom and come out to eat.

3. During an interview on 12/11/18 at 10:00 a.m., RN1 and APRN1 concurred with the findings that there were no problems, short term goals or interventions on PaientA2's Treatment Plan that addressed the neurocognitive deficits of the patient. Both staff members further indicated that the MTP listed goals not likely to be accomplished by the patient given (his/her) deficits.

4. During an interview on 12/11/18 at 1:45 p.m., the Medical Director concurred that the current MTP did not address the neurocognitive deficits of the patient and the listed short- term goals would be difficult for the patient to accomplish.

Based on record review, policy review and interview, the facility failed to provide Treatment Plans that identified patient-related, short-term and long-term goals in observable, measurable, behavioral terms for seven (7) of nine (9) sample patients (A1, A2, A3, A5, A6, A7, and A8). Specifically, the goals were often unrelated to the problems identified and were not measurable. This failure resulted in a document that did not identify expected treatment outcomes in a manner that can be understood by treatment staff and patients.

Findings Include:

A. Medical Records

1. Patient A1 was admitted on 11/7/18. The Master Treatment Plan (MTP) dated 11/8/18, had for the problem "Psychosis," the unmeasurable short-term goal, "Hold a 2-3-minute organized conversation without any psychotic reference."

2. Patient A2 was admitted on 11/29/18. The MTP dated 11/30/18, had for the problem "Unable to independently complete ADLs (Activities of Daily Living)," the unmeasurable short-term goal, "Demonstrate at least 2 behaviors daily that indicate improvement in self-care."

3. Patient A3 was admitted on 11/21/18. The MTP dated 11/27/18, had for the problem "Mood instability," the unmeasurable and unrelated short-term goal, "State 3 positive plan [sic] for the future."

4. Patient A5 was admitted on 11/26/18. The MTP dated 12/4/18, had for the problem "Psychosis," the unmeasurable short-term goal, "Hold a 2-3-minute organized conversation without any psychotic reference."

5. Patient A6 was admitted on 11/29/18. The MTP dated 12/4/18, had for the problem "Mood Instability," the unmeasurable and unrelated short-term goal, "State 3 positive plan [sic] for the future."

6. Patient A7 was admitted on 11/28/18. The MTP dated 12/4/18, had for the problem "Mood Instability," the unmeasurable and unrelated short-term goal, "Demonstrate improved social engagement."

7. Patient A8 was admitted on 11/22/18. The MTP dated 11/28/18, had for the problem "Mood Instability," the unmeasurable and unrelated short-term goals, "State 1 positive plan for the future" and "Demonstrate improved social engagement."

B. Policy Review

Review of the facility Policy Number 135, "Interdisciplinary Treatment Plan," revised 10/18 stated, "The plan includes the following: Identification of measurable, behavioral, and time limited attainable goals." Thus, the Treatment Plans did not follow facility policy in their development.

C. Interview

1. During an interview on 12/11/18 at 2:45 p.m., the Director of Adjunctive Therapy stated that the short-term goals on the MTPs were not behavioral and measurable.

2. During an interview on 12/12/18 at 9:10 a.m., the Director of Nursing stated the short-term goals were not individualized.

Based on record review, policy review and interview, it was determined that the hospital failed to develop treatment interventions based on the individual needs of the patients for nine (9) of nine (9) patients (A1, A2, A3, A4, A5, A6, A7, A8, and A9). Specifically, the interventions were identical generic discipline functions regardless of the patients' diagnoses or identified problems. This failure had the potential to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' individualized problems which can impact negatively on the patients' recovery.

Findings Include:

A. Medical Records:

Review of the Master Treatment Plans (MTPs) revealed that the interventions were identical for nine (9) of nine (9) sample patients, regardless of their diagnoses or identified needs (A1-MTP dated11/08/18, A2-MTP dated 11/30/18, A3-dated 11/27/18, A4-dated12/04/18, A5-dated12/04/18, A6-dated 12/04/18, A7-dated 12/04/18, A8-dated 11/28/18, and A9-dated12/04/18). The interventions were not aligned with the goals, making it difficult, if not impossible, to determine the treatment needed to meet the goals. The identical interventions for all problems were:

1. "Provider will provide evaluation/assessment"

2. "RN (Registered Nurse) will administer medications, monitor side effects & provide medication education"

3. "SW (Social Worker) will offer family meeting & connect to outpatient care with referrals/appointments"

4. "AT (Activity Therapy) will offer at least 3 groups daily to directly address identified treatment need & complete AT assessment"

5. "Medical team will meet with the patient to address condition and follow them based on their identified need"

6. "Other"

B. Policy Review

Review of the facility Policy Number 135, "Interdisciplinary Treatment Plan," revised 10/18 stated, "Staff interventions are clearly stated and will include specific treatment modalities, frequency, and duration of treatment, and identify the team member/discipline responsible for the intervention." Thus, the Treatment Plans failed to follow facility policy in their development.

C. Interviews

1. During an interview on 12/11/18 at 1:55 p.m., RN2 acknowledged that the interventions for all patients were the same.

2. During an interview on 12/11/18 at 2:45 p.m., the Director of Adjunctive Therapy stated that the groups offered by AT were not identified on the Treatment Plan and were not connected to specific goals.

3. During an interview on 12/12/18 at 9:10 a.m., the Director of Nursing said that she agreed that all the interventions for all the patients were the same and needed to be individualized.

Based on medical record review, policy review and interview, the hospital failed to ensure that the staff member responsible for each intervention was specifically identified in nine (9) of nine (9) Master Treatment Plans (MTPs) (A1, A2, A3, A4, A5, A6, A7, A8 and A9). This failure resulted in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented.

Findings Include:

A. Medical Record Review

Patient A1's MTP dated11/8/18, Patient A2's MTP dated 11/30/18, Patient A3's MTP dated 11/27/18, Patient A4's MTP dated 12/4/18, Patient A5's MTP dated 12/4/18, Patient A6's MTP dated 12/4/18, Patient A7's MTP dated 12/4/18, Patient A8's MTP dated 11/28/18, and Patient A9's MTP dated 12/4/18, all failed to consistently identify staff responsible for treatment interventions by name and discipline.

B. Policy Review

Review of the facility Policy Number 135, "Interdisciplinary Treatment Plan," Revised 10/18 stated, "The plan includes the following: Staff interventions are clearly stated and will include specific treatment modalities, frequency and durations of treatment, and identify the team member/discipline responsible for the intervention." Thus, the Treatment Plans failed to follow facility policy.

C. Interview

1. During an interview on 12/11/18 at 10:00 a.m., RN1 and APRN1 concurred with the finding that staff responsible for patient interventions were not consistently listed by name and discipline on the MTPs.

2. During an interview on 12/11/18 at 1:45 p.m., the Medical Director agreed that staff responsible for the listed patient interventions were not consistently identified by name and discipline on the MTPs.

3. During an interview on 12/12/18 at 9:10 a.m., the Director of Nursing concurred with the findings that staff responsible for patient interventions were not consistently identified by name and discipline on the MTPs.

Based on record review, observation and interviews, the facility failed to ensure that active treatment measures, such as group and/or individual treatment, were provided for four (4) of nine (9) sample patients (A1, A6, A7, and A8) who were unwilling, unable, or not motivated, to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patients' lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement.

Findings Include:

A. Specific Patient Findings

1. Patient A1 was admitted on 11/7/18. The Psychiatric Evaluation, dated 11/8/18, revealed the patient was admitted due to threating to kill others.
- During an observation on Unit 1 South on 12/10/18 at 1:25 p.m., 15 patients were observed in group. Eight (8) patients were in their rooms either asleep or resting. Patient A1 was in [his/her] bedroom and did not attend group.

- During interview on 12/10/18 at 1:30 p.m., Certified Nursing Assistant 1 (CNA1) and CNA2 confirmed the unit census was 23. When asked about the patients not in group, CNA1 indicated they were unable to "force" patients to go to groups and could only encourage them. RN1 indicated groups were announced from the Nursing Station to encourage patients to attend.

- During an interview on 12/10/18 at 1:45 p.m. Patient A1 stated that s/he did not go to groups. S/he further indicated that his/her interest was in going home, not going to group. After the interview RN1 indicated that s/he only likes to sit by the nursing station.

- Review of the group notes from 11/7/18-12/9/18 showed that Patient A1 was expected to attend 48 groups. The notes revealed that s/he only attended eight (8) of the 48 groups.

- Review of Patient A1's MTP disclosed that Patient A1's lack of group attendance was not addressed nor were alternative treatment interventions considered.

2. Patient A6 was admitted on 11/29/18. The Psychiatric Evaluation, dated 11/30/18, revealed the patient was admitted due to hearing voices, anxiety, racing thoughts and delusions (false, fixed beliefs).
- During observations on 2 North on 12/10/18 from 1:00 p.m.-1:45 p.m., two (2) of the 25 patients on the unit were observed attending the Step-Work Support Group (substance abuse group). Ten of the 25 patients were observed attending the Thoughts, Feelings, Behavior Group. Patient A6 did not attend either group and was asleep in bed.

- During an interview on 12/10/18 at 1:45 p.m., Psychiatric Aide 3 (PA3) acknowledged that 13 of the 25 patients were not in group and were either walking the halls or in their room. When asked why the patients weren't in group, PA3 stated that some patients were, "On and off with groups."

- During an interview on 12/10/18 at 1:50 p.m., Patient A6 stated that s/he attended some groups, but not others. S/he stated that mostly s/he watched television, played cards and slept.

- During observations on 2 North on 12/10/18 from 1:45 p.m.-3:00 p.m., eight (8) of the 25 patients were observed attending the Life Skills in Recovery Group. One patient was observed on the phone, and one patient was with the doctor. The remaining 15 patients were either in the hallway or in their rooms. Patient A6 did not attend the group and remained in bed.

- During an interview on 12/10/18 at 2:15 p.m., RN2, when asked about encouraging patients to go to group, replied that staff turned off the television and the phone during group time. When asked about the patient observed using the phone, RN2 replied that they must have forgotten to turn it off. RN2 remarked that the patients on 2 North did not like to be "controlled." RN2 further stated that the Life Skills in Recovery was not, "really a group," and patients usually went in just for the coffee and then would leave. The group was listed on the Unit Schedule for 2 North and a therapist was working with the patients in the group.

- During observations on 2 North on 12/11/18 from 1:00 p.m.-1:30 p.m., four (4) patients were observed attending a Music Therapy Group and eight (8) patients were observed attending a Grief and Loss in Recovery Group. The census this day was 22. Eight (8) patients (including Patient A6) were in bed, one (1) patient was on the phone and one (1) patient was walking the halls.

- Review of the group notes from 12/3/18-12/7/18 showed that Patient A6 was expected to attend 26 groups. The notes revealed that s/he did not attend eight (8) groups and only partially attended (left early) four (4) other groups.

- Review of Patient A6's MTP, dated 12/4/18, showed that Patient A6's lack of group attendance was not addressed nor were alternative treatment interventions considered.

3. Patient A9 was admitted 11/29/18. The Psychiatric Evaluation, dated 11/30/18, revealed the patient was admitted for aggression and stating that s/he was going to hurt someone.

- During observations on 2 Center on 12/11/18 from 9:30 a.m.-11:30 a.m., 10 of the 25 patients were observed attending the Wellness and Recovery Group. The Substance Recovery Group being held at the same time, started out with eight (8) patients in attendance. After ten minutes, there were five (5) patients in the Substance Recovery Group and after 15 minutes, there were only two (2) patients in the group. The patients who were not in group were either in bed or walking in the hallway. Patient A9 did not go into group therapy and was walking in the hallway.

- During an interview on 12/11/18 at 11:00 a.m., Patient A9 was unable to say whether s/he attended groups.

- During an observation on 2 Center at 1:35 p.m., eight (8) of the 25 patients were observed attending the Thoughts, Feelings, Behaviors Group. There were no patients from 2 Center attending the combined 2 Center/2 South Art Therapy Group, being held at the same time. Patient A9 was not in group and was observed in the dayroom.

- During an observation on 2 Center at 2:00 p.m., nine (9) of the 25 patients were observed attending the Healthy Lifestyles Group. Seven (7) patients were in bed, four (4) were in the dayroom, three (3) were in the hallway, and two (2) were in the bathroom.

- During an interview on 12/11/18 at 2:15 p.m., Psychiatric Aide 4 (PA4) stated that the staff "can't force patients" to go to group.

- Review of the group notes from 12/3/18-12/7/18 showed that Patient A9 was expected to attend 16 groups. The notes revealed that s/he did not attend nine (9) groups and only partially attended (left early) three (3) other groups.

- Review of Patient A9's MTP, dated 12/4/18, showed that Patient A9's lack of group attendance was not addressed nor were alternative treatment interventions considered.

B. Observation

During an observation on Unit 1 North on 12/10/18 at 2:05 p.m., RN2 confirmed there were 12 patients in group and 12 patients in their rooms or in the halls. RN2 stated that patients were encouraged to go to groups.

C. Interview

1. During an interview on 12/11/18 at 2:45 p.m., the Director of Adjunctive Therapy stated her knowledge that many of the patients did not attend groups.

2. In an interview on 12/11/18 at 1:34 p.m. the Medical Director concurred with the findings regarding the lack of active attendance at groups.

3. During an interview on 12/12/18 at 9:10 a.m., the Director of Nursing stated that she was aware that group attendance needed to be addressed and that they were doing so.

Based on medical record review, document review, observation and interview, the Medical Director failed to ensure:

I. The provision of Psychiatric Evaluations within 60 hours of admission for five (5) of nine (9) sample patients (A2, A3, A4, A8 and A9). Failure to document a signed authenticated Psychiatric Evaluation within 60 hours of admission had the potential to inhibit a treatment team's ability to initiate a timely beginning of patients' treatment and can increase patients' length of stay in the hospital. (Refer to B111)

II. The provision of a Psychiatric Evaluation that included the personal assets on which to base a meaningful Treatment Plan in nine (9) of nine (9) records reviewed (A1, A2, A3, A4, A5, A6, A7, A8 and A9). The failure to identify patient strengths had the potential to impair the treatment team's ability to choose treatment modalities which best utilize the patients' attributes in therapy. (Refer to B117)

III. The development of a Treatment Plan with all elements critical to effective treatment planning and implementation for one (1) of nine (9) active patients (Patient A2). The facility failed to address problems identified in the clinical assessments by the Psychiatrist, by the Advanced Practice Registered Nurse (APRN), and by the Social Worker on the Master Treatment Plan. The problems listed on the MTP did not address essential problems that were listed in the assessments. There were no goals or interventions in place to affect the treatment needed. This deficient practice has the potential to inhibit the patient's ability to progress toward discharge and may inhibit the patient's ability to accomplish the short-term goals listed on the treatment plan. (Refer to B118)

IV. That active treatment measures, such as group and/or individual treatment were provided for four (4) of nine (9) sample patients (A1, A6, A7, and A8) who were unwilling, unable, or not motivated, to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patients' lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125)

Interview

During an interview on 12/12/18 at 1:45 p.m., the Medical Director concurred with the findings regarding Psychiatric Evaluations, Master Treatment Plans, and the lack of active treatment.

Based on record review, observations and interview, the Director of Nursing failed to:

I. Ensure that nursing interventions were individualized to specific patient needs. Instead, all the nursing interventions were identical for nine (9) out of nine (9) sample patients (A1, A2, A3, A4, A5, A6, A7, A8, and A9). The nursing intervention, "RN will administer medications, monitor side effects & provide medication education," were generic discipline functions. (Refer to B122)

II. Ensure that responsible nurses were identified on the Master Treatment Plans (MTPs) by name and discipline for six (6) of nine (9) sample patients (A1, A4, A5, A6, A7, and A9.) Failure to identify the nurse responsible for therapeutic interventions can lead to interventions not being carried out and can deprive the patient of needed nursing care.

Findings Include:
1. Patient A1's MTP, dated 11/8/18; Patient A4's MTP, dated 12/4/18: Patient A5's MTP, dated 12/4/18; Patient A6's MTP, dated 12/4/18; Patient A7's MTP, dated 12/4/18 and A9's MTP, dated 12/4/18 all had under "assigned staff " only the designation "RN" without a name of the responsible person.