HospitalInspections.org

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

I. Ensure that the Master Treatment Plans for 4 of 8 active sample patients (C2, C7, D2, and D7) and 2 of 2 active non-sample patients (C4 and D4) selected to review active treatment, were based on the patients' cognitive abilities and were revised when the patients demonstrated inability to participate in prescribed treatment. These patients demonstrated severe cognitive impairment at admission, but treatments prescribed on the plans were interventions from which the patients were incapable of benefiting. The plans were not revised to provide modalities from which the patients could benefit. This failure hampers the staff's ability to provide active treatment to meet the specific treatment needs of patients. (Refer to B118)

II. Ensure that active individualized treatment was provided for 4 of 8 active sample patients (C2, C7, D2, and D7) and 2 of 2 active non-sample patients (C4 and D4) selected to review active treatment. These patients had severe cognitive deficits. The group programming provided for these patients did not address the identified problems or the patients were incapable of benefiting from the modalities. This failed practice results in patients being hospitalized without all interventions for recovery being provided in a timely manner, potentially delaying improvement. (Refer to B125-I)

III. Ensure adequate development of discharge options for 1 of 8 active sample patients (D2) and 1 of 1 active non-sample patients (D4) selected to review active treatment. Patient D2 had been hospitalized at the facility almost continuously for 53 years. Patient D4 had been hospitalized at the facility almost continuously for almost 11 years. Being hospitalized beyond the time needed to reach optimal benefits results in a lack of opportunity for the patients' mental health and psychosocial improvement through transitional community services and community integration. (Refer to B125-II)

Based on record review and staff interview, the facility failed to ensure complete neurological screening for 8 of 8 active sample patients (A3, A6, B1, B3, C2, C7, D2 and D7). Failure to document specific neurological testing compromises the staff's ability to identify pathology which may be pertinent to the current mental illness. It also compromises future comparative re-examinations to assess the patient's response to treatment interventions.

Findings include:

A. Record Review

For the following physical examinations (dates in parentheses), no complete neurological screening was documented for "cranial nerves 1-12." The findings were as follows:

Patient A3 (1/18/11): "LR (light reflex) + - nystagmus EOM (extraocular movement) nl (normal), (illegible)."

Patients A6 (1/16/11) and B1 (1/21/11): "intact."

Patient B3 (12/26/10): "no nystagmus, + facial symmetry."

Patients C2 (1/11/11) and C7 (11/30/10): "CN (cranial nerves) I-XII grossly intact."

Patient D2 (4/13/10): "- nystagmus, facial symmetry."

Patient D7 (1/16/11): "(illegible) a facial palsy. LR (light reflex) sluggish/cloudy cornea (illegible) eye."

B. Staff Interview

In an interview on 1/25/11 at 11:00a.m., the Medical Director acknowledged that the physical examinations for the sample patients did not include a complete neurological screening examination to identify pathology which may be pertinent to the current mental illness and for future comparative re-examination to assess patient's response to treatment interventions.

Based on record review and interview, the facility failed to ensure that Psychiatric Evaluations included an estimate of intellectual functioning and memory functioning, stated in measurable, behavioral terms for 6 of 8 active sample patients (A3, B1, B3, C2, C7 and D2). The tests used for the examinations also were not identified. This deficiency results in the absence of cognitive impairment data for use in diagnosis and treatment. It also does not provide comparative data for assessment of changes in cognitive impairment during treatment or at the time of possible future hospitalizations.

Findings include:

A. Record reviews (date of most recent psychiatric evaluation in parentheses):

1. Patient A3 (1/18/11): "Memory for long term and short term is intact. Funds of knowledge [sic] is average. General intelligence is average. Abstract thinking and executive functions are partially impaired. Concentration is fair. Retention and recall are fair."

2. Patient B1 (1/22/11): "Patient had problems with short term memory...Concentration, retention and recall were impaired. Insight into the illness is impaired. Judgment is fair as he is will [sic] to stay in the hospital..."

3. Patient B3 (12/27/11): "Memory-long term and short term intact, fund of knowledge and general intelligence average, abstract thinking and executive functions partially impaired, concentration fair, retention and recall fair."

4. Patient C2 (1/12/11): "His short-term memory is significantly worse then [sic] long term memory. He has fully preserved executive functioning and some insight."

5. Patient C7 (11/30/10): "Patient is alert, awake, but disorganized and confused; has memory deficits and cognitive decline. Fund of knowledge is low. General intelligence and abstract thinking and executive function are low. Concentration, retention and recall are impaired ...judgment is poor."

6. Patient D2 (11/10/10): "Her memory is poor for both recent and remote events. Her fund of knowledge is limited and her thinking is concrete. Her abstract thinking is impaired. She has poor attention span. She has poor retention and recall. Her insight, as well as judgment, is impaired."

B. Staff Interviews

During an interview on 1/25/11 at 11:00a.m., the Medical Director acknowledged that the psychiatric examinations did not include specific documentation of memory and intellectual functioning sufficient to allow assessment of changes in cognitive impairment during treatment or at the time of possible future hospitalizations.

Based on record review and staff interview, the facility failed to ensure that psychiatric evaluations included an inventory of specific patient assets that could be used in treatment planning for 8 of 8 active sample patients (A3, A6, B1, B3, C2, C7, D2 and D7). Failure to identify patient assets impairs the treatment team's ability to develop interventions utilizing the individual strengths of each patient.

Findings include:

A. Record Review

For the following Psychiatric Evaluations (dates in parentheses), no assets were identified for the patients:

Patient A3 (1/18/11), Patient A6 (1/16/11), Patient B1 (1/22/11), Patient B3 (12/27/10),
Patient C2 (1/12/11), Patient C7 (11/30/10), Patient D2 (11/10/10), and Patient D7 (1/16/11).

B. Staff Interview

During an interview on 1/25/11 at 11:00a.m., the Medical Director acknowledged that the psychiatric evaluations for the sample patients did not include an inventory of specific patient assets that could be used in treatment planning.

Based on observations, record review and interview, the facility failed to ensure that the Master Treatment Plans for 4 of 8 active sample patients (C2, C7, D2 and D7) and 2 of 2 active non-sample patients (C4 and D4) selected to review active treatment, were based on the patients' cognitive abilities and were revised when the patients demonstrated inability to participate in prescribed treatment. These patients demonstrated severe cognitive impairment at admission. However, many of the treatments prescribed on the plans were interventions from which the patients could not benefit. The plans were not revised to provide alternative treatment modalities that would be more beneficial for the patients. In addition, the treatment plan for Patient D2 had had not been revised at all since 11/02/05, despite his continued hospitalization. These deficiencies hamper the staff's ability to provide active treatment to meet the specific treatment needs of patients.

Findings include:

A. Patient C2

1. Patient C2 was an 89 year old male admitted on 1/11/11 with severe cognitive deficits due to dementia.

2. During an observation on A wing on 1/24/11 at 2:15p.m., Patient C2 was sitting in Living Skills group sleeping. The program schedule posted on the unit dated 1/24/11stated that all patients were to attend "Living Skills" group during that time.

3. During an observation on A wing on 1/25/11 at 10:15a.m. Patient C2 was sitting in Stress Reduction group sleeping. The program schedule posted on the unit dated 1/25/11 stated that all patients were to attend "Stress Reduction" group during this time.

4. A review of C2's Master Treatment Plan of 1/12/11 revealed the identified problem as "Suicidal ideation and feelings of hopelessness." The listed interventions for this problem included group therapies with sw [social work].The MTP did not address the impact of the patient's cognitive deficits on his inability to participate in the available group programming. There were no revisions on the plan to address the patient ' s lack of participation in groups or to provide alternative treatment to meet his needs.

B. Patient C4

1. Patient C4 was an 84 year old male admitted on 1/20/11 with severe cognitive deficits due to dementia.

2. During an observation on A wing on 1/24/11 at 2:15p.m., Patient C4 was sitting in Living Skills group sleeping. The program schedule posted on the unit dated 1/24/11stated that all patients were to attend "Living Skills" group during that time.

3. During an observation on A wing on 1/25/11 at 10:15a.m., Patient C4 was sitting in Stress Reduction group sleeping. The program schedule posted on the unit dated 1/25/11 stated that all patients were to attend "Stress Reduction" group during this time.

4. A review of Patient C4's Master Treatment Plan dated 1/21/11 revealed the patient's identified problem as "Behavior issues (agitation and paranoid type) and combative impacting on his ability to be cared for." The listed interventions for this problem included the following statement: ..."Patient will benefit from daily activities and groups..." The treatment plan did not address the impact of the patient's cognitive deficits on his inability to participate in available programming. The plan included no revisions to address the patient's cognitive deficits or to provide alternative treatment to meet his needs.

C. Patient C7

1. Patient C7 was a 45 year old female admitted on 11/30/10 with severe cognitive deficits due to mental retardation and dementia.

2. During an observation in A wing on 1/24/11 at 2:15p.m., Patient C7 was sitting in Living Skills group for less than 10 minutes when she started crying. Patient C7's 1:1 staff assisted her to leave the group room. The program schedule posted on the unit dated 1/24/11 stated that all patients were to attend "Living Skills Group" group during this time.

3. During an observation in A wing on 1/25/11 at 10:35a.m., Patient C7 was ambulating with staff in hallway. When the staff person was asked about why Patient C7 was not attending the "Stress Reduction group in progress, the staff person stated "Oh, she doesn't attend groups; she becomes upset in groups."

4. A review of Patient C7's Master Treatment Plan dated 12/1/10 revealed the patient's identified problem as "Crying episodes." The listed interventions for this problem included the "offered groups." The treatment plan did not address the patient's inability to benefit from the scheduled groups. No revisions were made on the treatment plan to better address the patient's needs.

D. Patient D2

1. Patient D2 was an 89 year old with severe cognitive deficits due to dementia and schizophrenia initially admitted to the facility on 1/24/57. The treatment plan had not been revised since 11/02/05 despite patient's continued hospitalization.

2. During the scheduled activities therapy and social work groups on 1/24/11 at 1:45p.m., 2:30p.m., 3:00p.m., and 4:00p.m., Patient D2 was observed sitting in a wheel chair in the group room. She displayed no involvement or reaction to the group activities.

3. Patient D2's Master Treatment Plan, dated 11/2/05, stated that the goal for the patient was "(decrease) in delusional thinking and (decrease) angry outbursts." The treatment plan did not address the impact of the patient's cognitive deficits on her inability to participate in available programming. There was no evidence on the plan of alternative programming to meet her needs.

E. Patient D4

1. Patient D4 was a 74 year old with severe cognitive deficits due to dementia and schizophrenia, initially admitted on 6/15/00.

2. During the scheduled Activities Therapy and social work groups on 1/24/11 at 1:45p.m., 2:30p.m., 3:00p.m., and 4:00p.m., and on 1/25/11 at 10:35a.m., Patient D4 was observed in her bedroom or sitting in a wheel chair in the hallway.

3. Patient D4's Master Treatment Plan (dated 1/8/10) did not address the patient's cognitive deficits or her non-participation in available programming. No revisions were on the plan.

F. Patient D7

1. Patient D7 was an 87 year old male admitted on 1/15/11 with severe cognitive deficits due to dementia.

2. During the scheduled Activities Therapy and social work groups on 1/24/11 at 1:45p.m., 2:30p.m., 3:00p.m., and 4:00p.m., and on 1/25/11 at 10:35a.m., Patient D7 was observed lying in a geri-chair in the group room. The majority of the time, he appeared to be asleep. He displayed no involvement or reaction to the group activities except when he was episodically guided by staff.

3. Patient D7's Master Treatment Plan (dated 1/17/11) did not address the patient's cognitive deficits or his non-participation in available programming. No revisions were on the plan.

G. Staff Interview

In an interview on 1/25/11 at 3:00p.m., the Medical Executive acknowledged that patients with severe cognitive deficits such as C2, C4, C7, D2, D4 and D7 could not be expected to benefit from verbally-based treatments such as the groups that were scheduled for them. He stated that these patients would more likely benefit from more "hands on" treatments involving sensory modalities and other behavioral interventions.

Based on record review and interview, the facility failed to include all needed discipline interventions on the Master Treatment Plans for 8 of 8 active sample patients (A3, A6, B1, B3, C2, C7, D2 and D7) and 1 of 2 non-sample patients (C4) selected to review active treatment. None of the 8 active sample patient's MTPs included psychiatrist interventions. The only listed nursing interventions were generic nursing tasks that were identical or very similar for all patients. In addition, the MTP for patient C4 did not include any nursing interventions. These treatment plan deficiencies hamper staff's ability to provide coordinated and effective treatment.

Findings include:

I. Lack of physician and/or nursing interventions/modalities

A. Record Review

1). The following Interdisciplinary Treatment Plans (dates in parentheses) included no treatment interventions to be performed by the psychiatrist: Patient A3 (1/19/11), Patient A6 (1/17/11), Patient B1 (1/24/11), Patient B3 (12/27/10), Patient C2 (1/12/11), Patient C7 (12/1/10), Patient D2 (11/2/05), and Patient D7 (1/17/11).

2). Non-sample Patient C4 was admitted on 1/21/11. His treatment plan dated 1/21/11 noted the following problem: "Behavior issues (agitation and paranoid type) and combative impacting "[sic]" on his ability to be cared for." There were no nursing interventions/modalities on the plan.

B. Staff Interview

During an interview on 1/25/11 at 11:00a.m., the Medical Director acknowledged that the sample patient's treatment plans did not include interventions to be performed by the psychiatrist.

II. Generic Nursing Interventions

A. Record Review

1. Patient A3 was admitted on 1/17/11. Her Master Treatment Plan dated 1/19/11 noted the following generic nursing functions for the identified problem "disorganized, confused state, hallucinating": "medication education at each med pass, medication counseling, 1:1 to establish trust and a therapeutic relationship, provide emotional support, obtain contract for safety each shift while on the unit, explanation of all care and procedures to patient before initiating, engage patient in social interaction, diet and nutrition education when appropriate, encourage fluids, encourage participation in unit activities."

2. Patient A6 was admitted on 1/16/11. His Master Treatment Plan dated 1/17/11 noted the following generic nursing functions for the identified problem "Depression ie hopeless about finances": "medication education at each med pass, medication counseling, 1:1 to establish trust and a therapeutic relationship, provide emotional support, obtain contract for safety each shift while on the unit, explanation of all care and procedures to patient before initiating, engage patient in social interaction, diet and nutrition education when appropriate, encourage fluids, encourage participation in unit activities, set limits when behavior warrants, refer all request to primary nurse."

3. Patient B1 was admitted on 1/21/11. His Master Treatment Plan dated 1/24/11 noted the following generic nursing functions for the identified problem "Suicidal Ideations with thoughts of jumping out a window": "medication education at each med pass, medication counseling, 1:1 to establish trust and a therapeutic relationship, provide emotional support, obtain contract for safety each shift while on the unit, explanation of all care and procedures to patient before initiating, engage patient in social interaction, diet and nutrition education when appropriate, encourage fluids, encourage participation in unit activities, set limits when behavior warrants, vital signs every shift, fall risk intervention."

4. Patient B3 was admitted on 12/26/10. Her Master Treatment Plan dated 12/27/10 noted the following generic nursing functions for the identified problem "Visual Hallucinations ie sees people in yard": "medication education at each med pass, medication counseling, 1:1 to establish trust and a therapeutic relationship, provide emotional support, obtain contract for safety each shift while on the unit, explanation of all care and procedures to patient before initiating, engage patient in social interaction, diet and nutrition education when appropriate, encourage fluids, encourage participation in unit activities, set limits when behavior warrants, refer all request to primary nurse, vital signs every shift, fall risk intervention."

5. Patient C2 was admitted on 1/11/11. His Master Treatment Plan dated 1/12/11 noted the following generic nursing functions for the identified problem "Suicidal ideation and feelings of hopelessness": "medication education at each med pass, medication counseling, 1:1 to establish trust and a therapeutic relationship, provide emotional support, obtain contract for safety each shift while on the unit, explanation of all care and procedures to patient before initiating, engage patient in social interaction, diet and nutrition education when appropriate, encourage fluids, encourage participation in unit activities, set limits when behavior warrants, refer all request to primary nurse, vital signs every shift, fall risk intervention."

6. Patient C7 was admitted on 11/30/10. Her Master Treatment Plan dated 12/1/10 noted the following generic nursing functions for the identified problem "Crying episodes": "medication education at each med pass, 1:1 to establish trust and a therapeutic relationship, provide emotional support, explanation of all care and procedures to patient before initiating, engage patient in social interaction, diet and nutrition education when appropriate, encourage fluids, encourage participation in unit activities, set limits when behavior warrants, refer all request to primary nurse, vital signs every shift, fall risk intervention."

7. Patient D2 was admitted on 1/28/57. Her Master Treatment Plan dated 11/02/05 noted the following generic nursing functions for the identified problem "Delusions with loud angry outburst": "medication education at each med pass, medication counseling, 1:1 for redirection, support validation, recognition: approach patient from the front, identify yourself, and speak directly to the patient, explanation of all care and procedures to patient before initiating, engage patient in social interaction..."

8. Patient D7 was admitted on 1/15/11. Her Master Treatment Plan dated 1/17/11 noted the following generic nursing functions for the identified problem "Agitation with aggressive assaultive behavior": "medication education at each med pass, 1:1 to establish trust and a therapeutic relationship, provide emotional support, obtain contract for safety each shift while on the unit, explanation of all care and procedures to patient before initiating, engage patient in social interaction, encourage fluids, encourage participation in unit activities, set limits when behavior warrants, vital signs every shift, fall risk intervention."

B. Staff Interviews

1. In an interview on 1/25/11 at 1:00p.m., the Director of Social Work agreed with the findings and stated that some of these interventions were "cookie-cutters...."

2. In an interview on 1/25/11 at 2:00p.m., the Director of Nursing agreed that the nursing interventions on the treatment plans were generic and routine nursing functions.

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

I. Ensure that active individualized treatment was provided for 4 of 8 active sample patients (C2, C7, D2 and D7) and 2 of 2 active non-sample patients (C4 and D4) selected to review active treatment. These patients had severe cognitive deficits, and were not capable of benefiting from the regularly-scheduled group treatment modalities. The facility failed to provide alternative programming for the patients or adequate modalities to address their identified problems.. This failed practice results in patients being hospitalized without all interventions for recovery being provided in a timely manner, potentially delaying improvement.

II. Ensure an adequate development of discharge options for 1 of 8 sample patients (D2) and 1 of 1 active non-sample patient (D4) selected to review active treatment. Patient D2 had been hospitalized at the facility almost continuously for 53 years. Patient D4 had been hospitalized at the facility almost continuously for almost 11 years. Being hospitalized beyond the time needed to reach optimal benefits results in a lack of opportunity for the patients' mental health and psychosocial improvement through transitional community services and community integration.

Findings include:

I. Failure to provide active individualized treatment

A. Patient C2:

1. The admission Psychiatric Evaluation, dated 1/12/11, stated that Patient C2 was a 89 year old male with a diagnosis of Senile dementia Alzheimer's type with behavioral disturbance, late onset, Major Depressive disorder admitted on 1/11/11.

2. During an observation on A wing on 1/24/11 at 2:15p.m., Patient C2 was sitting in Living Skills group sleeping. The program schedule posted on the unit dated 1/24/11stated that all patients were to attend "Living Skills" group during that time.

3. During an observation on A wing on 1/25/11 at 10:15a.m. Patient C2 was sitting in Stress Reduction group sleeping. The program schedule posted on the unit dated 1/25/11 stated that all patients were to attend "Stress Reduction" group during this time.

4. During an observation with Director of Nursing on 1/25/11 at 10:30a.m. the DON agreed that Patient C2 was sleeping in group. She stated that staff would discuss the patient's lack of participation with the doctor to assess Patient C2's medications.

5. Patient C2's Master Treatment Plan of 1/12/11 identified the patient's problem as "Suicidal ideation and feelings of hopelessness." The listed interventions for this problem were; "call staff [sic] to provide a safe and therapeutic milieu, group therapies with sw [social work], nursing, activities, discharge planning with SW, vital signs qshift, lab work, medications, medication education with each med pass, pain assessment shift." The plan did not address the impact of the patient's cognitive deficits on his inability to participate in group programming.

B. Patient C4:

1. The admission Psychiatric Evaluation, dated 1/21/11, stated that non-sample Patient C4 was a 84 year old male with a diagnosis of "senile dementia of Alzheimer's type with behavioral disturbance Status post delirious state," admitted on 1/20/11.

2. During an observation on A wing on 1/24/11 at 2:15p.m., Patient C4 was sitting in Living Skills group sleeping. The program schedule posted on the unit dated 1/24/11stated that all patients were to attend "Living Skills" group during that time.

3. During an observation on A wing on 1/25/11 at 10:15a.m., Patient C4 was sitting in Stress Reduction group sleeping. The program schedule posted on the unit dated 1/25/11 stated that all patients were to attend "Stress Reduction" group during this time.

4. During an observation with Director of Nursing on 1/25/11 at 10:30a.m., the DON agreed that Patient C4 was sleeping in Stress Reduction group in his recliner. She stated that staff would discuss the patient's lack of participation with the doctor to assess Patient C4's medications.

5. The Master Treatment Plan dated 1/21/11 identified patient's C4's problem as "Behavior issues (agitation and paranoid type) and combative impacting on his ability to be cared for." The listed interventions for this problem were "Patient will benefit from stabilization of medication participation in daily activities and groups. Patient will also benefit one on one [sic] sessions with therapist." The plan did not address the impact of the patient's cognitive deficits on his inability to participate in group programming.

C. Patient C7:

1. The admission Psychiatric Evaluation, dated 11/30/10, stated that Patient C7 was a 45 year old female with a diagnosis of "Dementia, not otherwise specified, Depressive Disorder, not otherwise specified, Mental Retardation and Down syndrome," admitted on 11/30/10.

2. During an observation with Director of Nursing (DON) 1/24/11 at 11:30a.m., Patient C7 was lying in her bed. A staff person was with her, doing a 1:1 for constant observation. When asked about the patient's programming, the DON stated "She is at a risk for falls and she tends to cry and become upset in groups."

3. During an observation in A wing on 1/24/11 at 2:15p.m., Patient C7 was sitting in Living Skills group for less than 10 minutes when she started crying. Patient C7's 1:1 staff assisted her to leave the group room. The 1/24/11 program schedule posted on the unit stated that all patient were to attend "Living Skills Group" group during this time.

4. During an observation in A wing on 1/25/11 at 10:35a.m., Patient C7 was ambulating with staff in hallway. When the staff person was asked about why Patient C7 was not attending a group, when the group was in progress, the staff person stated "Oh, she doesn't attend groups; she becomes upset in groups."

5. The Master Treatment Plan dated 12/1/10 identified the patient's problem as "Crying episodes." The listed interventions for this problem were "Patient will be offered frequent one on one visits for support, reassurance care and comfort. Patient will be offered groups. Observe VS qshift, obtain labs as ordered, medication as ordered, monitoring for safety, Tab alarm, Hip guard, non-skid socks, Floor Mat." While some interventions were appropriate for Patient C7's identified problem, other listed interventions such as "Observe VS qshift, Hip guard, non-skid socks, Floor Mat" were not specifically targeted to the identified problem. In addition, the treatment plan did not address the impact of the patient's cognitive deficits and depression on her inability to participate in group programming.

D. Patient D2

1. The admission Psychiatric Evaluation, dated 1/28/57, stated that Patient D2 was admitted on 1/24/57 with the following presentation: "a schizophrenic picture with a great deal of personality deterioration. She has had considerable treatment. Aside from the emotional blunting, auditory hallucinations are present, poverty of ideas and other characteristic findings." The patient's diagnosis was stated as "Dementia Precox, other types - chronic and differentiated Schizophrenic Reaction." The patient had been continuously hospitalized at the facility except for admissions to outside medical hospitals for medical care. The most recent re-admission to the facility was 11/1/05.

2. The annual Psychiatric Evaluation, dated 11/10/10, stated that Patient D2 was an 89 year old who was a "long term resident" of the facility "for treatment of schizophrenia, chronic, undifferentiated type....The schizophrenia has been superimposed with hyper-aggressive dementia with decline in her cognitive function, poor memory and poor concentration, and impaired insight and judgment...her speech is incoherent and irrelevant."

3. Patient D2's current Master Treatment Plan, dated 11/2/05, stated that the goal for the patient was "(decrease) in delusional thinking and (decrease) angry outbursts." The treatment plan had not been revised since 11/02/05 despite the patient's continued hospitalization. (See additional citation at B118)

4. During the scheduled Activities Therapy and social work groups on 1/24/11 at 1:45p.m., 2:30p.m., 3:00p.m., and 4:00p.m., Patient D2 was observed sitting in a wheel chair in the group room. She displayed no involvement or reaction to the group activities.

5. During an attempted interview with Patient D2 on 1/24/11 at 5:30p.m., the patient's responses were incoherent and were not directly related to the questions asked by the surveyor.

6. A review of the Medication Administration Record generated 1/25/11 at 10:28a.m. revealed that the standing psychotropic medications for Patient D2 had not been adjusted since 10/14/08.

7. In an interview on 1/25/11 at 11:00a.m., the Medical Director confirmed that Patient D2 had been hospitalized in the facility since 1957. He acknowledged that the treatment plan dated 11/2/05 had not been revised to address the patient's current behaviors or her continued hospitalization.

E. Patient D4

1. The admission Psychiatric Evaluation, dated 6/15/00, stated that Patient D4 was admitted on 6/15/00 for the following: "...ongoing long-term hospitalization. Problems have included an apparent chronic psychotic process with fluctuating mood symptoms, noncompliance with medication and other treatment interventions, disorganized thinking, periods of agitation and screaming." The patient had been continuously hospitalized at the facility except for admissions to outside medical facilities for medical care.

2. The annual Psychiatric Evaluation, dated 5/14/10, stated Patient D4 was a 74 year old "who is a long term resident" of the facility. Her diagnoses were "Schizoaffective disorder, bipolar type" and "Dementia, Alzheimer's type with behavioral disturbance." She was described as: "appearing to be responding to internal stimuli...speech was non-fluent aphasia and when she started to talk she was incoherent. She is disoriented today, month, year, place and person. She has very poor concentration and poor attention span." The "estimated length of stay" was "long term placement in geriatric unit." The "anticipated placement/disposition" was that Patient D4 "will continue to be a resident of (the facility's) long term psychiatric program."

3. During the scheduled Activities Therapy and social work groups on 1/24/11 at 1:45p.m., 2:30p.m., 3:00p.m., and 4:00p.m., Patient D2 was observed sitting in a wheel chair in the group room. She displayed no involvement or reaction to the group activities.

4. During an interview with Patient D4 on 1/25/11 at 10:40a.m., the patient was seen to be an elderly female sitting in a wheelchair. She smiled and attempted to hug the surveyor. The patient's verbal responses were incoherent and were not directly related to the questions asked by the surveyor.

5. During the scheduled Activities Therapy and social work groups on 1/24/11 at 1:45p.m., 2:30p.m., 3:00p.m., and 4:00p.m., and on 1/25/11 at 10:35a.m., Patient D4 was observed in her bedroom or sitting in a wheel chair in the hallway.

6. In an interview on 1/25/11 at 11:00a.m., the Medical Director confirmed that Patient D4 had been hospitalized in the facility since 2000. He also acknowledged that the treatment plan had not been revised to address the patient's current behaviors or her continued hospitalization.

F. Patient D7

1. According to the admission Psychiatric Evaluation (1/16/11), Patient D7 was an 87 year old admitted due to "aggressive behavior" in a general hospital where he had been admitted following multiple strokes with resulting "cognitive impairment." His diagnosis was "vascular dementia with behavioral disturbance." The PE gave the following description of the patient: " very incoherent during the assessment... the rest of the mental status could not be performed because of severe cognitive impairment...Cognitive function - he is alert and oriented to himself only. He does not know his birthday and is unable to state his age correctly. He was able to identify one body part after repeated requests...He has no insight and judgment is impaired."

2. In an interview with Patient D7 on 1/24/11 at 1:40p.m., the patient was seen to be an elderly male lying in a geri-chair, initially asleep. His responses were in Spanish. According to the Spanish-speaking staff assisting Patient D7, his responses were incoherent and not related to the surveyor's questions.

3. During the scheduled Activities Therapy and social work groups on 1/24/11 at 1:45p.m., 2:30p.m., 3:00p.m., and 4:00p.m., and on 1/25/11 at 10:35a.m., Patient D7 was observed lying in a geri-chair in the group room. The majority of the time, he appeared to be asleep. He displayed no involvement or reaction to the group activities except when he was episodically guided by staff.

E. Staff Interview

During an interview on 1/25/11 at 3:00p.m., the Medical Executive acknowledged that patients with severe cognitive deficits such as Patients C2, C4, C7, D2, D4, and D7 could not be expected to benefit from verbally-based treatments such as the groups that were being scheduled for them. He stated that these patients would be more likely to benefit from more "hands on" treatments involving sensory modalities and from behavioral treatments.

II. Inadequate Discharge Planning

A. Patient D2

1. The admission Psychiatric Evaluation, dated 1/28/57, stated that at the time of admission, Patient D2 had the following presentation: "a schizophrenic picture with a great deal of personality deterioration. She has had considerable treatment. Aside from the emotional blunting, auditory hallucinations are present, poverty of ideas and other characteristic findings." The patient's diagnosis was "Dementia Precox, other types - chronic and differentiated Schizophrenic Reaction." She had been continuously hospitalized at the facility since 1957 except for discharges to outside medical facilities for medical care. The most recent re-admission was 11/1/05.

2. The annual Psychiatric Evaluation, dated 11/10/10, stated that Patient D2 was an 89 year old who was a "long term resident" of the facility: "for treatment of schizophrenia, chronic, undifferentiated type. The schizophrenia has been superimposed with hyper-aggressive dementia with decline in her cognitive function, poor memory and poor concentration, and impaired insight and judgment...her speech is incoherent and irrelevant." The only "justification for level of care" was "could not be managed in a long term nursing home facility due to her chronic psychotic state." The "estimated length of stay" was "365 days" and the "anticipated placement/disposition" was that Patient D2 "will continue to be a long term resident" of the facility.

3. The monthly social work progress notes stated the following:

2/5/10 at 8:45a.m.: "Patient is not to be discharged. Patient is a long term resident."
6/4/10 at 12:00p.m.: "Patient is a long term resident. No plans for discharge."
7/21/10 at 8:30a.m.: "Patient is a LTC (long term care) resident. No plans for d/c (discharge)."
9/15/10 at 10:00a.m., 11/10/10 at 4:00p.m., and 12/8/10 at 9:50a.m.: "Patient is a long term resident. No plans for discharge."
1/7/11 at 10:00a.m.: "No discharge plans. Patient is a long term resident at (the facility) since 1957 "

B. Patient D4

1. The admission Psychiatric Evaluation, dated 6/15/00, stated that Patient D4 was admitted "for ongoing long-term hospitalization. Problems have included an apparent chronic psychotic process with fluctuating mood symptoms, noncompliance with medication and other treatment interventions, disorganized thinking, periods of agitation and screaming." The patient had been continuously hospitalized at the facility since 2000 except for discharges to outside medical facilities for medical care.

2. The annual Psychiatric Evaluation, dated 5/14/10, stated Patient D4 was a 74 year old "who is a long term resident" of the facility. Her diagnoses were "Schizoaffective disorder, bipolar type" and "Dementia, Alzheimer's type with behavioral disturbance." The "estimated length of stay" was "long term placement in geriatric unit" and the "anticipated placement/disposition" was that Patient D4 "will continue to be a resident of (the facility) long term psychiatric program."

C. Staff Interview

During an interview on 1/25/11 at 3:00p.m., the Medical Executive acknowledged that patients D2 and D4 remained in the facility because "there is nowhere else for them to go." He stated that Patient D2 was receiving "custodial care." He agreed that there was not active discharge planning for these patients because they were "long term" patients at the facility.

Based on record review, interviews and observations, the Medical Director failed to provide adequate supervision and oversight to the medical staff to:

I. Ensure complete neurological screening exams for 8 of 8 active sample patients (A3, A6, B1, B3, C2, C7, D2 and D7). Failure to document specific neurological testing compromises the staff ' s ability to identify pathology which may be pertinent to the current mental illness. It also compromises future comparative re-examination to assess patient's response to treatment interventions. (Refer to B109)

II. Ensure that Psychiatric Evaluations included an estimate of intellectual functioning and memory functioning, stated in measurable, behavioral terms for 6 of 8 active sample patients (A3, B1, B3, C2, C7 and D2), and that the tests used for the examinations were identified. This deficiency results in the absence of data for use in diagnosis and treatment and does not allow assessment of changes in cognitive impairment during treatment or at the time of possible future hospitalizations. (Refer to B116)

III. Ensure that psychiatric evaluations included an inventory of specific patient assets that could be used in treatment planning for 8 of 8 active sample patients (A3, A6, B1, B3, C2, C7, D2 and D7). Failure to identify patient assets impairs the treatment team's ability to develop interventions utilizing the individual strengths of each patient. (Refer to B117)

IV. Ensure that the Master Treatment Plans for 4 of 8 active sample patients (C2, C7, D2, and D7) and 2 of 2 active non-sample patients (C4 and D4) selected to review active treatment, were based on the patients' cognitive abilities and were revised when the patients demonstrated inability to participate in prescribed treatment. These patients demonstrated severe cognitive impairment at admission, but treatments prescribed on the plans were interventions from which the patients were incapable of benefiting. The plans were not revised to provide modalities from which the patients could benefit. This failure hampers the staff's ability to provide active treatment to meet the specific treatment needs of patients. (Refer to B118)

V. Ensure that the Master Treatment Plans of 8 of 8 active sample patients (A3, A6, B1, B3, C2, C7, D2 and D7) and 1 of 2 non-sample patients (C4) selected to review active treatment included all needed discipline interventions. None of the 8 active sample patients treatment plans included psychiatrist interventions, and they only listed generic nursing tasks. In addition, the MTP for 1 of 2 non-sample patients (C4) did not include any nursing interventions. These treatment plan deficiencies hamper staff's ability to provide coordinated and effective treatment. (Refer to B122)

VI. Ensure that active individualized treatment was provided for 4 of 8 active sample patients (C2, C7, D2, and D7) and 2 of 2 active non-sample patients (C4 and D4) selected to review active treatment. These patients had severe cognitive deficits and could not benefit from the scheduled group programming. The programming provided did not address the patient's identified problems and/or the patients were incapable of benefiting from the offered modalities. This failed practice results in patients being hospitalized without all interventions for recovery being provided in a timely manner, potentially delaying improvement. (Refer to B125-I)

VII. Ensure adequate development of discharge options for 1 of 8 sample patients (D2) and 1 of 1 active non-sample patient (D4) selected to review active treatment. Patient D2 had been hospitalized at the facility almost continuously for 53 years. Patient D4 had been hospitalized at the facility almost continuously for almost 11 years. Being hospitalized beyond the time needed to reach optimal benefits results in a lack of opportunity for the patients' mental health and psychosocial improvement through transitional community services and community integration. (Refer to B125-II)

Based on record review and interview, the Director of Nursing (DON) failed to ensure that nursing interventions/modalities were developed to address the individual needs of 8 of 8 active sample patients (A3, A6, B1, B3, C2, C7, D2 and D7). The nursing interventions on the patients' treatment plans were generic nursing functions with no specification of how or how often they would be provided. In addition, the treatment plan for 1 of 2 active non-sample patients (C4) included no nursing interventions. This deficient practice hampers staff ' s ability to provide coordinated and effective treatment.

Findings include:

A. Record Review

1. Patient A3's treatment plan dated 1/19/11 noted the following generic and routine nursing functions for the identified problem "disorganized, confused state, hallucinating." Registered Nurse- "medication education at each med pass, medication counseling, 1:1 to establish trust and a therapeutic relationship, provide emotional support, obtain contract for safety each shift while on the unit, explanation of all care and procedures to patient before initiating, engage patient in social interaction, diet and nutrition education when appropriate, encourage fluids, encourage participation in unit activities."

2. Patient A6's treatment plan dated 1/17/11 noted the following generic and routine nursing functions for the identified problem "Depression ie hopeless about finances." Registered Nurse- "medication education at each med pass, medication counseling, 1:1 to establish trust and a therapeutic relationship, provide emotional support, obtain contract for safety each shift while on the unit, explanation of all care and procedures to patient before initiating, engage patient in social interaction, diet and nutrition education when appropriate, encourage fluids, encourage participation in unit activities, set limits when behavior warrants, refer all request to primary nurse."

3. Patient B1's treatment plan dated 1/24/11 noted the following generic and routine nursing functions for the identified problem "Suicidal Ideations with thoughts of jumping out a window." Registered Nurse- "medication education at each med pass, medication counseling, 1:1 to establish trust and a therapeutic relationship, provide emotional support, obtain contract for safety each shift while on the unit, explanation of all care and procedures to patient before initiating, engage patient in social interaction, diet and nutrition education when appropriate, encourage fluids, encourage participation in unit activities, set limits when behavior warrants, vital signs every shift, fall risk intervention."

4. Patient B3's treatment plan dated 12/27/10 noted the following generic and routine nursing functions for the identified problem "Visual Hallucinations ie sees people in yard." Registered Nurse- "medication education at each med pass, medication counseling, 1:1 to establish trust and a therapeutic relationship, provide emotional support, obtain contract for safety each shift while on the unit, explanation of all care and procedures to patient before initiating, engage patient in social interaction, diet and nutrition education when appropriate, encourage fluids, encourage participation in unit activities, set limits when behavior warrants, refer all request to primary nurse, vital signs every shift, fall risk intervention."

5. Patient C2's treatment plan dated 1/12/11 noted the following generic and routine nursing functions for the identified problem "Suicidal ideation and feelings of hopelessness." Registered Nurse- "medication education at each med pass, medication counseling, 1:1 to establish trust and a therapeutic relationship, provide emotional support, obtain contract for safety each shift while on the unit, explanation of all care and procedures to patient before initiating, engage patient in social interaction, diet and nutrition education when appropriate, encourage fluids, encourage participation in unit activities, set limits when behavior warrants, refer all request to primary nurse, vital signs every shift, fall risk intervention."

6. Patient C4's treatment plan dated 1/21/11 noted the following problem: "Behavior issues (agitation and paranoid type) and combative impacting on his ability to be cared for." There were no nursing interventions to address the problem.

7. Patient C7's treatment plan dated 12/1/10 noted the following generic and routine nursing functions for the identified problem "Crying episodes." Registered Nurse- "medication education at each med pass, 1:1 to establish trust and a therapeutic relationship, provide emotional support, explanation of all care and procedures to patient before initiating, engage patient in social interaction, diet and nutrition education when appropriate, encourage fluids, encourage participation in unit activities, set limits when behavior warrants, refer all request to primary nurse, vital signs every shift, fall risk intervention."

8. Patient D2's treatment plan dated 11/02/05 noted the following generic and routine nursing functions for the identified problem "Delusions with loud angry outburst." Registered Nurse- "medication education at each med pass, medication counseling, 1:1 for redirection, support validation, recognition: approach patient from the front, identify yourself, and speak directly to the patient, explanation of all care and procedures to patient before initiating, engage patient in social interaction..."

9. Patient D7's treatment plan dated 1/17/11 noted the following generic and routine nursing functions for the identified problem "Agitation with aggressive assaultive behavior." Registered Nurse- "medication education at each med pass, 1:1 to establish trust and a therapeutic relationship, provide emotional support, obtain contract for safety each shift while on the unit, explanation of all care and procedures to patient before initiating, engage patient in social interaction, encourage fluids, encourage participation in unit activities, set limits when behavior warrants, vital signs every shift, fall risk intervention."

10. Most of the listed nursing interventions on the above patient's treatment plans failed to specify the frequency of the intervention or the modality to be used to deliver the intervention. For example, if "Provide emotional support" was checked under "Modalities and Interventions" in a Master Treatment Plan, there was no indication or specification regarding how, or how often the emotional support was to be provided. Other examples of modalities and interventions that were checked but not specified included, "Encourage fluids", "Encourage participation in unit activities", "Engage patient in social interaction" etc.

B. Staff Interviews

In an interview with the Director of Nursing on 1/25/11 at 2:00p.m. the lack of patient-specific nursing interventions on the treatment plans was discussed. The DON replied "I agree..."