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Based on medical review, policy review, and interview, the facility failed to:

1. Ensure the provision of Master Treatment Plans (MTPs) that included patient-related goals stated in measurable terms for five (5) of six (6) active sample patients (A2, A3, A4, A5 and A6). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions based on changes in patient behaviors. (See B 121)

2. Ensure the MTP interventions by physicians and nursing staff consistently addressed specific treatment needs for six (6) of six (6) active sample patients (Patients A1, A2, A3, A4, A5 and A6). Specifically there were no physician interventions on the MTPs and nursing interventions were primarily stated as generic discipline functions. Failure to document specific treatment approaches has the potential to interfere with the assurance of consistency of approach to each patient's problems and could result in prolonged hospitalization. (See B122)

3. Ensure that the specific nursing staff member responsible for each intervention was identified in six (6) of six (6) treatment plans (A1, A2, A3, A4, A5 and A6). 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. (See B123)

The absence of an integrated, comprehensive treatment plan has the potential to result in a lack of coordinated and organized treatment.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that include patient-related goals stated in measureable terms for five (5) of six (6) active sample patients (A2, A3, A4, A5 and A6). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions based on changes in patient behaviors.

Findings include:

A. Policy Review

Hospital policy, "Administrative Policy & Procedure Treatment Plan", revised 6/2016, stated that, "The treatment plan should include: (b) Treatment goals which are measurable (describing the desired action or behavior to be achieved.) ..."

B. Specific Patient Findings

1. Patient A2 was admitted on 6/20/17. The Admission Psychiatric Evaluation dated 6/20/17 identified the diagnosis as, "Major neurocognitive disorder with behavioral syndrome secondary to Alzheimer's disease and microvascular disease." The Master Treatment Plan (MTP) dated 6/26/17 identified the problem, "Impaired Daily Functioning Related to Changes in Memory/Cognition." The short-term goal for this problem was "[Patient] will achieve the following: less aggressive behavior will be demonstrated x [times] 3 days prior to discharge."

2. Patient A3 was admitted on 6/21/17. The Admission Psychiatric Evaluation dated 6/22/17 identified the diagnosis as "Major neurocognitive disorder with behavioral syndrome secondary to Alzheimer's disease." The Master Treatment Plan (MTP) dated 6/26/17 identified the problem, "Violence." The long-term goal for this problem was "[Patient] will be calm, cooperative and compliant by the end of hospitalization."

3. Patient A4 was admitted on 6/14/17. The Admission Psychiatric Evaluation dated 6/14/17 identified the diagnosis as, "Major neurocognitive disorder with behavioral syndrome secondary to Alzheimer's disease." The MTP dated 6/19/17 identified the problem, "Impaired Daily Functioning Related to Changes in Memory/Cognition." The short-term goals for this problem included, "[Patient] will demonstrate improved level of cooperation with staff."

4. Patient A5 was admitted on 6/19/17. The Admission Psychiatric Evaluation dated 6/20/17 identified the diagnosis, "Major neurocognitive disorder with behaviors." The MTP dated 6/23/17 identified the problem, "Elopement Risk". The long-term goal for this problem was "[Patient] will be free from injury of elopement attempts x 3 days prior to discharge."

5. Patient A6 was admitted on 6/20/17. The Admission Psychiatric Evaluation dated 6/20/17 identified the diagnosis, "Major vascular disorder with behavioral syndrome." The MTP dated 6/23/17 identified the problem. "Violence." The long-term goal for this problem was "[Patient] will be calm & cooperative along with compliant by the end of hospitalization."

B. Interview

During interview on 6/27/17 at 10:30 a.m., the Director of Nursing (DON), the Risk Manager and the Assistant Director of Nursing acknowledged that the shared short-term and long-term goals were not measurable or observable.

Based upon medical record review, policy review, and interview the facility failed to ensure the MTP interventions by physicians and nursing staff consistently addressed specific treatment needs for six (6) of six (6) active sample patients. (Patients A1, A2, A3, A4, A5 and A6) Specifically there were no physician interventions on the MTP and nursing interventions were primarily stated as generic discipline functions. Failure to document specific treatment approaches has the potential to interfere with the assurance of consistency of approach to each patient's problems and could result in prolonged hospitalization.

Findings include:

I. Lack of Physician Interventions

A. Medical Record Review

1. Patient A1's Master Treatment Plan (MTP) dated 6/16/17, Patient A2's MTP dated 6/26/17, Patient A3's MTP dated 6/26/17, Patient A4's MTP dated 6/19/17, Patient A5's MTP dated 6/23/17, and Patient A6's MTP dated 6/23/17 did not contain physician interventions on the MTPs.

B. Policy Review

Hospital policy, "Administrative Policy & Procedure Treatment Plan" revised 6/2016 stated "The treatment plan should include: (c) Methods and individualized approaches of treatment."

C. Interviews

1. In an interview on 6/27/17 at 9:15 a.m., the Director of Social Work indicated there were no physician interventions listed on the MTPs.

2. In an interview on 6/27/17 at 10:30 a.m., the Director of Nursing, the Risk Manager and the Assistant Director of Nursing concurred that there were no physician interventions present on the patients' MTPs.

3. In an interview on 6/27/17 at 11:30 a.m., the CEO concurred that there were no physician interventions noted on the patients' MTPs.

II. Generic Nursing Interventions

A. Medical Record Review

1. Patient A1 was admitted on 6/13/17. The Admission Psychiatric Evaluation dated 6/13/17 identified the diagnoses as, "Delusional disorder" and "Major neurocognitive disorder with behavioral syndrome secondary to Alzheimer's disease." The MTP dated 6/16/17 identified the problem, "Violence." The nursing interventions for this problem included: "Monitor patients [sic] for triggers every day" and "Monitor for signs of distress- crying, throwing objects, hitting others."

2. Patient A2 was admitted on 6/20/17. The Admission Psychiatric Evaluation dated 6/20/17 identified the diagnosis as "Major neurocognitive disorder with behavioral syndrome secondary to Alzheimer's disease and microvascular disease." The Master Treatment Plan (MTP) dated 6/26/17 identified the problem, "Violence." The nursing interventions for this problem included: "Monitor patients for triggers every day" and "Monitor for signs of distress-cursing, hitting objects/others."

3. Patient A3 was admitted on 6/21/17. The Admission Psychiatric Evaluation dated 6/22/17 identified the diagnosis as "Major neurocognitive disorder with behavioral syndrome secondary to Alzheimer's disease." The Master Treatment Plan (MTP) dated 6/26/17 identified the problem, "Violence." The nursing interventions for this problem included: "Monitor patients for triggers every day" and "Monitor for signs of distress-yelling, hitting others."

4. Patient A4 was admitted on 6/14/17. The Admission Psychiatric Evaluation dated 6/14/17 identified the diagnosis as, "Major neurocognitive disorder with behavioral syndrome secondary to Alzheimer's disease." The MTP dated 6/19/17 identified the problem, "Violence." The nursing interventions for this problem included: "Monitor patients [sic] for triggers every day" and "Monitor for signs of distress- crying." Other interventions for this problem included: "Explain procedures", "Speak with a calm steady voice" and "Orient to unit and the routine meds as ordered, monitor for effectiveness and SE (side effects)."

5. Patient A5 was admitted on 6/19/17. The Admission Psychiatric Evaluation dated 6/20/17 identified the diagnosis, "Major neurocognitive disorder with behaviors." The MTP dated 6/23/17 identified the problem, "Violence." The nursing interventions for this problem included: "Monitor patients [sic] for triggers every day" and "Monitor for signs of distress- crying/yelling, hitting objects/others, cursing."

6. Patient A6 was admitted on 6/20/17. The Admission Psychiatric Evaluation dated 6/20/17 identified the diagnosis, "Major vascular disorder with behavioral syndrome." The MTP dated 6/23/17 identified the problem. "Violence." The nursing interventions for this problem included: "Monitor patients [sic] for triggers every day" and "Monitor for signs of distress- throwing objects, hitting objects/others.

B. Interview

During interview on 6/27/17 at 10:30 a.m., the Director of Nursing (DON), the Risk Manager and the Assistant Director of Nursing acknowledged that the nursing interventions shared with them were not individualized and were generic discipline functions.

Based on medical record review, policy review and interview, it was determined that the hospital failed to ensure that the specific nursing staff member responsible for each intervention was identified in six (6) of six (6) treatment plans (Patients.A1, A2, A3, A4, A5 A6). This failure resulted in the patient and other staff being unaware of which staff person was assuming responsibility for the nursing intervention being implemented and documented.

Findings include:

A. Medical Record Review

Patient A1's Master Treatment Plan (MTP) dated 6/16/17, Patient A 2's MTP dated 6/26/17, Patient A3's MTP dated 6/2 6/17, Patient A4's MTP dated 6/19/17, Patient A5's MTP dated 6/23/17, and Patient A6's MTP dated 6/23/17, did not contain a listing of specific nursing staff responsible for the implementation of nursing interventions on the MTPs.

B. Policy Review

Hospital policy, "Administrative Policy & Procedure Treatment Plan" revised 6/2016 stated "The treatment plan should include: Who is responsible for carrying out the plans by name and discipline."

C. Interviews

1. In an interview on 6/27/17 at 10:30 a.m., the Director of Nursing, the Risk Manager and the Assistant Director of Nursing concurred that the patients' MTPs did not contain a listing of specific nursing staff responsible for the implementation of nursing interventions on the MTPs.

2. In an interview on 6/27/17 at 11:30 a.m., the CEO concurred that the patients' MTPs did not contain a listing of specific nursing staff responsible for the implementation of nursing interventions on the MTPs.

Based on record review, policy review and interview the medical director failed to:

1. Ensure the provision of Master Treatment plans that include patient-related goals stated in measurable terms for five (5) of six (6) active sample patients (PatientsA2, A3, A4, A5 and A6). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions based on changes in patient behaviors. (See B121)

2. Ensure the MTP interventions by physicians and nursing staff consistently address specific treatment needs for six (6) of six (6) active sample patients (A1, A2, A3, A4, A5 and A6). Specifically there were no physician interventions on the MTP and nursing interventions were primarily stated as generic discipline functions. Failure to document specific treatment approaches has the potential to interfere with the assurance of consistency of approach to each patient's problems and could result in prolonged hospitalization. (See B122)

3. Ensure that the specific nursing staff member responsible for each intervention was identified in six (6) of six (6) treatment plans (Patients.A1, A2, A3, A4, A5 and A6). This failure resulted in the patient and other staff being unaware of which nursing staff person was assuming responsibility for the intervention being implemented and documented. (See B123)

The absence of an integrated, comprehensive treatment plan has the potential to result in a lack of coordinated and organized treatment.

Interview

1. In an interview with the Medical Director on 6/27/17 at 2:00 p.m., the above findings were discussed. He voiced his opinion that the Treatment Planning process was a paper exercise. He did not dispute the above findings.

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

1. Ensure that nursing interventions listed on patients' MTPs addressed individualized patient needs for six (6) of six (6) active patients (A1, A2, A3, A4, A5 and A6). Instead, the interventions were stated in vague terms and were non-individualized, generic discipline functions rather than individualized patient specific nursing interventions. This deficiency results in a failure to guide nursing staff regarding the specific treatment purpose of each intervention and limits the therapeutic nursing interventions available to patients. (See B122)

2. Ensure that the specific nursing staff member responsible for each intervention was identified in six (6) of six (6) treatment plans (Patients.A1, A2, A3, A4, A5 and A6). This failure resulted in the patient and other staff being unaware of which nursing staff person was assuming responsibility for the intervention being implemented and documented. (See B123)

Interview

In an interview on 6/27/17 at 10:30 a.m., the Director of Nursing, the Risk Manager and the Assistant Director of Nursing concurred that the nursing interventions shared with them were not individualized and were generic discipline functions. They also agreed that the MTPs did not contain a listing of specific nursing staff responsible for the implementation of nursing interventions on the MTPs.