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Based on document review and interview, the registered nurse failed to ensure the nurse practitioner (NP) orders witten in the medical record (MR) were followed for two (2) of four (4) patient MR's reviewed. (Patient # 6 & Patient # 7)

Findings include:

1. Review of the hospital policy entitled, "The Role of the Director of Nursing", policy number 4016191, effective date 03/2016, indicated the Director of Nursing (DON) "is responsible" for the development, organization, and management of all nursing activities. The DON provides supervision for organized nursing care. Patient care standards and nursing practice/professional standards are developed established, and "implemented under the supervision of the DON". This policy was last revised on 09/2017.

2. On 02/20/2018 at approximately 10:28 am with administrative staff member A # 2 (DON), the medical records (MR's) for patient # 6 and patient # 7 were reviewed. The following NP orders were not completed:
A. On 02/18/2018 at 2:00 pm NP # 1 (Nurse Practitioner) wrote an order in patient # 6's medical record to obtain the culture report from H # 2 (Acute Care Hospital). The culture report was not in the patients chart.
B. On 02/17/2018 at 4:00 pm NP # 1 wrote an order in patient # 7's medical record to obtain an "orthostatic blood pressure (BP) "now" and put results on the chart". The Vital Signs Flow sheet was reviewed and lacked the BP information for that date and time.

3. Interview on 02/20/2018 at approximately 5:05 pm with administrative staff member A # 2, confirmed the above orders written by NP # 1 were not implemented.

Based on document review and interview, the facility failed to have a qualified nutrition professional order a therapeutic diet for one of five patient diets reviewed (PT#1).

Findings Include:

1) Policy titled, "Nutrition Screening/Consults, Expiration: 07/2018, Effective: 01/2012" indicated the following on page 2 of 4, "...2. The RD, if state scope of practice allows to do so, will write specific nutrition orders in the medical record. The attending care provider will be required to counter sign acknowledging the order..."

2) Review of medical record titled, "Pharmacy and Dietary Profile", indicated a signature at the bottom of the page ordering a therapeutic diet for PT#1 on 2/8/17 at 0200 hrs. The signature was identified as SP-16, who is not a qualified nutrition professional, nor the patient's practitioner responsible for his/her care at the time the order was executed.

3) In interview on 2/20/18 at 9:21 am, SP-5 confirmed the therapeutic order for PT#1 on 2/8/17 at 0200 hrs, was not ordered by a qualified nutrition professional nor the patient's practitioner responsible for his/her care.

A Life Safety Code Validation Survey for a Psychiatric Hospital was conducted by the Indiana State Department of Health in accordance with 42 CFR 482.41(b).

Survey Dates: 02/21/2018

Provider Number: 154059

At this Life Safety Code Survey, Sycamore Springs was found not in compliance with Requirements for Participation Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety From Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This facility is a one story building that was determined to be of Type II (111) construction and fully sprinklered. The facility has a fire alarm system with smoke detection in the corridors, in all areas open to the corridors with hard wired smoke detectors in all resident rooms. The facility has a capacity of 48 and had a census of 47 at the time of this visit.

All areas where residents have customary access were sprinklered. All areas providing facility services were sprinklered.

Based on record review, observation and interview; the facility failed to document sprinkler system inspections in accordance with NFPA 25 for 1 of 1 sprinkler system (see tag K353), the facility failed to install the kitchen range hood system in accordance with the requirements (see tag K324), the facility failed to ensure the spray pattern for sprinkler heads were not obstructed in 1 of 1 dining room (see tag K351), the facility failed to ensure 1 of 2 recreation rooms were not using flexible cords as a substitute for fixed wiring (see tag K920), the facility failed to ensure 12 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills for the last 4 quarters (see tag K712), the facility failed to ensure 1 of 1 emergency generator was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' stations (see tag K916).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on record review, observation and interview; the facility failed to document sprinkler system inspections in accordance with NFPA 25 for 1 of 1 sprinkler system. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients and staff in the facility.

Findings include:

Based on review of Tyco / Simplex Grinnell's "Elements of Performance" documentation dated 03/13/17, 06/14/17, 09/18/2017, and 12/16/2017 on 02/21/18 at 11:30 a.m., there were no documented monthly sprinkler gauge inspections noted. In addition, weekly inspection documentation for all sprinkler system control valves was also not available for review. Based on interview at the time of record review, the EOC Manager acknowledged monthly sprinkler system gauge inspection documentation and weekly control valve inspection documentation, for the aforementioned periods was not available for review.

Based on observation and interview, the facility failed to install the kitchen range hood system in accordance with the requirements of LSC 9.2.3. Section 9.2.3 states commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96, 2011 edition, Section 6.2.4.1 states kitchen range hood system filters shall be equipped with a drip tray beneath their lower edges. The tray shall be kept to the minimum size needed to collect grease and shall be pitched to drain into an enclosed metal container having a capacity not exceeding 1 gal (3.785 L). This deficient practice could affect up to 24 patients, as well as 4 staff and 2 visitors, the Dining room area contained a cooler that met with a bulkhead. This bulkhead contained a sprinkler head that was approximately four inches from the top of the cooler.

2) Based on observation and interview, the facility failed to provide sprinkler coverage for 2 of 2 areas outside and attached to the building and constructed of partially combustible material. NFPA 13, The Standard for the Installation of Sprinkler Systems at 8.15.7.1 requires sprinklers be installed under exterior roofs, canopies, porte-cocheres, balconies, decks, or similar projections exceeding four feet in width. This deficient practice could affect all patients in the facility using the patio areas, the facility failed to ensure 1 of 2 recreation rooms were not using flexible cords as a substitute for fixed wiring. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects up to 22 patients and 4 staff.

Findings include:

1. Based on observation with the EOC Manager during a tour of the facility at 11:40 a.m. on 02/21/18, one of one designated locations underneath the kitchen range hood system drip tray was missing an enclosed metal container for grease to drain into. The designated location for a grease container had a one inch in diameter hole in the drip tray beneath the system filters and had an affixed bracket for holding a container but no container was present. Based on interview at the time of observation, the EOC Manager acknowledged the designated location underneath the kitchen range hood system drip tray was missing an enclosed metal container for grease to drain into.

2. Based on interview at the time of observation, the EOC Manager acknowledged the aforementioned condition, and gave the listed measurement.

3. NFPA 13, The Standard for the Installation of Sprinkler Systems at 8.15.7.1 requires sprinklers be installed under exterior roofs, canopies, porte-cocheres, balconies, decks, or similar projections exceeding four feet in width. This deficient practice could affect all patients in the facility using the patio areas.

4. Based on observation on 02/21/18 at 11:55 a.m. during a tour of the facility with the EOC Manager, there was a twenty seven by thirty foot overhang attached to the building outside both the Meadows and the Willows. This "patio" area contained four ceiling fans, and wood planking attached to the ceiling of the patio. The patio area was attached directly to the building. There was no sprinkler coverage provided under the overhang. Based on interview at the time of observation, the EOC Manager acknowledged there was no sprinkler coverage under the Meadows or the Willows patio overhang, or documentation that the wood planking was inherently flame retardant.

5. Based on observation with the EOC Manager on 02/21/18 at 12:21 p.m., a fifteen foot extension cord was run from an electrical outlet to a flat-screen television mounted on the wall in the Meadows recreation room. Based on interview at the time of the observation, the EOC Manager acknowledged the use of an extension cord powering a flat-screen television in the Meadows recreation room.

Based on record review and interview, the facility failed to ensure 12 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. This deficient practice affects all patients in the facility as well as staff and visitors.

Findings include:

Based on record review of the document titled "Fire Drill Critique" with the EOC Manager on 02/21/18 at 11:44 a.m., the documentation for the drills for the past twelve months lacked verification of the transmission of the signal for drills. Based on interview at the time of record review, the EOC Manager stated that he did ask the monitoring company for confirmation of the signal being received during his drills, but failed to document the verification of the transmission of the fire alarm signal in his records.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generator was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' stations. NFPA 99, 2012 Edition, Health Care Facilities Code, at 6.4.1.1.17 requires a remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
(1) Individual visual signals shall indicate:
a. When the emergency or auxiliary power source is operating to supply power to load.
b. When the battery charger is malfunctioning.
(2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
a. Low lubricating oil pressure.
b. Low water temperature.
c. Excessive water temperature.
d. Low fuel when the main fuel storage tank contains less than a 4-hour operating supply.
e. Overcrank (failed to start).
f. Overspeed.
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 6.4.1.1.17(1) and (2) occur but need not display these conditions individually. This deficient practice could affect all patients, as well as visitors and staff in the facility.

Findings include:

Based on interview during record review on 02/21/18 at 10:38 a.m., the EOC Manager said the facility has an emergency generator. When asked, the EOC Manager said there was a remote alarm annunciator panel for the generator at a 24 hour station in the Willows staff lounge. Based on observation during a tour of the facility, this was confirmed with the EOC Manager on 02/21/18 at 12:15 p.m. When tested, the alarm would sound and was said to be loud enough to alert the nurses at the nurse's station. Upon testing the alarm and asking nursing staff what the alarm was, they thought the alarm was coming from the bathroom assistance alarm. The remote alarm annunciator panel for the emergency generator not being at any nurses' station, or in a 24 hour supervised area was acknowledged by the EOC Manager at the time of the testing.

Based on document review, observation and interview, the infection control officer failed to ensure documentation of communicable disease history for sixteen of sixteen staff member files reviewed (SP-2, SP-8, SP-9, SP-10, SP-12, SP-13, SP-14, SP-15, N # 1, N # 4, N # 5, A # 2, P # 1, P # 2, P # 3, and P # 4) and the facility failed to ensure the infection control plan was followed for identifying, reporting, investigating, and/or controlling the spread of possible infections in seven (6) instances.

Findings Include:

1. Review of facility document titled, "Sycamore Springs 2018 Infection Prevention and Control Plan", page 1, paragraph titled, "PURPOSE" indicated the following: "The development of policies and interventions will be guided by recommended practices of the Association of Professionals in Infection Control (APIC), the Centers for Disease Control (CDC), and others.

2. Review of CDC (Centers for Disease Control) document titled, " Immunization of Health-Care Personnel Recommendations of the Advisory Committee on Immunization Practices (ACIP) Recommendations and Reports / Vol. 60 / No. 7 November 25, 2011..." indicated the following,

a. "...Hepatitis B HCP and trainees in certain populations at high risk for chronic hepatitis B (e.g., those born in countries with high and intermediate endemicity) should be tested for HBsAg and anti-HBc/anti-HBs to determine infection status..."

b. "...Measles, mumps, and rubella (MMR) History of disease is no longer considered adequate presumptive evidence of measles or mumps immunity for HCP; laboratory confirmation of disease was added as acceptable presumptive evidence of immunity. History of disease has never been considered adequate evidence of immunity for rubella. The footnotes have been changed regarding the recommendations for personnel born before 1957 in routine and outbreak contexts. Specifically, guidance is provided for 2 doses of MMR for measles and mumps protection and 1 dose of MMR for rubella protection..."

c. "...Varicella Criteria for evidence of immunity to varicella were established. For HCP they include written documentation with 2 doses of vaccine, laboratory evidence of immunity or laboratory confirmation of disease, diagnosis of history of varicella disease by health-care provider, or diagnosis of history of herpes zoster by health-care provider..."

3. Review of the hospital policy entitled, "Employee Health Program", policy number 3849624, effective date 01/2012, indicated the hospital "is dedicated to promote and maintain optimal employee health while ensuring that its employees.... do not present a health hazard to patients or other employees". This policy was last revised on 08/2017.

4. Review of the HCP health files on 02/20/2018 and 02/21/2018, indicated the following personnel: Review of personnel files for SP-2 (Director of Dietary), SP-8 (PCA-Patient Care Assistant), SP-9 (PCA), SP-10 (Registered Nurse - RN), SP-12 (RN), SP-13 (Dietitian), SP-14 (Dietary Manager), SP-15 (Cook), N # 1 (RN), N # 4 (House Supervisor), N # 5 (Nurse Manager), A # 2 (Director of Nursing-DON) P # 1 (PCA), P # 2 (PCA), P # 3 (PCA), and P # 4 (Housekeeper), and were missing confirmation documentation showing evidence of immunity that should have been maintained according to the CDC guidelines related to Hepatitis B, Measles, Mumps, Rubella, and Varicella vaccines.

5. In interview on 2/20/18 at 10:13 am, staff member SP-7 (Human Resource Manager), confirmed the above findings.

6. Interview on 02/21/2018 at approximately 4:45 pm with administrative staff member A # 4 (Director of Quality/Infectionist), confirmed the facility did not have a policy requiring HCP to prove confirmation of immunity for MMR or Varicella.

7. Interview on 02/21/2018 at approximately 4:48 pm with administrative staff member A # 5 (Human Resource Manager), confirmed the "facility has never required proof" of immunity".


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8. Review of the hospital policy entitled, "Appearance Standard", policy number 3652815, effective date 01/2012, indicated as recommended by the Centers for Disease Control and Prevention (CDC), only "natural fingernails are permitted" (artificial nails are prohibited) for caregivers who have "direct contact with patients", staff who prepare sterile fluids in pharmacy, all staff involved with "cleaning processes". The definition of artificial nails includes but is not limited to "acrylic nails, gels, all overlays, tips, bondings, extensions, tapes, inlays, and wraps". This policy was last revised on 07/2017.

9. On 02/20/2018 at approximately 11:10 am with administrative staff member A # 2 Director of Nursing (DON), an observation was made of RN # 1 wearing artificial nails.

10. On 02/20/2018 at approximately 12:35 pm with administrative staff member A # 2, an observation was made of HK # 1 (Housekeeper) wearing artificial nails.

11. Interview on 02/22/2018 at approximately 12:45 pm with administrative staff member A # 2, confirmed RN # 1, and HK # 1 should have not been wearing artificial nails.

12. Review of the hospital policy entitled, "Linen Management", policy number 4626936, effective date 02/2018, indicated the housekeeping staff will transport the linen cart to clean linen room.

13. On 02/20/2018 at approximately 10:05 am with administrative staff member A # 2, an observation was made of the clean utility/linen room on M # 1 (Unit). Four (4) of four (4) linen carts were observed to have dust on the bottom shelf.

14. On 02/20/2018 at approximately 12:25 pm with administrative staff member A # 2, an observation was made of the clean utility/linen room on W # 1 (Unit). Four (4) of four (4) linen carts were observed to have dust on the bottom shelf.

15. Interview on 02/22/2018 at approximately 12:45 pm with administrative staff member A # 2, confirmed the linen carts needed to be cleaned.

16. Review of the hospital policy entitled, "General Cleaning Policy", policy number 4626982, effective date 02/2018, indicated to dust ledges, and other horizontal building and furniture surfaces to remove obvious soil. Use a "treated dust cloth or short handled dusting tool" daily.

17. On 02/20/2018 at approximately 10:10 am with administrative staff member A # 2, an observation was made of the storage room on M # 1. The top of the patient lockers were dusty.

18. Interview on 02/22/2018 at approximately 12:45 pm with administrative staff member A # 2, confirmed the top of the lockers needed to be cleaned.

19. Review of the hospital policy entitled, "Cleaning and Disinfecting of Patient Care Items and Equipment", policy number 3833630, effective date 01/2012, indicated the low-level disinfection program is designed to reduce risks of the spread of infection and is not used to replace the need for higher levels of cleaning or disinfection. This policy was last revised 07/2017.

20. Review of the "True Metrix Pro" manufacturers recommendations, indicated that "cleaning removes blood and soil from the meter". Disinfecting removes most, but not all possible "infectious agents (bacteria or virus) from the meter", including blood-borne pathogens. "Clean and disinfect the meter with (EPA # 9480-4) ONLY Super Sani-Cloth wipes" on all outside surfaces of the "meter" and "make sure the meter remains wet for two (2) minutes".

21. Interview on 02/20/2018 at approximately 10:20 am with RN # 2 (Licensed Practical Nurse-LPN), on unit # M 1, confirmed the glucometers were cleaned with alcohol wipes, which is confirmation of the facility using the wrong type of cleanser, according to the manufacturer's recommendations.

22. Interview on 02/20/2018 at approximately 12:30 pm with RN # 3 (RN), on unit # W 1, confirmed the glucometers were cleaned with Sani-Cloth Plus, and it needs to remain wet for thirty (30) seconds, which is confirmation of the facility using the wrong type of cleanser and incorrect amount of time to remain wet, according to the manufacturer's recommendations.

23. Interview on 02/22/2018 at approximately 12:45 pm with administrative staff member A # 2, confirmed the facility did not have the correct product to clean the glucometers per manufactures recommendations.

24. Review of the hospital policy entitled, "Care of Patients with MRSA" (Methicillin-resistant Staphylococcus aureus), policy number 4101060, effective date 01/2012, indicated the "nursing staff" should "isolate the patient in a private room" when "MRSA" of a draining wound is "suspected". This policy was last revised on 11/2016.

25. Review of the "Treatment Planning Problem Sheet", dated 02/18/2018, indicated patient # 6 was being "actively treated for the medical problem" of "MRSA in boil L (left) arm".

26. Review of the microbiology wound culture and sensitivity (C&S) report faxed from H # 2 (Acute Care Hospital) on 02/20/2018 at approximately 4:45 pm, indicated the patient's left upper arm abscess culture was resulted on 02/07/2018. The final results were three plus "(3+ many) Staphylococcus aureus (MRSA)".

27. Review of the skin assessment on the "Inpatient Admission Assessment" dated 02/16/2018, indicated the patient had a wound on the left upper arm.

28. On 02/20/2018 at approximately 10:28 am with administrative staff member A # 2, an observation was made of patient # 6 sharing a room.

29. Interview on 02/20/2018 at approximately 10:30 am with administrative staff member A # 2, confirmed the nursing staff had not placed patient # 6 in a private room for isolation of MRSA.

30. Review of the hospital policy entitled, "Care of Patients with MRSA", policy number 4101060, effective date 01/2012, indicated all staff should "wear gloves and gowns" when entering the room if substantial contact with the patient is anticipated. This policy was last revised on 11/2016.

31. On 02/20/2018 at approximately 4:07 pm with RN # 2, an observation was made of patient # 6's left upper arm dressing change. The nurse donned gloves prior to performing the dressing change, but removed them before the dressing was completed. The nurse did not don an isolation gown.

32. Interview on 02/21/2018 at approximately 12:00 pm with administrative staff member A # 4 (Director of Quality Assurance), confirmed the nurse should have worn a gown when entering the room of a patient with MRSA, and should have kept the gloves on during the entire dressing change process.

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

I.Provide a psychiatric evaluation containing a statement of strengths and assets for three (3) of eight (8) active sample Patients (A3,A8, and A9). This failure has the potential to impact the treatment plan processes, which may result in inappropriate treatment goals and activities. (Refer to B117)

II. Document a Master Treatment Plan (MTP) for one (1) of eight (8) active sample patients (A3). The failure to develop a Master Treatment Plan for this patient has the potential to inhibit the staff's ability to provide individualized and coordinated care as well as the potential to result in the patient's treatment needs not being met. (Refer to B118)

III.Provide a substantiated diagnosis for one (1) of eight (8) active sample patients (A3). This practice has the potenital to compromise the staff's ability to formulate and deliver a clinically focused plan of care. (Refer to B120)

IV. Ensure that active treatment measures, such as group and/or individual treatment were provided for three (3) of eight (8) active sample patients (A6, A8 and A9) who were unwilling, or not motivated, to attend or participate in active treatment groups. The 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 patients 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 a Psychiatric Evaluation containing a statement of strengths and assets in descriptive, not interpretive fashion for three (3) of eight (8) active sample patients (A3, A8, and A9). This failure has the potential to impact the treatment plan processes, which may result in inappropriate treatment goals and activities.

Findings Include:

A. Medical Record Review

Patient A3's Psychiatric Evaluation dated 2/12/18, Patient A8's Psychiatric Evaluation dated 2/9/18, and Patient A9's Psychiatric Evaluation dated 2/16/18 did not contain a listing of assets and strengths.

B. Document Review

Facility Medical Staff Rules and Regulations (PolicyStat ID: 39009588) Revised 8/2017, page 4, states the following: "C. Comprehensive Psychiatric Evaluation will include: (m) Mental status and Patient assets."

C. Interviews

1. In an interview on 2/20/19 at 1:00 p.m., the Director of Quality Improvement concurred that the Psychiatric Evaluations did not have documented patient assets and strengths.

2. In an interview on 2/21/18 at 10:00 a.m., the Medical Director concurred that the Psychiatric Evaluations did not have documented patient assets and strengths.

Based on medical record review, document review, and interview, the facility failed to document a Master Treatment Plan (MTP) for one (1) of eight (8) active sample patients (A3). The failure to develop a Master Treatment Plan for this patient has the potential to inhibit the staff's ability to provide individualized and coordinated care as well as the potential to result in the patient's treatment needs not being met.

Findings Include:

A. Medical Records

On 2/19/18 at 10:30 a.m., the surveyor requested copies of MTPs for the eight (8) active sample patients. At 1:00p.m. on 2/20/18, the surveyor noted that a copy of A3's MTP had not been provided. The surveyor again requested a copy of the MTP for patient A3. On 2/20/18at 2:45 p.m., the Director of Clinical Services indicated that the plan could not be located and was therefore not available to the surveyor or treatment team at that time.

B. Document Review

1. Facility Policy ID: 3820047, Revised 8/2017 titled "Treatment Planning - Philosophy and Purpose" indicates the following:

"The Hospital believes that the interdisciplinary Treatment Plan can be an effective therapeutic tool which is productive and helpful to staff as well as to patients ...."

" ...the assurance that every patient admitted will have an individualized plan specific to his/her assessed needs and that the patient's attending physician will direct and participate in all phases of the treatment planning process ...."In IN [Indiana], AZ [Arizona], KS [Kansas], Ok[Oklahoma], and CO[Colorado] the treatment plan will be formulated within 72 hours of admission."

C. Interviews

1. In an interview on 2/20/18at 2:45 p.m., the Medical Records Director indicated that she had been unable to locate the psychiatric MTP for Patient A3.

2. In an interview on 2/20/18 at 3:30 p.m., the Director of Clinical Services indicated that the Psychiatric MTP for patient A3 could not be located.

3. In an interview on 2/21/18 at 10:00 a.m., the Medical Director agreed that Patient A3 should have had a psychiatric treatment plan.

Based on medical record review, document review, and interview, the facility failed to provide a substantiated diagnosis for one (1) of eight (8) active sample patients (A3). This practice has the potenital to compromise the staff's ability to formulate and deliver a clinically focused plan of care.

Findings Include:

A. Medical Records

Patient A3 was admitted on 2/11/18 at 5:30 p.m. The Psychiatric Evaluation dictated on2/12/18 at 1:38 p.m. indicated a patient with a "history of bipolar disorder and alcohol dependence who presented to this facility with suicidal ideation and a strong urge to detoxify and begin long term treatment." The Psychiatric Evaluation did not document a psychiatric diagnosis upon which a treatment plan could be established.

B. Document Review

Medical Staff rules and Regulations Revised 8/20/17 page 4, Section C, indicates the following requirement: "C. Comprehensive Psychiatric evaluation will include: (n) Primary diagnosis."

C. Interviews

1. In an interview on 2/21/18 at 10:00 a.m., the Medical Director concurred that the Psychiatric Evaluation for patient A3 should contain a substantiated psychiatric diagnosis.

2. In an interview on 2/20/18 at 1:00 p.m., the Director of Quality Improvement concurred that the Psychiatric Evaluation for patient A3 did not contain a substantiated psychiatric diagnosis.

Based on medical record review, document review, and interview, the facility failed to provide treatment plans that identified patient-related short term and long-term goals documented in observable, measurable, behavioral terms. This failure has the potential to result in a document that fails to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients in three (3) of eight (8) active sample patients. (A1,A6, and A7).

Findings Include:

A. Medical Record Review

1. Patient A1's MTPdated 2/7/18 listed the problem, "Pt [Patient] has been using ½ gram of heroin and $40 of ETOH [alcohol] per day for the past1 - 2 years." The hand written non-measurable goal for this patient was, "verbalize an understanding of why relapse continues to occur."

2.Patient A6's MTP dated 2/12/18 listed the problem, "suicide attempt with plan. Pt attempted to overdose on [his/her] Wellbutrin and Depakote. Current stressors include bills and weight gain." The preprinted MTP goals listed the non- measurable goal, "Patient will report a decrease in symptoms of depression on community goals sheets."(Community goals sheets showing a decrease in depression could not be located).

3. Patient A7's MTP dated 2/14/18 listed the problem, "Pt. experiencing SI [suicidal ideation] without a plan or intent. Pt wrote suicide notes to friends and mom." The hand written non-measurable goal was "[he/she] will eliminate all SI and identify 3 reasons plus hope for the future."

B. Document Review

Facility Policy ID: 3820047, Revised 8/2017 (untitled) "Treatment Planning - Philosophy and Purpose,"under "Procedure" indicates the following requirements for MTPs: "4. The plan of care, treatment, and service includes, but may not be limited to:

2. Measurable goals based on the assessed needs, strengths and the patient's limitations."

"1. Sufficiently specific to evaluate the patient's progress.

2. Expressed in behavioral terms that specify measurable indices of progress."

C. Interviews

1. In an interview on 2/20/18 at 10:50 a.m., the Clinical Director concurred that the MTPs did not contain short term goals written in observable, measurable, behavioral terms.

2. In an interview on 2/20/18 at 1:00 p.m., the Director of Quality Improvement concurred that the MTP's did not contain short term goals written in observable, measurable, behavioral terms.

3. In an interview on 2/21/18 at 10:00 a.m.,the Medical Director concurred with the lack observable, measurable, behavioral short-term goals on the treatment plans.

Based on medical record review, document review, and interview, the hospital failed to develop treatment interventions based on the individual needs of the patients for three (3) of eight (8) active sample patients (A1, A6, and A7). This failure has the potential to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings Include:

A. Medical Record Review

1. Patient A1's Master Treatment Plan (MTP) dated 2/7/18 listed the problem, "Pt [Patient] has been using ½ gram of heroin and $40 of ETOH [alcohol] per day for the past 2 years." The hand written non-measurable goal for this patient was, "verbalize an understanding of why relapse continues to occur." The generic preprinted nursing treatment intervention listed for this goal was, "Nursing will assess patient q 15 [every 15 minutes] for Detox [detoxification] behavior and effectiveness of medications." The non-individualized social work intervention listed was, "Staff will provide CBT [Cognitive Behavioral Therapy] group BID [twice a day] for I hour in order to help patient with identify [sic] triggers/negative consequences from usage."

2. Patient A6's MTP dated 2/12/18 listed the problem, "suicide attempt with plan. Pt attempted to overdose on [his/her] Wellbutrin and Depakote. Current stressors include bills and weight gain." The preprinted non- measurable goal for this patient was, "Patient will report a decrease in symptoms of depression on community goals sheets." (Community goals sheets measuring a decrease in depression could not be located.) The generic preprinted nursing intervention listed was, "Nurse will assess patient q 15 for safety, behavior, and effectiveness of medication."The non-individualized social work intervention listed was, "Staff will provide CBT group 2 x days for 1 hour in order to help patient with learning to manage symptoms of depression."

3. Patient A7's MTP dated 2/14/18 listed the problem, "Pt. experiencing SI [suicidal ideation] without a plan or intent. Pt wrote suicide notes to friends and mom." The following hand written non-measurable goal was, "[he/she] will eliminate all SI and identify 3 reasons plus hope for the future." The generic preprinted nursing intervention listed was, "Nursing will assess patient daily for side effect of meds, behavior and effectiveness of medications."Non-individualized social work interventions listed were, "Staff will provide CBT group 2 x days for 1 hour in order to help patient with learning to manage symptoms of depression."

B. Document Review

1. Facility Policy ID: 3820047, Revised 8/2017, untitled, "Treatment Planning - Philosophy Policyand Purpose"does not indicate the requirement for individualized patient specific staff interventions.

C. Interviews

1. In an interview on 2/20/18 at 9:00 a.m., the Director of Nursing concurred that the nursing interventions were generic discipline functions and were not individualized.

2. In an interview on 2/20/18 at 10:50 a.m., the Clinical Director concurred that the MTPs did not contain treatment interventions that were individualized to meet the treatment needs of the patients.

3. In an interview on 2/20/18 at 1:00 p.m., the Director of Quality Improvement concurred that the MTP's did not contain treatment interventions which were individualized to meet the needs of the patients.

4. In an interview on 2/21/18 at 10:00 a.m., the Medical Director agreed that staff interventions should be individualized to meet the needs of the patients.

Based on medical record review, observation, and interviews, the facility failed to ensure that active treatment measures, such as group and/or individual treatment were provided for three (3) of eight (8) active sample patients (A6, A8 and A9) who were unwilling, 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 A6 was admitted on 2/12/18. The Psychiatric Evaluation dated 2/14/18 listed the diagnoses as "Bipolar disorder, most recent episode is depression, Generalized anxiety disorder, and Posttraumatic stress disorder [PTSD]." The MTP dated 2/12/18 for the problem, "Suicidal attempt with plan," identified interventions as "Staff [Social Worker] will provide CBT [Cognitive Behavioral Therapy] 2x [times] daily for 1 hour in order to help patient with learning skills that will help manage symptoms of depression"; "Staff [Social Worker] will provide relaxation group weekly for 1 hour in order to help patient with coping skills to help manage anxiety," and " Rec [Recreational] Therapy 2x daily to practice positive coping skills for anxiety to prevent self harm."

Review of the "Close Observation Record" for 2/13/18-2/18/13 revealed the following:

2/13/18-Patient stated that s/he was "not going to attend a lot of groups because s/he had been here before and feels s/he not getting anything out of the groups."

2/14/18-Patient attended one (1) of the nine (9) groups offered.

2/15/18-Patient attended four (4) of the nine (9) groups offered.

2/16/18-Patient attended zero (0) of the nine (9) groups offered. Personal Care Assistant (PCA) note for day shift stated, "Pt. was pleasant, but withdrawn. Pt slept a lot today." PCA note for evenings stated, "Patient did not attend groups and was withdrawn to [his/her] room."

2/17/18-Patient attended one (1) of the eight (8) groups offered.

2/18/18-Patient attended one (1) of the eight (8) groups offered. PCA note for evening shift stated, "Pt sat around the dayroom with a male peer and did not attend groups."

2. Patient A8 was admitted on 2/8/18. The Psychiatric Evaluation dated 2/9/18 listed the diagnoses as "Bipolar disorder, most recent episode depression with psychotic features, Generalized anxiety disorder and PTSD." The MTP dated 2/8/18 for the problem, "Pt. presents with SI [Suicidal Ideation] with plan ...," identified interventions as "Staff [Social Worker] will provide CBT/DBT [Dialectical Behavior Therapy] group 2x/day for 1 hour in order to help patient with developing distraction techniques to eliminate /reduce cutting," and "Rec Therapy 2x daily to find coping skills to manage hallucinations as alternative to self-harm."

Review of the "Close Observation Record for 2/9/18-2/18/18 revealed the following:

2/9/18-Patient attended one (1) of the nine (9) groups offered. The Personal Care Assistant (PCA) note stated, "Pt was withdrawn to [him/herself]. Pt stayed in bed a lot and didn't socialize much."

2/10/18-Patient attended two (2) of the eight (8) groups offered. The PCA note for evening shift stated, "Pt was observed to be withdrawn throughout most of shift and isolated to [him/herself] in [his/her] room."

2/11/18-Patient attended two (2) of the eight (8) groups offered. The PCA note for evening shift stated, "Pt was isolative and withdrawn to his room asleep for most of the evening."

2/12/18-Patient attended zero (0) of the nine (9) groups offered. The PCA note for evening shift stated, "Pt did not attend any groups."

2/13/18-Patient attended zero (0) of the nine (9) groups offered. The PCA note for day shift stated, "Patient attended no a.m. groups." The evening PCA note stated, "Pt was withdrawn to [his/her] room in bed sleeping the majority of shift."

2/14/18-Patient attended three (3) of the nine (9) groups offered.

2/15/18-Patient attended four (4) of the nine (9) groups offered.

2/16/18-Patient attended one (1) of the nine (9) groups offered. The PCA note for the day shift stated, "Pt slept much of shift. Pt attended one group." The PCA note for the evening shift stated, "Pt does not attend groups."

2/17/18-Patient attended three (3) of eight (8) groups offered.

2/18/18-Patient attended three (3) of eight (8) groups offered.

3. Patient A9 was admitted on 2/15/18. The Psychiatric Evaluation dated 2/16/18 listed the diagnoses as "Bipolar 1 disorder by history, most recently depressed." The MTP dated 2/15/18 for the problem, "Pt. is gravely disabled due to depression ...," listed the interventions as "Staff [Social Worker] will provide CBT group 2x daily for 1 hour in order to help patient with identifying coping skills to use when depressed"; "Staff [Social Worker] will provide CBT group 2x daily for 1 hour in order to help patient with learning to identify what triggers his depression," and "Rec Therapy 2x daily to practice coping skills and motivational enhancement strategies to decrease depressive symptoms and regain functionality."

Review of the "Close Observation Record for 2/16/18-2/18/18 revealed the following:

2/16/18-Patient attended zero (0) of the nine (9) groups offered. The PCA note for the day shift stated, "Pt did not attend groups." The PCA note for the evening shift stated, "Watched tv and refused all groups."

2/17/18-Patient attended zero (0) of the eight (8) groups offered. The PCA note for the day shift stated, "Pt has been in bed all morning and afternoon ..." The PCA note for the evening shift stated, "Pt voiced n/c [no complaints] and attended no groups."

2/18/18-Patient attended zero (0) of the eight (8) groups offered. The PCA note for the evening shift stated, "Refused all groups ..."

B. Observations

All observations were conducted on the Mental Wellness/Willows Unit on 2/19/18 and 2/20/18.

1. On 2/19/18 from 10:50 a.m.-11:45 a.m., a Rec Therapy group was being held in the group room. The census on the unit was 25 patients. Eleven patients were in group. Patient A6 and A8 were sitting together in the dayroom talking with one another. Patient A9 was in bed. There were three (3) additional patients in the dayroom and (8) additional patients in bed.

2. On 2/19/18 from 1:15 p.m.-2:00 p.m., a Continuing Care-Rec Therapy group was being held in the recreation room. The census on the unit was 23 patients. Eight (8) patients were in the group. Patient A6 and A8 were sitting together in the dayroom and Patient A9 was in bed. There were four (4) additional patients in the dayroom, six (6) additional patients in bed and 2 patients in their rooms.

3. On 2/19/18 from 3:15 p.m.-3:45 p.m., an Exercise Group was being held in the group room. The census on the unit was 23 patients. Ten (10) patients were in the group. Patient A6 and A8 were coloring in the recreation room with two (2) other patients. (This was a patient initiated group and was not a treatment alternative group.) PCA 2 approached the group in the recreation group and told them that they were supposed to be writing in their journal and not socializing if they were not in group. The patients continued to color and socialize with one another. Patient A9 was in bed. Five (5) patients (two on phones) were in the dayroom, and three (3) additional patients were in bed.

4. On 2/19/18 from 3:50 p.m.-4:10 p.m., a Nursing Group was held in the recreation room. The census on the unit was 23 patients. Fourteen (14) patients were in the group including Patients A6 and A8 who remained in the recreation room and continued to color as they had done the previous hour. Patient A9 was in bed. One (1) patient was in the dayroom and seven (7) additional patients were in bed.

5. On 2/20/18 from 9:45 a.m.-10:45 a.m., two (2) Psychotherapy Groups were held (one in the group room and one in the recreation room). The census on the unit was 24 patients. A total of 12 patients were in the two groups. Patient A9 was in bed. Six (6) additional patients were in bed, one (1) patient was with the doctor, and four (4) patients were in the dayroom.

6. On 2/20/18 from 10:45 p.m.-11:45 p.m., a Recreation Group was held in the group room. The census on the unit was 24 patients. Eleven (11) patients were in the group. A6 was alone in the recreation room and was coloring at a table, Patient A8 was A9 were in bed. Five (5) additional patients were in bed, two (2) were in their rooms, and three (3) were in the dayroom.

C. Interviews

1. During interview on 2/19/18 at 11:00 a.m., the Nurse Manager stated that the staff encouraged patients to go to group but not all of the patients wanted to go.

2. During interview on 2/19/18 at 2:30 p.m., Personal Care Assistant 1 (PCA1) stated that if a patient was asleep, "We would not wake them up for group."

3. During interview on 2/20/18 at 3:30 p.m., PCA 2 stated that patients were not to be socializing or using the phones during group time.

4. During interview on 2/20/18 at 11:00 a.m., RN2 acknowledged that Patient A9 did not usually attend groups.

5. During interview on 2/20/18 at 11:45 a.m., the Clinical Director concurred that many of the patients do not go to group.

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

I.Ensure the provision of Psychiatric Evaluations containing a statement of strengths and assets for three (3) of eight (8) active sample Patients (A3, A8, and A9). This failure has the potential to impact the treatment plan processes, which may result in inappropriate treatment goals and activities. (Refer to B117)

II. Ensure the documentation of a Master Treatment Plan (MTP) for one (1) of eight (8) active sample patients (A3). The failure to develop a Master Treatment Plan for this patient has the potential to inhibit a staffs' ability to provide individualized and coordinated care as well as the potential to result in the patient's treatment needs not being met. (Refer to B118)

III. Ensure the provision of a substantiated diagnosis for one (1) of eight (8) active sample patients (A3). This practice has the potenital to compromise the staff's ability to formulate and deliver a clinically focused plan of care. (Refer to B120)

IV. Ensure that active treatment measures, such as group and/or individual treatment were provided for three (3) of eight (8) active sample patients (A6, A8 and A9) who were unwilling, 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

In an interview on 2/21/18 at 10:00 a.m., the Medical Director concurred with the findings of absence of assets on psychiatric evaluations, the lack of a psychiatric diagnosis, and absence of the MTP, and the need for a more active treatment program for patients.

Based on medical record review and interview, the Director of Nursing failed to ensure that nursing interventions on the MTPs were based on the individual needs of the patients for three (3) of eight (8) active sample patients(A1, A6, and A7). The nursing interventions were generic discipline practice. This failure can result in patients not having their nursing needs addressed which can potentially delay recovery.

Findings Include:

A. Medical Record Review

1. Patient A1's Master Treatment Plan (MTP) dated 2/7/18 listed the problem, "Pt [Patient] has been using ½ gram of heroin and $40 of ETOH [alcohol] per day for the past 2 years." The hand written non-measurable goal for this patient was, "verbalize an understanding of why relapse continues to occur." The generic preprinted nursing treatment intervention listed for this goal was, "Nursing will assess patient q 15 [every 15 minutes] for Detox [detoxification] behavior and effectiveness of medications."

2. Patient A6's MTP dated 2/12/18 listed the problem, "suicide attempt with plan. Pt attempted to overdose on [his/her] Wellbutrin and Depakote. Current stressors include bills and weight gain." The preprinted non- measurable goal for this patient was, "Patient will report a decrease in symptoms of depression on community goals sheets." (Community goals sheets measuring a decrease in depression could not be located.) The generic preprinted nursing intervention listed was, "Nurse will assess patient q 15 for safety, behavior, and effectiveness of medication."

3. Patient A7's MTP dated 2/14/18 listed the problem, "Pt. experiencing SI [suicidal ideation] without a plan or intent. Pt wrote suicide notes to friends and mom." The following hand written non-measurable goal was, "[he/she] will eliminate all SI and identify 3 reasons plus hope for the future." The generic preprinted nursing intervention listed was, "Nursing will assess patient daily for side effect of meds, behavior and effectiveness of medications."

B. Interviews

In an interview on 2/20/18 at 9:00 a.m., the Director of Nursing concurred that the nursing interventions were generic discipline functions and were not individualized.