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Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure treatment plans were signed by the patient for four of 31 medical records reviewed (MR9, MR24, MR27 and MR28).

Findings include:

Review on November 7, 2016, of the facility's "Notice of Patient Rights and Responsibilities" policy, last reviewed September 2016, revealed "You have the right to: ... Participate in decisions about your care, including developing your treatment plan, discharge planning and having your family and personal physician promptly notified of your admission. ... Receive information about the outcomes of your care, treatment and services, including unanticipated outcomes. ..."

1) Review on November 7, 2016, of the facility's "Treatment Planning" policy, last revised February 2016, revealed "Policy: ... The Master Treatment Plan must be reviewed with the patient and/or his family or legal guardian and signed and dated within 72 hours of admission. Any changes to the treatment plan must be shared with the patient/family and noted in the progress notes, by the social services representative. The multidisciplinary treatment planning process incorporates the plan of care for each discipline, thereby eliminating the need for separate planning documents for any discipline. Procedure: ... B. Master Treatment Plan: ... 2. Problems will be identified/prioritized and will be the focus of care during the hospitalization. Each active problem will have a specific individualized problem sheet identifying goals and objectives to address the problem. ... 6. The specific interventions to help the patient meet the expected outcomes will be listed and will include the therapeutic modality to be provided, by whom, and frequency. ... C. Weekly Treatment Plan Update: 1. The treatment plan, including the patient's progress towards meeting established goals, will be reviewed each week in the treatment team meeting. Problem oriented updates will include any diagnostic change, the patient's progress towards goals, any newly identified problems, any changes in medication or other treatment interventions, and the expected outcomes. 2. The designated team member will compile the information given in the team meeting regarding the patient's progress and update the treatment plan accordingly, with the approval of the attending psychiatrist. 3. The assigned therapist will review the Treatment Plan Update with the patient, parent or guardian and seek their agreement with the plan."

Review of MR9 on November 7, 2016, revealed the patient was admitted to the facility on June 6, 2016, with an initial problem list of Suicidal thoughts, Risk of violence, Depression and Disruptive and Impulsive behaviors. The facility completed updates to MR9's Treatment Plan on June 13, 2016, and on June 20, 2016. There was no documentation MR9 signed these updated Treatment Plans on June 13, 2016, and on June 20, 2016, and there was no documentation of the patient's refusal or inability to sign the updated Treatment Plan.

Review of MR24 on November 8, 2016, revealed the patient was admitted to the facility on October 5, 2016, with an initial problem list of Risk of violence, Depression and Disruptive and Impulsive behaviors. The facility completed updates to MR24's Treatment Plan on October 7, 12, 19 and 26, 2016, and on November 2, 2016. There was no documentation MR24 signed these updated Treatment Plans on October 7, 12, 19 and 26, 2016, and on November 2, 2016, and there was no documentation of the patient's refusal or inability to sign the updated Treatment Plan.

Review of MR27 on November 8, 2016, revealed the patient was admitted to the facility on October 21, 2016, with an initial problem list of Suicidal thoughts, Risk of violence, Depression and Disruptive and Impulsive behaviors. The facility completed an update to MR27's Treatment Plan on November 1, 2016. There was no documentation MR27 signed this updated Treatment Plan, and there was no documentation of the patient's refusal or inability to sign the updated Treatment Plan.

Review of MR28 on November 8, 2016, revealed the patient was admitted to the facility on September 1, 2016, with an initial problem list of Suicidal thoughts, Risk of violence, Depression and Disruptive and Impulsive behaviors and Trauma. The facility completed an update to MR28's Treatment Plan on October 3, 2016. There was no documentation MR28 signed this updated Treatment Plan, and there was no documentation of the patient's refusal or inability to sign the updated Treatment Plan.

Interview with EMP12 on November 8, 2016, at approximately 9:45 AM confirmed MR9, MR24, MR27 and MR28 were admitted to the facility. EMP12 confirmed there was no documentation MR9, MR24, MR27 and MR28's medical record indicating these patients' signed the updated Treatment Plan and there was no documentation of these patients' refusal or inability to sign the updated Treatment Plans.

Interview with EMP12 on November 8, 2016, at approximately 10:00 AM revealed the purpose for obtaining a patient's signature on a treatment plan was to verify the patient reviewed and participated in the development of the individualized treatment plan.

Based on Life Safety Code Validation survey completed on November 9, 2016, the Condition for Physical Environment is not met. See the Life Safety Code 2567 for the deficiencies.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure the hospital environment on the Children's patient care unit, on Adolescent 1 and Adolescent 2 patient care units, and on Adult patient care units 4 and 5 was maintained in a safe and sanitary manner; and the facility failed to ensure all non-regulated medical waste was stored and disposed of in a manner to prevent vermin infestation.

Findings included:

1) Review on November 9, 2016, of facility policy "Room Quality Inspection," last reviewed March 2016, revealed "Purpose: To detail the procedure for ensuring that cleaning quality is maintained throughout the facility. Procedure: The quality of cleaning in all areas of the facility is monitored on a regular basis by EVS [environmental services] management staff. Documented inspections of each area are completed ... The supervisor will inspect all listed areas of the room or space for cleanliness. These areas include walls, furniture, floors, equipment, windows, curtains, baseboards, doors, etc. ..."

Review on November 9, 2016, of facility policy "Touch Point Cleanliness Inspections," last reviewed September 2011, revealed "P13000 Inspection Points [and] Description Of Pass For Quality Inspection Inspection Point Description of Pass Floor Shine/Stains Hard Floor is dust free and has high gloss, carpets are clean and stain free Corners [and] Edges No dust or debris in corners, along edges and under furniture ..."
Observation on November 7, 2016, of the Children's unit revealed dirt, gray dust, paper debris and strips of plastic along the edges of the room and under the clean linen cart in the Clean Linen room. There was dirt and gray dust along the entire parameter of the Supply Closet. The wall mounted fire extinguisher box was kicked in with four metal tabs with sharp edges protruding out from the box. The molding was hanging from the sky lights and brown stained ceiling tiles in the Small Day room. There were brown stained ceiling tiles, a non-working ceiling mounted light, and food and liquid spillage in the refrigerator of the Kitchenette off the Small Day room.

Interview with EMP4 on November 7, 2016, at approximately 10:00 AM confirmed the dirt, gray dust, paper debris and strips of plastic along the edges of the room and under the clean linen cart in the Clean Linen room; dirt and gray dust along the entire parameter of the Supply Closet; the wall mounted fire extinguisher box kicked in with 4 metal tabs with sharp edges protruding out from the box; molding hanging from the sky lights and brown stained ceiling tiles in the Small Day room; the brown stained ceiling tiles, a non-working ceiling mounted light and food and liquid spillage in the refrigerator of the Kitchenette off the Small Day room.

Observation on November 7, 2016, of patient rooms 515, 516 and 518 on the Children's unit revealed these rooms were locked and not accessible for patient entry. Further observation of these rooms revealed clumps of gray dust measuring the size of a golf ball when gathered together in the corners of these rooms.

Interview with EMP4 on November 7, 2016, at approximately 10:15 AM confirmed the clumps of gray dust measuring the size of a golf ball when gathered together in the corners of patient rooms 515, 516 and 518. EMP4 revealed housekeeping had just finished cleaning the patient rooms and the patient care unit for the day.

Observation on November 7, 2016, of the Adolescent 1 patient care unit revealed clumps of gray dust measuring the size of a golf ball when gathered together in the Big Day room.

Interview with EMP4 on November 7, 2016, at approximately 11:00 AM confirmed the clumps of gray dust measuring the size of a golf ball when gathered together in the Big Day room. EMP4 revealed housekeeping had just finished cleaning the patient care unit for the day.

Observation on November 7, 2016, of the Adolescent 2 patient care unit revealed clumps of gray dust measuring the size of a golf ball when gathered together in the Day room. There were six open and partially used containers of laundry detergent in an unlocked cabinet in the laundry room.

Interview with EMP4 on November 7, 2016, at approximately 11:30 AM confirmed the clumps of gray dust measuring the size of a golf ball when gathered together in the Day room and the six open and partially used containers of laundry detergent in an unlocked cabinet in the laundry room.

Observation on November 7, 2016, of the examination room between Adult units 4 and 5 revealed a phone cord coiled on the floor which extended from one wall to a second wall. This phone cord measured approximately 12' and was not secured. There were four blue rubber gloves and soiled sheets and blankets in the red trash can.

Interview with EMP4 on November 7, 2016, at approximately 12:00 PM confirmed the examination room between Adult units 4 and 5 had a phone cord coiled on the floor which extended from one wall to a second wall which measured approximately 12' and was not secured and the four blue rubber gloves and soiled sheets and blankets in the red trash can. EMP4 revealed this examination room was last used over the weekend and should have been cleaned following its use.

Observation on November 7, 2016, of the patient rooms on the Children's unit, Adolescent 1 and Adolescent 2 revealed all patient room bathrooms had three areas where the door hinges were attached to the door jam. There were three holes in each of the hinges measuring approximately 0.5" in diameter.

Interview with EMP4 on November 7, 2016, at the time of the observation confirmed patient room bathrooms on the Children's unit, Adolescent 1 and Adolescent 2 had three areas where the door hinges were attached to the door jam, and there were three holes with sharp edges in each of the hinges measuring approximately 0.5" in diameter. EMP4 confirmed these holes posed an injury risk and that a child or adolescent could insert a finger into one of these holes and severely cut themselves.

Observation on November 9, 2016, of the Adult patient care unit 4 revealed a housekeeping cart with a clear plastic liner in the garbage collection bag.

Interview with EMP10 and EMP12 on November 9, 2016, at the time of the observation confirmed the housekeeping cart with the clear plastic liner.

Observation on November 9, 2016, of the Adult patient care unit 5 revealed a housekeeping cart with a clear plastic liner in the garbage collection bag, a role of clear plastic bags, a container containing a blue liquid and a box of vinyl gloves.

Interview with EMP11 and EMP12 on November 9, 2016, at the time of the observation confirmed the housekeeping cart with a clear plastic liner in the garbage collection bag, a role of clear plastic bags, a container containing a blue liquid and a box of vinyl gloves. EMP11 revealed the bottle containing a blue liquid was a cleaning solution.

Interview with EMP12 on November 9, 2016, at approximately 9:45 AM revealed the clear plastic bags lining the garbage collection bag, the role of clear plastic bags, the container with blue cleaning solution and the box of vinyl gloves should not be stored on top of the cleaning cart and should be stored in the locked area of the cleaning cart since these items pose a risk to a patient with suicidal or self-harming thoughts.

2) Review on November 9, 2016, of facility policy "Touch Point Cleanliness Inspections," last reviewed September 2011, revealed "P13000 Inspection Points & [and] Description Of Pass For Quality Inspection Inspection Point Description of Pass ... Dumpsters Dumpsters are free of debris, spillage and splatters. ... Housekeeper Cart No unattended carts. Housekeeper Cart is free of dust, debris and splatters. Supplies properly arranged, labeled and in correct quantities.... "

Observation of the facility's dumpsters on November 8, 2016, at approximately 11:00 AM, revealed one dumpster was overflowing with four trash bags. The lid could not be closed.

Interview with EMP5, EMP6 and EMP7 on November 8, 2016, at approximately 11:00 AM, confirmed one out of their four dumpsters was overflowing with trash bags. EMP6 confirmed the trash was to be picked up daily, if not in the morning, then in the afternoon. The facility was to call the trash service to come extra if needed.

Observation of the facilities dumpsters on November 8, 2016, at 8:30 AM, revealed the continued overflow of trash bags in one out of four dumpsters.

Interview with EMP6 November 9, 2016, at approximately 12:10 PM, confirmed one out of four dumpsters continued with the overflow of trash bags.

Based on medical record review and staff interview it was determined that for seven (7) of 10 patients their Psychosocial Assessments had no description of the anticipated role of the social service staff in discharge planning. Also, for one (1) of 10 Psychosocial Assessments there did not occur an assessment throughout the hospital stay. This failure results in neither the patient nor members of the multidisciplinary team knowing what efforts toward discharge planning were being pursued. (Patients: B1, B2, B3, B4, B5, A1, A4 and A5).

Findings include:

I. Medical Record Review:

1. Patients B1, B2, B3, B4, B5, A4 and A5 whose Psychosocial Assessment dates are in parenthesis lacked any information about anticipated social service efforts. B1 (9/29/16), B2 (9/19/16), B3 (10/29/16), B4 (date undetermined as it was illegible and written over), B5 (11/02/16), A4 (10/31/16), and A5 (11/01/16).

2. Patient A2: This patient had been hospitalized from 10/23/2016 to 11/07/2016. It was documented that "Pt. (patient) refused assessment 10/24/16." There was no documentation that any other effort to obtain a Psychosocial Assessment had been done throughout the entire in-patient stay.

II. Staff Interview:

On 11/08/2016 at 3:40 p.m. the surveyors met with the Director of Social Services and the Clinical Regional Director of the facility's parent organization. The Director of Social Services was shown the Psychosocial Assessments of Patients B1, B3 and B5. After looking at them the Director agreed that the role of the social services staff was not described.

After looking at Patient A2's Psychosocial Assessment form, the Director concurred that no Psychosocial Assessment had been done throughout Patient A2's hospital stay. The Director, also, stated that there does not exist a Policy and/or Procedure that would guide social service staff to continue their efforts to obtain one when initially unsuccessful.

Based on medical record review and staff interview it was determined that for 10 of 10 patients their treatment plans (both Master Treatment Plan and/or Treatment Plan Reviews) were not comprehensive. The treatment plans failed to disclose the responsible staff member, the individualized medical and nursing staff interventions or revisions to the Treatment Plan if indicated. This failure results in an inability to hold staff specifically responsible, and disclose patient specific modalities or interventions operative at the time of treatment planning. (Patients A1, A2, A3, A4, A5, B1, B2, B3, B4, B5).

Findings include:

1. See B122 for description of findings re. Treatment interventions.

2. See B123 for description of findings re. Responsible staff.

Based on medical record review, staff interview and document review the facility failed to insure that the comprehensive treatment plans of 10 of 10 patients (Patients A1, A2, A3, A4, A5, B1, B2, B3, B4 and B5) included physician and nursing treatment modalities (interventions) that were not individualized. Instead, modalities were a pre-printed listing of generic monitoring, assessing and documenting functions. In addition, treatment plan updates did not reflect revised interventions when indicated for six (6) of 10 patients (Patients B1, B2, B3, B4, A1, and A2). This resulted in a treatment plan that did not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings Include:

A.Record Review

1. Patient B2: admitted 09/19/2016. MTP, Problem #1 Medical Physical (seizure disorder) dated 09/22/16 documented Physician "interventions" as: "Assess patients medical condition/functioning"; "ongoing review and assessment of medications"; and "consult medical physician as needed." These are generic professional medical functions not specifically related to the patients' medical condition. The documented nursing interventions were: "assess patient's medical condition once every shift"; "follow up on signs and symptoms of illness"; "encourage compliance with treatment, administer medications as ordered by physician"; "monitor vital signs once/shift"; "notify physician of abnormality/change in patient's physical condition as needed"; "assess patient's level of understanding of illness/condition and prescribed medication"; and "provide necessary teaching/education of patient's medical condition, signs/symptoms of illness, risk factors to his/her level of understanding." These are generic professional nursing functions not specific to the patients' medical condition. Problem #2, Risk of Violence, dated 09/22/16 documented Physician "interventions" as: "assess patient daily; prescribe medication to assist patient in anger and behavioral management"; "assess patient's response to medication and monitor for potential side effects"; "educate patient and/or family at his/her level of understanding regarding medication, therapeutic benefits and potential side effects." These are generic professional medical functions not specific to the patient. Problem #3, Disruptive/Impulsive Behavior dated 09/22/16, listed the following physician "interventions": "assess and adjust medication as needed"; "1:1 session 5-7 times per week" and "assess medication for efficacy and potential side effects." These are generic medical functions not specific to the patient. This MTP was updated on the following dates: 09/29/16; 10/06/16; 10/13/16; 10/24/16; 10/31/16 and 11/07/16 there was no documentation to support that the interventions/modalities were evaluated for necessary revisions, additions or deletions on any of these updates.

2. Patient B1: admitted 09/27/16. MTP, Problem #1 Self Abuse/self-Mutilation dated 09/29/16 listed the following Physician "interventions": "assess patient daily for self-injurious behavior or impulses"; "prescribe daily body assessments"; "evaluate daily for medication for symptom management, assess response to medication and monitor for potential side effects"; and "educate patient and/or family at his/her level of understanding on rationale for medication and side effect profile." These interventions are generic professional medical functions and not specific to the patient. Nursing interventions listed included: "medication teaching daily at patient's level of functioning"; complete daily body assessments as per physician order, document findings and report negative findings to physician"; "provide patient with support and safety in the therapeutic milieu"; "instruct patient at his/her level of understanding on adaptive coping skills and problem solving skills"; "monitor family visits per unit policy and provide support as needed." These nursing interventions are generic functions and not specifically related to the patient. Problem #2 Risk of Violence listed the identical Physician "interventions" for this patient as found on the MTP Patient B2. This MTP was updated on the following dates: 10/01/16; 10/10/16; 10/17/16; 10/24/16; 10/31/16 and 11/07/16 there was no documentation to support that the interventions/modalities were evaluated for necessary revisions, additions or deletions on any of these updates.

3. Patient B4: admitted 10/05/16. MTP, Problem #1 Risk of Violence, dated 10/07/16 had the identical Physician and Nursing interventions listed for this patient as found on Patient B2. Problem #2 Depression identified the following Physician "interventions", "assess need for antidepressant medication and prescribe as needed"; "assess and adjust medications seven times per week and/or needed"; "evaluate patient daily to assess level of depressive symptoms and provide support." These interventions are generic professional medical functions and not specific to the patient. The nursing interventions listed included: "assess and document presence of depressive symptoms every shift"; "monitor medication efficacy and assess for potential side effects." These interventions are generic functions and not specific to the patient. Problem #3 Disruptive/Impulsive Behavior listed the following Physician "interventions": "assess and adjust medication as needed"; "1:1 session 1-2 times per week"; "monitor therapeutic medication levels at least five times per week" and "assess medication for efficacy and potential side effects." These are generic professional functions not specific to the patient. The nursing interventions included: "assess and document presence of disruptive behaviors, inattention, hyperactivity, impulsivity each shift"; "monitor and document hours of sleep each night"; "provide medication teaching precautions, risks and benefits, reinforcing as needed." These nursing interventions are generic functions and not specifically related to the patient. This MTP was updated on the following dates: 10/12/16; 10/19/16; 10/26/16; 11/03/16 there was no documentation to support that the interventions/modalities were evaluated for necessary revisions, additions or deletions on any of these updates.

4. Patient A2: admitted 10/23/16. MTP, Problem #1 Suicidal Thought, Plan, Intent, Attempt dated 10/26/16 documented Physician "interventions" as: "Complete suicide risk assessment within 24 hours"; and "assess patient seven days per week to assess mood and suicide risk, prescribe medication, evaluate for efficacy, assess for side effects and educate patient on rationale for medication, side effect profile daily." These are generic professional medical functions not specific to the patient. The documented nursing interventions were: "assess patient through 1:1 contact for suicidal thoughts per observational level, every 15 minutes"; administer medication daily as prescribed by the physician. Monitor of side effects and efficacy. Reinforce with patient at his/her level of understanding on purpose of medication and potential side effects"; and "patient will attend recovery and safety planning group 1-2 times by discharge." These are generic professional nursing functions not specific to the patient. Problem #2 Thinking Disturbance documented Physician interventions as: "assess/adjust medication efficacy during each visit and/or as needed"; "educate patient and/or family on rationale for medication and side effect profile"; "assess for severity of impairment in daily functioning at least one time per session"; monitor for irrational beliefs at least one time per session." These are generic professional medical functions not specific to the patient. Problem #3, Depression documented the following physician interventions: "assess need for antidepressant medication and prescribe as needed"; "assess and adjust medications as needed"; "monitor and educate daily/as needed risks, benefits and potential side effects of medication." These are generic professional medical functions not specific to the patient. There was no treatment plan update for this patient from the date of the MTP as per the facility treatment planning policy.

5. Patient A1: admitted 10/26/16. MTP, Problem #1 Risk of Violence dated 10/27/16 documented Physician "interventions" as "assess patient daily, prescribe medication to assist patient in anger and behavioral management"; "assess patient's response to medication and monitor of potential side effects"; and "educate patient and/or family at his or her level of understanding regarding medication, therapeutic benefits and potential side effects." These are generic professional medical functions not specific to the patient. The documented nursing interventions were: "administer medication daily as prescribed by physician, monitor for side effects and efficacy, reinforce with patient at his or her level of understanding on purpose of medication and potential side effects"; "monitor patient's behavior each shift and document findings"; "administer PRN medication for agitation as prescribed by physician after all other interventions have failed." These are generic nursing functions not specific to the patient. Problem #2 Mania had documented the following physician "interventions": "assess and adjust medications (frequency) 5-7 times weekly"; "1:1 evaluation 5-7 times per week to assess mood, response to medication"; and "monitor for therapeutic medication levels (frequency) 5-7." These are generic professional medical functions not specific to the patient. This MTP was updated on 11/03/16 there was no documentation to support that the interventions/modalities were evaluated for necessary revisions, additions or deletions.

6.Patient B3: admitted 10/28/16. MTP, Problem #1 Risk of Violence dated 10/31/16 had the identical Physician and Nursing interventions listed as on the MTP for Patient's B1, B4 and A1. Problem #2 Disruptive/Impulsive Behavior had the identical Physician and Nursing interventions as listed on the MTP for Patient B4. This MTP was updated on 11/07/16 there was no documentation to support that the interventions/modalities were evaluated for necessary revisions, additions or deletions.

7. Patient A3: admitted 10/31/16. MTP, Problem #1 Thinking disturbance, dated 11/3/16 documented the following Physician "interventions"; "assess medication efficacy during each visit and/or as needed"; "educate patient and/or family on rationale for medication and side effect profile"; "assess for severity of impairment in daily functioning at least one time per day." These are generic professional medical functions not specific to the patient. The nursing interventions documented were: "administer medication as prescribed, monitor for desired and untoward effects of prescribed medication at least prn times per day"; and "educate patient/family regarding disease process prn times as needed." These are generic nursing functions not specific to the patient. Problem #2 Depression had documented the following Physician "interventions": "assess need for antidepressant medication and prescribe as needed"; "assess and adjust medications seven times per week and/or as needed"; "monitor and educate daily/as needed risks, benefits and potential side effects of medication." These are generic professional medical functions not specific to the patient. Nursing interventions documented for this problem were: "provide medication teaching regarding precautions, risks, and benefits, reinforcing as needed at least prn"; and "direct and assist patient to groups and activities each shift." These are generic nursing functions not specific to the patient.

8. Patient A4: admitted 10/31/16. MTP dated 11/2/16 for Problem #1 Suicidal Thought, Plan, Intent, Attempt had the identical Physician interventions documented that were documented on the MTP for Patient A2. Nursing interventions documented were also identical to those documented on the MTP for Patient A2. Problem #2 Anxiety documented the following Physician "interventions": "assess/adjust medications daily and/or as needed"; and "monitor and educate regarding precautions, risks, benefits, and side effects as needed." These are generic professional medical functions not specific to the patient.

9. Patient A5: admitted 10/31/16: MTP dated 11/2/16 for Problem #1 Suicidal Thought, Plan, Intent, Attempt had the identical Physician and nursing interventions documented that were documented on the MTP for Patients A2 and A4. Problem #2 Anxiety had the identical physician interventions documented on the MTP for patient A4.

10. Patient B5: admitted 11/02/16: MTP dated 11/03/15 for Problem #1 Depression had the identical physician and nursing interventions as identified on the MTP for Patient A3. Problem #2 Disruptive/Impulsive Behavior listed the identical Physician and nursing interventions as identified on the MTP's for Patients B3 and B4.

B. Interview

During an interview with the CNO on 11/09/16 at 11:50 a.m., the MTP's for Patient B2 and A1 were reviewed. The CNO acknowledged that on both of these treatment plans "there were identical nursing interventions" that were selected for the problems identified and "there was no individualization of the interventions for either of the patients." It was also noted when these plans were reviewed that one of these patients was a child and the other was an adult. The CNO agreed the interventions "should have been individualized based on the patient ages."

C. Document Review

Facility Policy, titled "Treatment Planning," dated 02/16, section B. Master Treatment Plan #6 states "the specific interventions to help the patient meet the expected outcomes will be listed and will include the therapeutic modality to be provided, by whom and frequency."

Based on record review, interview and document review the facility failed to clearly identify responsible staff for interventions/modalities on the MTP. The MTP and/or treatment plan reviews for 10 of 10 patients (PatientsA1, A2, A3, A4, A5, B1, B2, B3, B4 and B5) lacked necessary signatures for the physician and/or nurse that was listed as the responsible person. In seven (7) of 10 patients (Patients A1, A2, A4, A5, B1, B3 and B4) the attending psychiatrist did not either sign the MTP and/or treatment updates. In addition, the responsible nursing staff member identified on the MTP in 10 of 10 patients (Patients A1, A2, A3, A4, A5, B1, B2, B3, B4 and B5) was the Nurse Manager for each designated unit. This failure resulted in the inability to determine what physician and/or nursing staff member was responsible.

Findings Include:

A. Record Review

1. Patient B2: admitted 09/19/16, MTP dated 09/22/16 identified RN4 as the responsible person to carry out nursing interventions. RN4 is the nurse manager for Adolescent units one (1) and two (2), therefore, does not take a patient care assignment.

2. Patient B1: admitted 09/27/16, MTP dated 09/29/16 identified RN1 as the responsible person to carry out nursing interventions. RN 1 is the nurse manager for Adult Unit A1 and the Children's Unit, therefore does not take a patient care assignment. The MTP or the treatment plan update completed on 11/07/16 did not have the attending Psychiatrist signature documented.

3. Patient B4: admitted 10/05/16, MTP dated 10/07/16 identified RN4 as the responsible person to carry out nursing interventions. RN4 is the nurse manager for Adolescent units one (1) and two(2), therefore, does not take a patient care assignment. The MTP and subsequent treatment plan reviews completed on 10/12/16; 10/19/16; 10/26/19 and 11/02/16 did not have the attending Psychiatrist signature documented.

4. A2: admitted 10/23/16. MTP dated 10/26/16 identified RN2 as the responsible person to carry out nursing interventions. RN2 is the nurse manager for Adult Units A2 and A4, therefore, does not take a patient care assignment. There was no treatment plan update for this patient from the date of the MTP as per the facility treatment planning policy.

5. Patient A1: admitted 10/26/16. MTP dated 10/27/16 identified RN1 as the responsible person to carry out nursing interventions. RN1 is the nurse manager for Adult Unit A1 and the Children's Unit, therefore, does not take a patient assignment. In addition, the 11/03/16 Treatment Plan update did not have the patient's attending Psychiatrist signature.

6. Patient B3: admitted 10/28/16, MTP dated 10/31/16identified RN4 as the responsible person to carry out nursing interventions. RN4 is the nurse manager for Adolescent units one (1) and two (2), therefore, does not take a patient care assignment. The MTP and subsequent treatment plan review completed on 10/31//16 did not have the attending Psychiatrist signature documented.

7. Patient A3: admitted 10/31/16, MTP dated 11/3/16 identified RN3 as the responsible person to carry out nursing interventions. RN3 is the nurse manager for Adult Unit A3 and A5, therefore, does not take a patient care assignment.

8. Patient A4: admitted 10/31/16, MTP dated 11/2/16 identified RN2 as the responsible person to carry out nursing interventions. RN2 is the nurse manager for Adult Unit A2 and A4, therefore, does not take a patient care assignment. In addition, this MTP was not signed by the patient's attending Psychiatrist.

9. Patient A5: admitted 10/31/16, MTP dated 11/2/16 identified RN2 as the responsible person to carry out nursing interventions. RN2 is the nurse manager for Adult Unit A2 and A4, therefore, does not have the responsibility of a patient assignment. This MTP was not signed by the patient's attending Psychiatrist.

10. Patient B5: admitted 11/02/16, MTP dated 11/03/16 identified RN3 as the responsible person to carry out nursing interventions. RN3 is the nurse manager for Adult Unit A3 and A5, therefore, does not take a patient care assignment.

B. Interviews

1. During an interview with the CNO, on 11/08/16 at 9:32 a.m., the treatment plan for Patient A1 was reviewed to discuss the nursing role in development of the patient's treatment plan. In this interview the CNO stated "the nurse managers name is written in by the scribe (clinician) doing the treatment plan because it the nurse manager who is responsible for the over sight of all nursing duties." The CNO, acknowledged that the nurse manager does not take a daily assignment or document on patients on the units and as a result does not carry out the nursing interventions with the patient or evaluate the effectiveness of these interventions/modalities in assisting the patient to reach their goals.

2. During an interview with RN2, on 11/08/16 at 2:20 p.m, RN2, when shown the treatment plan of Patient A5, RN2 stated "I don't agree that my name should be on that treatment plan because I don't document." RN2 stated, "The clinicians have been told to write the name of the manager on the form as the responsible nursing person." RN2 further acknowledged when reviewing the treatment plan update for Patient A2 "there is not a place for the RN to sign that they have either reviewed or updated the treatment plan during treatment plan reviews."

3. In interview with the Clinical Director on 11/09/2016 at 10:10 a.m. the Clinical Director was shown two different patients and the preprinted list of interventions for the same Problem. He agreed that there was no difference between the two documents that would make them patient specific.


C. Document Review

1. Facility Policy, titled "Treatment Planning," dated 02/16, Part B #6 states: " the specific interventions to help the patient meet the expected outcomes will be listed and will include the therapeutic modality to be provided, by whom, and frequency."

Based on medical record review and staff interview it was determined that for 10 of 10 patients the Clinical Director failed to insure that treatment plans disclosed responsible staff members and that interventions selected were patient specific (Patients A1, A2, A3, A4, A5, B1, B2, B3, B4 and B5).

Findings include:

1. Based on medical record review and staff interview it was determined that for 10 of 10 patients their treatment plans (both Master Treatment Plan and/or Treatment Plan Reviews) were not comprehensive. The treatment plans failed to disclose the responsible staff member, the individualized medical and nursing staff interventions or revisions to the Treatment Plan if indicated. This failure results in an inability to hold staff specifically responsible, and disclose patient specific modalities or interventions operative at the time of treatment planning. (Patients A1, A2, A3, A4, A5, B1, B2, B3, B4, B5). Based on medical record review, staff interview and document review the facility failed to insure that the comprehensive treatment plans of 10 of 10 patients (Patients A1, A2, A3, A4, A5, B1, B2, B3, B4 and B5) included physician and nursing treatment modalities (interventions) that were not individualized. Instead, modalities were a pre-printed listing of generic monitoring, assessing and documenting functions. In addition, treatment plan updates did not reflect revised interventions when indicated for six (6) of 10 patients (Patients B1, B2, B3, B4, A1, and A2). This resulted in a treatment plan that did not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.


2. Based on medical record review, staff interview and document review the facility failed to insure that the comprehensive treatment plans of 10 of 10 patients (Patients A1, A2, A3, A4, A5, B1, B2, B3, B4 and B5) included physician and nursing treatment modalities (interventions) that were not individualized. Instead, modalities were a pre-printed listing of generic monitoring, assessing and documenting functions. In addition, treatment plan updates did not reflect revised interventions when indicated for six (6) of 10 patients (Patients B1, B2, B3, B4, A1, and A2). This resulted in a treatment plan that did not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. See, also, B122 for details.


3. Based on record review, interview and document review the facility failed to clearly identify responsible staff for interventions/modalities on the MTP. The MTP and/or treatment plan reviews for 10 of 10 patients (PatientsA1, A2, A3, A4, A5, B1, B2, B3, B4 and B5) lacked necessary signatures for the physician and/or nurse that was listed as the responsible person. In seven (7) of 10 patients (Patients A1, A2, A4, A5, B1, B3 and B4) the attending psychiatrist did not either sign the MTP and/or treatment updates. In addition, the responsible nursing staff member identified on the MTP in 10 of 10 patients (Patients A1, A2, A3, A4, A5, B1, B2, B3, B4 and B5) was the Nurse Manager for each designated unit. This failure resulted in the inability to determine what physician and/or nursing staff member was responsible. See, also, B123 for details.

Based on medical record review and staff interview it was determined that for 10 of 10 patients the Chief Nursing Officer ( Director of Nursing) failed to insure that treatment plans included individualized, patient specific nursing interventions/modalities and an appropriate responsible nursing staff member (Patients A1, A2, A3, A4, A5, B1, B2, B3, B4, B5).

Findings include:

A. Medical Record Review

1. Patient B2: admitted 09/19/2016. MTP, Problem #1 Medical Physical (seizure disorder) dated 09/22/16 documented nursing interventions were: "assess patient's medical condition once every shift"; "follow up on signs and symptoms of illness"; "encourage compliance with treatment, administer medications as ordered by physician"; "monitor vital signs once/shift"; "notify physician of abnormality/change in patient's physical condition as needed"; "assess patient's level of understanding of illness/condition and prescribed medication"; and "provide necessary teaching/education of patient's medical condition, signs/symptoms of illness, risk factors to his/her level of understanding." These are generic professional nursing functions not specific to the patients' medical condition. This MTP was updated on the following dates: 09/29/16; 10/06/16; 10/13/16; 10/24/16; 10/31/16 and 11/07/16 there was no documentation to support that the interventions/modalities were evaluated by nursing personnel for necessary revisions, additions or deletions. In addition, the assigned responsible nursing person for this treatment plan was the unit nurse manager who does not have a patient assignment and therefore cannot evaluate the effectiveness of the nursing interventions/modalities for the patient.

2. Patient B1: admitted 09/27/16. MTP, Problem #1 Self Abuse/self-Mutilation dated 09/29/16 nursing interventions listed included: "medication teaching daily at patient's level of functioning"; complete daily body assessments as per physician order, document findings and report negative findings to physician"; "provide patient with support and safety in the therapeutic milieu"; "instruct patient at his/her level of understanding on adaptive coping skills and problem solving skills"; "monitor family visits per unit policy and provide support as needed." These nursing interventions are generic functions and not specifically related to the patient. This MTP was updated on the following dates: 10/01/16; 10/10/16; 10/17/16; 10/24/16; 10/31/16 and 11/07/16 there was no documentation to support that the interventions/modalities were evaluated by nursing personnel for necessary revisions, additions or deletions. In addition, the assigned responsible nursing person for this treatment plan was the unit nurse manager who does not have a patient assignment and therefore cannot evaluate the effectiveness of the nursing interventions/modalities for the patient.


3. Patient B4: admitted 10/05/16. MTP, Problem #1 Risk of Violence, dated 10/07/16 had the identical Nursing interventions listed for this patient as found on Patient B2. Problem #2 Depression, listed the following nursing interventions: "assess and document presence of depressive symptoms every shift"; "monitor medication efficacy and assess for potential side effects." These interventions are generic functions and not specific to the patient." Problem #3 Disruptive/Impulsive Behavior listed the following nursing interventions: "assess and document presence of disruptive behaviors, inattention, hyperactivity, impulsivity each shift"; "monitor and document hours of sleep each night"; "provide medication teaching precautions, risks and benefits, reinforcing as needed." These nursing interventions are generic functions and not specifically related to the patient. This MTP was updated on the following dates: 10/12/16; 10/19/16; 10/26/16; 11/03/16 there was no documentation to support that the interventions/modalities were evaluated by nursing personnel for necessary revisions, additions or deletions. In addition, the assigned responsible nursing person for this treatment plan was the unit nurse manager who does not have a patient assignment and therefore cannot evaluate the effectiveness of the nursing interventions/modalities for the patient.

4. Patient A2: admitted 10/23/16. MTP, Problem #1 Suicidal Thought, Plan, Intent, Attempt dated 10/26/16 documented nursing interventions were: "assess patient through 1:1 contact for suicidal thoughts per observational level, every 15 minutes"; administer medication daily as prescribed by the physician. Monitor of side effects and efficacy. Reinforce with patient at his/her level of understanding on purpose of medication and potential side effects"; and "patient will attend recovery and safety planning group 1-2 times by discharge." These are generic professional nursing functions not specific to the patient. There was no treatment plan update for this patient from the date of the MTP as per the facility treatment planning policy, and no evidence that nursing personnel evaluated the treatment plan for necessary revisions, additions or deletions. In addition, the assigned responsible nursing person for this treatment plan was the unit nurse manager who does not have a patient assignment and therefore cannot evaluate the effectiveness of the nursing interventions/modalities for the patient.

5. Patient A1: admitted 10/26/16. MTP, Problem #1 Risk of Violence dated 10/27/16 documented nursing interventions were: "administer medication daily as prescribed by physician, monitor for side effects and efficacy, reinforce with patient at his or her level of understanding on purpose of medication and potential side effects"; "monitor patient's behavior each shift and document findings"; "administer PRN medication for agitation as prescribed by physician after all other interventions have failed." These are generic nursing functions not specific to the patient. This MTP was updated on 11/03/16 there was no documentation to support that the interventions/modalities were evaluated by nursing personnel for necessary revisions, additions or deletions. In addition, the assigned responsible nursing person for this treatment plan was the unit nurse manager who does not have a patient assignment and therefore cannot evaluate the effectiveness of the nursing interventions/modalities for the patient.

6. Patient B3: admitted 10/28/16. MTP, Problem #1 Risk of Violence dated 10/31/16 had the identical Nursing interventions listed as on the MTP for Patient's B1, B4 and A1. Problem #2 Disruptive/Impulsive Behavior had the identical Nursing interventions as listed on the MTP for Patient B4. This MTP was updated on 11/07/16 there was no documentation to support that the interventions/modalities were evaluated by nursing personnel for necessary revisions, additions or deletions. In addition, the assigned responsible nursing person for this treatment plan was the unit nurse manager who does not have a patient assignment and therefore cannot evaluate the effectiveness of the nursing interventions/modalities for the patient.


7. Patient A3: admitted 10/31/16. MTP, Problem #1 Thinking disturbance, dated 11/3/16 documented the following nursing interventions documented were: "administer medication as prescribed, monitor for desired and untoward effects of prescribed medication at least prn times per day"; and "educate patient/family regarding disease process prn times as needed." These are generic nursing functions not specific to the patient. Problem #2 Depression had documented the following Nursing interventions documented for this problem were: "provide medication teaching regarding precautions, risks, and benefits, reinforcing as needed at least prn"; and "direct and assist patient to groups and activities each shift." These are generic nursing functions not specific to the patient. In addition, the assigned responsible nursing person for this treatment plan was the unit nurse manager who does not have a patient assignment and therefore cannot evaluate the effectiveness of the nursing interventions/modalities for the patient.

8. Patient A4: admitted 10/31/16. MTP dated 11/2/16 for Problem #1 Suicidal Thought, Plan, Intent, Attempt had nursing interventions documented that were identical to those documented on the MTP for Patient A2. These interventions are generic nursing functions and are not specific to the patient. In addition, the assigned responsible nursing person for this treatment plan was the unit nurse manager who does not have a patient assignment and therefore cannot evaluate the effectiveness of the nursing interventions/modalities for the patient.

9. Patient A5: admitted 10/31/16: MTP dated 11/2/16 for Problem #1 Suicidal Thought, Plan, Intent, Attempt had the identical nursing interventions documented that were documented on the MTP for Patients A2 and A4. In addition, the assigned responsible nursing person for this treatment plan was the unit nurse manager who does not have a patient assignment and therefore cannot evaluate the effectiveness of the nursing interventions/modalities for the patient.

10. Patient B5: admitted 11/02/16: MTP dated 11/03/15 for Problem #1 Depression had the identical nursing interventions as identified on the MTP for Patient A3. Problem #2 Disruptive/Impulsive Behavior listed the identical nursing interventions as identified on the MTP ' s for Patients B3 and B4. In addition, the assigned responsible nursing person for this treatment plan was the unit nurse manager who does not have a patient assignment and therefore cannot evaluate the effectiveness of the nursing interventions/modalities for the patient.

B. Interview

1. During an interview with RN1, on 11/07/16 at 11:00 a.m. she verified there is "no place to document additions or deletions of interventions on the treatment plan."

2. During an interview with RN2 on 11/08/16 at 2:30 p.m. also stated "I am know my name is listed as the assigned responsible person, I don't agree with that because I am not the person who takes care of the patient, it is my staff who has that responsibility." RN2 also stated, "I don't even know where we would document if there were changes to our interventions. I guess we could write next to the intervention a date or a note, but there really isn't anywhere to do that. Maybe we could use the "other lines."

3. During the interview with the Chief Nursing Officer (Director of Nursing) on 11/09/16 at 11:50 a.m. she stated "there currently is no process for conducting quality audits for treatments for nursing staff, unless someone else is doing that. I do not review the treatment plans."

Based on medical record review and staff interview it was determined that the Director of Social Services failed to ensure that seven (7) of 10 patients had Psychosocial Assessments that included a description of the role of the social service staff in discharge planning. (Patients: B1, B2, B3, B4, B5, A4 and A5). Also that for one (1) of 10 patients there was no Psychosocial Assessment completed during the entire hospital stay. (Patient A2).

Based on medical record review and staff interview it was determined that for seven (7) of 10 patients their Psychosocial Assessments had no description of the anticipated role of the social service staff in discharge planning. Also, for one (1) of 10 Psychosocial Assessments there did not occur an assessment throughout the hospital stay. This failure results in neither the patient nor members of the multidisciplinary team knowing what efforts toward discharge planning were being pursued. (Patients: B1, B2, B3, B4, B5, A1, A4 and A5).

Findings include:

I. Medical Record Review:

1. Patients B1, B2, B3, B4, B5, A4 and A5 whose Psychosocial Assessment dates are in parenthesis lacked any information about anticipated social service efforts. B1 (9/29/16), B2 (9/19/16), B3 (10/29/16), B4 (date undetermined as it was illegible and written over), B5 (11/02/16), A4 (10/31/16), and A5 (11/01/16).

2. Patient A2: This patient had been hospitalized from 10/23/2016 to 11/07/2016. It was documented that "Pt. (patient) refused assessment 10/24/16." There was no documentation that any other effort to obtain a Psychosocial Assessment had been done throughout the entire in-patient stay.

II. Staff Interview:

On 11/08/2016 at 3:40 p.m. the surveyors met with the Director of Social Services and the Clinical Regional Director of the facility's parent organization. The Director of Social Services was shown the Psychosocial Assessments of Patients B1, B3 and B5. After looking at them the Director agreed that the role of the social services staff was not described.

After looking at Patient A2's Psychosocial Assessment form, the Director concurred that no Psychosocial Assessment had been done throughout Patient A2's hospital stay. The Director, also, stated that there does not exist a Policy and/or Procedure that would guide social service staff to continue their efforts to obtain one when initially unsuccessful.