HospitalInspections.org

Based on document review and interview, it was determined for 2 of 2 (laboratory and surgical services) contracted services, the Hospital failed to ensure the contracted services were evaluated as required. This potentially affected 119 patients on the census.

Findings include:

1. On 8/17/16 at approximately 11:30 AM, the Hospital's laboratory and surgical services contracts were reviewed.

2. On 8/17/16 at approximately 12:20 PM, the Hospital's policy titled, "Governance Overview" (revised 7/01/13) was reviewed and indicated, "... The Governing Body Duties and Process: 1. ...The governing body shall monitor the quality of patient care assuring the involvement of patients, family members, community providers..." The policy did not include a process for evaluating contracted services.

3. On 8/17/16 at approximately 1:00 PM, the Governing Body meeting minutes from January 2016 to July 2016 were reviewed. The meeting minutes did not include evaluation of the Hospital's contracted services.

4. On 8/17/16 at approximately 11:30 AM, an interview was conducted with Hospital Administrator who stated that the Hospital did not have a process for evaluating contracted services unless issues arise.

Based on document review and interview, it was determined for 1 of 3 (radiology) contracted services provided, the Hospital failed to ensure a contract was in place. This potentially affected 119 patients on census.

Findings include:

1. On 8/17/16 at approximately 1:00 PM, the Hospital's list of contracted services was reviewed. The list included radiology as one of the contracted services, but did not include the scope and nature of the services provided.

2. On 8/17/16 at approximately 2:00 PM, the Hospital records indicated radiology services were provided May through July 2016: 5/16, 5/17, 5/24, 5/25, 6/24, 7/02, 7/20, 7/26, 7/28, and 7/30/16. However, a contract for the radiology services provided by the company, was not provided for review.

3. On 8/17/16 at approximately 1:30 PM, an interview was conducted with the Hospital Administrator who stated that the Hospital does not have a contract for their radiology services.

Based on observation, document review and interview, for 1 of 1 housekeeper (E #3), it was determined the Hospital failed to ensure the patients were cared for in a safe setting. This potentially affected all 27 patients on census, with 5 of those patients on suicide precaution.

Findings include:

1. During an observational tour of Pavilion 5 conducted on 8/16/16 between 10:00 AM and 11:30 AM, the following was observed:

- E #3, a housekeeping staff, was observed entering room 112 pulling a cleaning cart, with plastic bag lined trash bin and a tan plastic bag on top of the cart. E #3 entered the bathroom, located within the bedroom to mop and clean the floor, leaving the cleaning cart with a tan plastic bag on top of the cart unattended outside the bathroom door. Patients were observed pacing by the bedroom and the cart was accessible to the patients.

- A plastic bag lined trash bin was observed in the middle of the day room, next to a wall, where all patients attend group meetings, eat meals and interact with each other and staff.

2. The Hospital policy titled, "Housekeeping Department Manual" (rev 3/12/15), required, "...While completing your cleaning assignments during your shift, your housekeeping cart is solely your responsibility. Therefore it is important that you ensure that: The cart is never left unattended and is always within your eyesight to protect the cart, its contents and the patients."

3. An interview was conducted with the Nurse Manager for the 5 Pavilion on 8/16/16 at approximately 1:30 PM who stated that housekeeping is supposed to pull their carts into the room and keep an eye on their cart while cleaning.

Based on document review and interview it was determined for 2 of 3 (Pt #13 and 15) clinical records reviewed in Pavilion #2, the Hospital failed to ensure the Master Treatment Plans were completed as required.

Findings include:

1. Hospital policy entitled, "Assessment of Patient Needs and Treatment Planning," (revised 12/15/15) required, "I. Each patient that presents to ...for services shall receive a comprehensive, multi-disciplinary assessment that identifies their individual treatment needs...The master treatment plan must be completed within 72 hours of admission...III. Procedure...P. The outline for the treatment planning process includes: formulation of the problem list..."

2. The clinical record of Pt #13 was reviewed on 8/17/16 at approximately 11:00 AM. Pt #13 was a 53 year old female admitted on 8/11/16 with a diagnosis of psychosis unspecified. Pt #13's clinical record contained a master treatment plan problem list dated 8/11/16. Pt #13's treatment plan included interventions for a P2 (psychiatric problem) that had not been identified on the problem list at time of admission.

3. The clinical record of Pt #15 was reviewed on 8/17/16 at approximately 11:20 AM. Pt #15 was a 24 year old male admitted on 8/11/16 with a diagnosis of bipolar disorder. Pt #15's clinical record contained a master treatment plan problem list dated 8/16/16. Pt #15's treatment plan included interventions for P1 and P3 problems that were not identified on the problem list at admission.

4. The Charge Nurse for Pavilion 2 stated during an interview on 8/17/16 at approximately 11:30 AM that the master treatment plans should have been completely filled out to include the problem list within 72 hours.

Based on document review and interview, it was determined, the Hospital failed to ensure medical records were completed as required.

Findings include:

1. Hospital Health Information policy (untitled reviewed and revised 1/20/15) required, "Procedure...V. Designation of Delinquency: 1. Any Chart with uncorrected deficiencies that remain after 30 days from discharge, will be designated as delinquent."

2. On 8/17/16 the Hospital presented an attestation letter dated August 17, 2016 that indicated, "Total number of delinquent charts that are still incomplete as of August 17, 2016 = 102."

3. The Health Information Manager stated during an interview on 8/18/16 at approximately 9:15 AM that the medical records should be completed within the required 30 days.

A. Based on document review, observational tour, and interview, it was determined, for 2 of 3 (refrigerator 1 and 2) refrigerators and 4 of 4 "100 pound" dry food containers (rice, black eyed beans, oatmeal, and split peas), the Hospital failed to ensure opened food products/containers were labeled, as required, potentially affecting the health of 119 patients on census.

Findings include:

1. On 8/17/16 at 2:30 PM, Dietary policy titled, "Food Storage", lacking an effective date, was reviewed. The policy required, "...Any food items removed from the original package must be labeled with product name, date, and time. Any prepared foods requiring refrigeration must be promptly covered and labeled with name of the food, date, and time."

2. On 8/17/16 from 11:00 AM until 12:10 PM, an observational tour was conducted in the dietary department. The following was observed:

- Refrigerator 1 had containers of prepared food (1 small salad bowl, 1 pan of red jello, 13 cups of punch, and 1 cup of pudding) all lacking labels with the date and time opened.

- Refrigerator 2 had opened containers (sweet relish, maple syrup, and vinegar) lacked labels including the date and time opened.

- In the food storage room there were 4 "100 pound" containers, partially filled with rice, black eyed beans, oatmeal, and split peas. There was no label on the containers with the date the containers were filled.

3. On 8/17/16 at 11:10 AM, an interview was conducted with the Dietary Manager who stated the food in refrigerator 1 was "left over from another meal" and the containers in refrigerator 2 should included dates opened.

The Dietary Manager also stated she did not know if the food in the bottom of the "100 pound" containers were emptied before the containers were refilled or if the new food product was added to the old food and did not know when the "100 pound" containers were filled or when the containers were disinfected.

B. Based on document review, observational tour, and interview, it was determined, for 4 of 4 packages of frosting mix, the Hospital failed to ensure dry food was protected from moisture, potentially affecting the health of 119 patients on census.

Findings include:

1. On 8/17/16 at 2:30 PM, Dietary policy titled, "Food Storage", lacking an effective date, was reviewed. The policy required, "All foods or food items not requiring refrigeration shall be stored... on shelves... Storage rooms must be ventilated, not subject to contamination by... leakage..."

2. On 8/17/16 from 11:00 AM until 12:10 PM, an observational tour was conducted in the dietary department. In the dry storage room, there were 2 wet boxes containing bottled water. Below the boxes was a wet box containing 4 wet paper bags of frosting mix.

3. On 8/17/16 at 11:20 AM, an interview was conducted with the Dietary Manager who stated she did not know how the boxes became wet.

C. Based on document review, observational tour, and interview, it was determined, for 1 of 6 dietary tray line workers (E #6), the Hospital failed to ensure adherence to food safety, as required, potentially affecting the health of 119 patients on census.

Findings include:

1. The Dietary Department Manual included "Food Services Sanitation" which utilized the Illinois Department of Public Health Regulations was reviewed on 8/18/16 at 11:30 AM. Section 750.530 General - Employee Practices included, "f) Food employees... shall conform to good hygienic practices during all working periods in the food services establishment."

2. On 8/17/16 from 11:00 AM until 12:10 PM, an observational tour was conducted in the dietary department. At 12:07 PM, a Dietary Worker (E #6) was ladling sauerkraut into individual styrofoam containers to be place on the food line. E #6's ID badge touched the inside of several of the styrofoam containers which were to be served to patients. The Cook told E #6 to put his ID badge into his apron.

3. As E #6 picked up the styrofoam containers, he placed each container against his apron to achieve a better grip and then added the sauerkraut. Again the Cook intervened and E #6 then began placing the containers on the tray without touching his apron.

4. E #6 was observed not wearing gloves while preparing patient food trays, but later placed a plastic glove on the right hand. E #6's ungloved left hand touched the inside of some of the styrofoam containers.

5. On 8/17/16 at 12:15 PM, an interview was conducted with the Dietary Manager who stated dietary staff had called off for the day and with the tray line starting late, the staff was trying to get the lunches to the patients.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety portion of a full survey due to complaint conducted on August 16-17, 2016 the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety portion of a full survey due to complaint conducted on August 16-17, 2016 the surveyors find that the facility does not comply with the applicable provisions of the 2000 edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies identified with K-tags on the CMS form 2567, dated August 17, 2016.

Based on document review and interview, it was determined, for 1 of 4 (Pt.#6) records reviewed on Pavilion #5, the Hospital failed to ensure all patients were evaluated for discharge planning.

Findings include:

1. The Facility policy titled, "Assessment of Patient Needs and Treatment Planning" (rev. 12/15/15) required, "The master treatment plan must be completed with in 72 hours of admission....Discharge planning commences with the presentation of the patient for services and concludes with a discharge staffing for each patient. ...Procedure: The Master Treatment plan is completed by the Treatment Team within 72 hours of admission. At that time, the team assesses the needs for the further assessments in the Area of: Discharge Planning".

2. The Facility policy titled, "Discharge and Aftercare Planning" (rev 9/15/15) required, "The discharge planning process should be ongoing and documented in the medical record."

3. The clinical record for Pt. #6 was reviewed on 8/16/16. Pt #6 was a 29 year old male admitted on 8/2/16, with a diagnosis of schizoaffective disorder. The 72 hour master treatment plan lacked documentation of the initial discharge plan evaluation, in addition the progress notes did not include documentation of ongoing discharge planning.

4. The above finding was discussed with the 5 Pavilion Nurse Manager on 8/16/16, at approximately 1:30 PM, who stated that initial discharge evaluation should be completed within 72 hours with the treatment plan and document ongoing discharge plans in the progress notes.

Based on document review and interview, it was determined, the Hospital failed to ensure readmissions of less than 30 days were evaluated to determine if readmissions were potentially due to problems in the discharge planning process, potentially affecting the appropriate discharge of 119 patients on census.

Findings include:

1. On 8/17/16 at 10:05 AM, the fourth quarter Fiscal Year 2016 Strategic Plan was reviewed. The strategic plan included the percentage of readmissions in less than 30 days, for the past 5 years: 2012 - 18.8%; 2013 - 15.2%; 2014 - 15.6%; 2015 - 15.8%; and 2016 - 13.4%.

The report did not include discussion of any evaluation of readmissions or potential problems in the discharge planning process.

2. On 8/16/16 at 1:30 PM, Social Work Meeting Minutes from 9/15/15 through 5/24/16 were reviewed. There was no discussion of readmission evaluations or potential problems in the discharge planning process.

3. On 8/16/16 at 2:00 PM, the Medical Executive Meeting Minutes from 8/6/15 through 6/6/16 were reviewed. There was no discussion of readmission evaluations or potential problems in the discharge planning process.

4. On 8/16/16 at 2:15 PM, the Governing Body Meeting Minutes from 5/19/15 through 5/12/16 were reviewed. There was no discussion of readmission evaluations or potential problems in the discharge planning process.

5. On 8/17/16 at 11:00 AM, the Quality Assurance meeting minutes for 2016 were reviewed. There was no discussion of readmission evaluations or potential problems in the discharge planning process.

6. On 8/17/16 at 9:45 AM, an interview was conducted with Director of Social Work who stated that readmissions less than 30 days post discharge are discussed by the Social Workers, but there are no minutes of the meetings.

7. On 8/17/16 at 10:05 AM, an interview was conducted with the Hospital Administrator who stated there had been no discussion of readmissions because "there is no problem".

8. On 8/18/16 at 10:05 AM, an interview was conducted with the Medical Director who stated, the Interdisciplinary Team discusses readmissions of less than 30 days, but there are no meeting minutes.

Based on document review and interview, it was determined for 2 of 2 (organ/tissue and eye bank) agreements, the Hospital failed to ensure agreements were in place as required. This potentially affected all 119 patients on the census.

Findings include:

1. On 8/17/16 at approximately 12:00 PM, the Hospital's policy titled, " Patient Death" (revised 7/22/2016) was reviewed and required, "...1. Medical Director or Medical Director's Physician Designee: a. If the clinical record states the patient is an organ and tissue donor, notify the Regional Organ Bank of Illinois so they may determine potential for donation. (The Organ and Tissue Procurement agreement shall be on file in the Medical Director and Hospital Administrator Offices)".

2. On 8/17/16 at approximately 12:00 PM, the Hospital's Organ and Tissue Procurement Agreement was requested. The agreement could not be provided.

3. On 8/17/16 at approximately 1:00 PM, an interview was conducted with the Hospital Administrator who stated that the Hospital did not have an approved agreement between the Hospital and the organ and tissue bank

Based on medical record review and staff interview it was determined that for eight (8) of eight (8) patients (Patients A1, A3, A4, A5, A6, A9, A12 and A13) the facility failed to:

1. Ensure Psychosocial Assessments contained information about efforts social service staff anticipated as necessary in discharge planning. (Refer to B108)

2. Ensure Psychiatric Evaluations contained an assessment of patient assets in descriptive, not interpretive fashion. (Refer to B117)

3. Ensure Master Treatment Plans identified patient related short-term goals that were stated in observable, measurable, behavioral terms. (Refer to B121)

4. Ensure Master Treatment Plans disclosed treatment team member interventions that were individualized, and were not generic discipline tasks and .failed to adequately develop and document individualized treatment interventions with specific purpose and focus based on the presenting psychiatric problems. (Refer to B122)

5. Ensure that the use of standing prn (as necessary) physician Orders for antipsychotic and/or antianxiety medications described what patient specific behaviors necessitated them and did not result in nursing staff having to work outside their scope of practice. (Refer to B125)

Based on medical record review and staff interview it was determined that for four (4) of eight (8) patients the Psychosocial Assessments failed to describe the anticipated role of the social service staff in discharge planning. This failure results in no information for the other members of the multidisciplinary treatment team as to what was considered as appropriate measures for these patients. (Patients A3, A6, A12 and A13).

The findings include:

I. Medical Record Review:

1. Patient A3: The Psychosocial Assessment dated 7/22/2016 had no description of what the anticipated role for social service staff toward discharge planning would be. This Psychosocial Assessment was incomplete at the 72 hour deadline established by facility policy. There was no notation on the Psychosocial Assessment that any further attempts to obtain information had been made to complete the assessment.

2. Patient AA6: The Psychosocial Assessment dated 8/8/2016 had no description of what the anticipated role for social service staff toward discharge planning would be.

3. Patient A 12: The Psychosocial Assessment dated 8/11/2016 stated "will seek o/p (out-patient) tx (treatment) resources for linkage." No further explanation was given for what "resources" were to be explored.

4. Patient A13:The Psychosocial Assessment dated 8/11/2016 had no description of what the anticipated role for social service staff toward discharge planning would be.

B. Staff Interview:

On 8/17/2016 at 10:40 AM the Director of Social Services was interviewed. The Director was shown the findings described in Section I, above. The Director stated that individualized discharge planning efforts were not described. The Director, also, stated that the Psychosocial Assessment of Patient A3 was incomplete.

Based on medical record review and staff interview it was determined that for seven (7) of eight (8) patients their Psychiatric Evaluation failed to describe in descriptive not interpretive fashion patient assets. This failure results in the treatment team members not being aware of what personal attributes, interests, etc. might be utilized in therapeutic endeavors. (Patients A3, A4.A5, A6, A9, A12 and A13).

The findings include:

I. Medical Record Review:

1. PatientA3: The Psychiatric Evaluation dated 7/20/2016 described as the patient's assets "states he wants help, generally healthy." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

2. Patient A4: The Psychiatric Evaluation dated 7/25/2016 described patient's assets as "good health, history of treatment." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

3. Patient A5: The Psychiatric Evaluation dated 8/01/2016 described the patient's assets as "good health, history of treatment." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

4. Patient A6: The Psychiatric Evaluation dated 8/04/2016 described the patient's assets as "healthy, wants help." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

5. Patient A9: The Psychiatric Evaluation dated 8/07/2016 described as the patient's assets "wants treatment." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

6. Patient A12: The Psychiatric Evaluation dated 8/10/2016 stated as patient assets "wants treatment." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

7. Patient A13: The Psychiatric Evaluation dated 8/10/2016 stated as patient assets "healthy, has family." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

II. Staff Interview:

On 8/18/2016 at 9:15 AM the facility's clinical director was interviewed. The clinical director was shown the findings described in Section I., above. The clinical director stated that these evaluations were inadequate in describing individualized, personal or inherent patient assets.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that identified patient related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (A1, A3, A4, A5, A6,A9, A12 and A13). In addition, many Master Treatment Plans contained similarly worded short-termed goals for patients, which were not measurable outcome behaviors. This deficient practice hinders the treatment team's ability to measure individualized behavioral changes in the patients and may contribute to failure of the team to modify the Master Treatment Plans (MTPs) in response to patients' needs.

Findings include:

A. Record Review:

The MTPs for the following active sample patients were examined (dates of plans and/or their most recent updates are in parenthesis): A1 (5/25/16), reviewed 8/5/16; A3 (7/20/16), reviewed 8/5/16; A4 (7/25/16), reviewed 8/10/16; A5 (8/2/16); A6 (8/5/16); A9 (8/7/16); A12 (8/10/16) and A13 (8/10/16). This examination of MTPs revealed the following deficient short-term goals (STG) formulated by various disciplines including Nursing, Psychiatry, Social Work, AT (Activity Therapy) and Psychology. Several STG statements were similarly worded.

I. Patient A1

Problem statement: "Danger to self/suicidal ideation as manifested by plan to jump in front of traffic." The short-term goals (STG) formulated were:

Nursing: "Patient will no longer express feelings to jump in front of traffic or hurt self and verbalize ways of coping with feelings within 5-7 days of discharge." This STG was not stated in behavioral terms reflecting what the patient would be doing to reduce thoughts/impulses to hurt self, and how he/she will develop ways of coping with such feelings.

Psychiatry: "o/e (on examination) Pt (patient) will have euthermic mood + (and) affect and no SI (suicide ideation)(sic)" This STG was stated as staff expectation/compliance in treatment rather than behavior outcomes to evaluate whether the patient's stated problem has been reduced/resolved.

Social Work: "Pt (patient) will identify two coping strategy {sic} with social worker to deal with depression." This STG "two coping strategy" (not specific) to deal with depression was not measurable.

Activity Therapy: "Pt (patient) will attend and participate in all assigned leisure grips (groups) to help cope with issues/stress." This STG was ambiguous in that it did not identify the leisure groups.

Psychology: "Pt (patient) will verbalize 2 benefits of good coping to deal with negative thoughts (sic)." This STG was incomplete and not stated in measurable/behavioral terms.

II. Patient A3

Problem statement: "Danger to self/SI with plan to stand in front of train as manifested by Pt (patient) reported to be suicidal with plan to stand in front of train, also feeling depressed." The short-term goals formulated were:

Nursing: "Pt (patient) will report two coping skills in dealing with stress. Pt (patient) will report to staff he no longer feels depressed and suicidal." This STG was not measurable due to the fact that there was no way to determine whether patient was sharing his/her feelings via reporting to staff.

Psychiatry: " Pt. (patient) will report at least 2 benefits of psychotropic meds. (medications)." "o/e(on examination) Pt (patient) will have eurythmic mood + (and) affect and no SI (suicide ideation)(sic)" This STG was stated as staff expectation/compliance in treatment rather than behavior outcomes to evaluate whether the patient's stated problem has been reduced/resolved.

Social Work: "Pt (patient) will verbalize 3 coping skills to be utilized in managing depression and stress to avoid SI (suicidal ideation) and other related symptoms at least 4 days prior to D/C (discharge)." This STG was not written in behavioral, observable, and measurable terms.

Activity Therapy: "Pt (patient) will engage appropriately with peers during AT groups and identify 2 relaxation techniques to practice on a regular basis in order to improve his/her ability to cope with life stressors." This STG "Engage appropriately" is not measurable.

Psychology: "Pt (patient) will verbalize 2 examples of good coping to deal with negative thoughts and feelings (sic)." This STG was incomplete and goal was not stated in observable and measurable terms.

III. Patient A4

Problem statement: "Alteration in thought process as manifested by patient feeling paranoid thinks somebody is trying to kill him/her, sexually preoccupied, noncompliant with medication." The short-term goals formulated were:

Nursing: "Patient no longer exhibits symptoms of paranoia/psychotic symptoms at least 3 days prior to discharge." This STG was stated as staff expectation.

Psychiatry: "Patient will have no episodes of agitation or aggression and will not demonstrate any signs of paranoia or psychosis for 3 days prior to discharge." This STG was stated as staff expectation.

Social Work: "Pt (patient) will identify two coping strategies with Social Worker weekly to deal with depressive symptoms." This STG " two coping strategies" is not specific. "To deal with depressive symptoms," is not measurable.

Activity Therapy: " Pt (patient) will identify 2 relaxation techniques he/she can practice on a regular basis in order to more effectively cope with symptoms of mental illness and life stressors." This STG was not stated in observable, measurable behavior to be achieved reflecting what the patient would be doing.

Psychology: No goals identified.

IV. Patient A5

Problem statement: "Alteration in thought process as manifested by patient with paranoia, irritability, verbally abusive, noncompliant with medications, was picked wandering the streets." The short-term goals formulated were:

Nursing: "Patient will report a decrease in symptoms with improved thought process at least 3 days prior to discharge." This STG was not written in observable, measurable patient behaviors to be achieved. Determination whether patient would share his/her decreased symptoms and improved thought process with staff could not be substantiated.

Psychiatry: "Patient to be free of paranoid thoughts and irritability and compliant with medications at least 3 days prior to discharge." This STG reflected staff expectation and not written in observable, behavioral, and measurable terms.

Social Work: "Pt (patient) will verbalize increased understanding and insight pertaining to MI (Mental Illness) symptoms at least 4 days prior to discharge." This STG was not written in observable, measurable patient behaviors to be achieved.

Activity Therapy: " Pt (patient) will identify 2 leisure interests to participate in to support his/her recovery process and cope with stress." This STG was not written in behavioral, observable, and measurable terms.

Psychology: No goals identified.

V. Patient A6

Problem statement: "In ability to care for himself as manifested by delusional, slow to respond, poor eye contact." The short-term goals formulated were:

Nursing: "Pt (patient) will be able to hold eye contact, respond appropriately, will no longer exhibit delusions at least 3 days prior to discharge." This STG reflected staff expectation/compliance in treatment and not written in observable, behavioral, and measurable terms.

Psychiatry: "o/e (on examination) pt (patient) will not be thought disordered." This STG was not stated in behavioral terms reflecting what the patient would be doing/saying to reduce "thought disorder."

Social Work: "Pt (patient) will identify two coping strategies with Social worker to deal with his strange behaviors and depression symptoms." This STG was not written in observable, measurable, patient behaviors to be achieved.

Activity Therapy: "Pt (patient will focus and engage in AT (Activity Therapy) groups and display socially appropriate behaviors at least 3 days prior to discharge." This STG was stated as staff expectation/compliance in treatment rather than behavior outcomes to evaluate whether the patient's stated problem has been reduced/resolved.

Psychology: "Pt (patient) will weekly 2 example {sic}of good coping to deal with negative thoughts and feelings {sic}." This STG was not stated clearly. "Good coping to deal with negative thoughts and feelings." was not measurable.

VI. Patient A9

Problem statement: "Potential for suicide as manifested by depression with suicidal ideation, no plans, noncompliant with medication." The short-term goals formulated were:

Nursing: "Patient will no longer (have) thoughts of harming self and improve mood 3 days prior to discharge {sic}." This STG was written as a staff expectation, and not stated in behavioral, observable and measurable terms reflecting specific focus for patient utilizing alternative non-harmful behavior.

Psychiatry: " o/e (on examination) Pt (patient) will have eurythmic mood + (and) affect and no SI (suicide ideation){sic}" This STG was stated as staff expectation/compliance in treatment rather than behavior outcomes to evaluate whether the patient's stated problem has been reduced/resolved.

Social Work: "Client will remain free of SI (suicide ideation). Will report no longer being depressed. Will maintain mood range, affect with positive verbalizations 4 consecutive days (sic)." This STG statement failed to give specific focus to treatment. Determination whether patient was sharing his/her feelings "will report no longer being depressed" was not a measurable goal. It also failed to identify what the patient would be doing to remain "free of SI (suicide ideation)."

Activity therapy: " Pt (patient) will identify 2 relaxation strategies to practice in order to cope with stress more effectively." What the relaxation strategies and how they would be used by the patient to cope with stress were not described. This STG was not stated in observable, behavioral, and measurable terms.

Psychology: No goals identified.

VII. Patient A12

Problem statement: "Danger to self/hearing voices telling him/her to hurt him/her as manifested by reported to be feeling suicidal, hearing voices telling him/her and also depressed." The short-term goals formulated were:

Nursing: "Pt (patient) will report to staff that he/she is less depressed and also not hearing voices telling him/her to hurt him/her self." This STG was not stated in behavioral, observable, and measurable terms.

Psychiatry: "Pt (patient) to be free of hallucinations suicide ideations less depressed at least 3 days prior to d/c (sic) (discharge)." This STG was not stated in observable, behavioral, and measurable terms.

Social Work: "Client will remain free of any thoughts of self-harm and will not report depression for 5 consecutive days." This STG was not measurable or in behavioral terms. It was written as a staff expectation rather than a patient strategy

Activity Therapy: "Pt (patient) will identify 2 leisure interests to participate in order to more effectively cope with life stressors." The STG was not stated in observable, measurable, and behavioral terms.

Psychology: No goals identified.

VIII. Patient A13

Problem statement: "Bizarre behavior, disorganized with flight of ideas, as manifested by reported to be acting bizarre, sleeping under the bridge, wondering {sic}round, talking to self with flight of ideas, urinating and defecating on himself." The short-term goals (STG) formulated were:

Nursing: "Pt (patient) will not exhibit bizarre behavior and thought process will be more organized. The STG was stated as staff expectation/compliance in treatment rather than behavior outcomes to evaluate whether the patient's stated problem has been reduced/resolved.

Psychiatry: "Pt (patient) will not exhibit delusions about his job/work, and will not attend to internal stimuli." This STG was stated as staff expectation/compliance in treatment rather than behavior outcomes to evaluate whether the patient's stated problem has been reduced/resolved.

Social Work: "Patient will learn taken his medication (sic) will decrease his bizarre behavior and disorganized thinking." This STG was stated as staff expectation/compliance in treatment rather than behavior outcomes to evaluate whether the patient's stated problem has been reduced/resolved.

Activity Therapy: "Pt (patient) will engage and focus in AT (Activity therapy) groups without responding to internal stimuli for at least 3 days prior to discharge." This STG was not stated in behavioral terms reflecting what the patient would be doing (how would he/she be engaged).

Psychology: "Pt (patient) will verbalize 2 examples of good coping to deal with negative thoughts and feelings {sic}." This STG reflected an incomplete patient goal and did not address the identified patient behavior.

B. Interviews

I. In an interview on 8/17/16 at 1:05 p.m., with the Director of Nursing (Pavilion 4), the MTPs were discussed. "I agree with you, the goals and interventions need to be better. I am aware of that, and we are working on it." the Director of Nursing stated.

II. In an interview on 8/17/16 at 10:55 a.m., with the Unit Nurse Manager for Pavilion 4, the MTPs were reviewed. The Unit Nurse Manager agreed that the short-term treatment goals were not written in observable, measurable patient behaviors to be achieved. "We are working hard trying to be more specific; and had training recently."

III. In an interview on 8/18/16 at 1:00 p.m. with the Unit RN Charge Nurse for the 7-3 shift the MTPs were reviewed. The Charge Nurse acknowledged that they "Need to do better."

Based on interview and record review, the facility failed to adequately develop and document individualized treatment interventions with specific purpose and focus based on the presenting psychiatric problems for eight (8) of eight (8) active sample patients (A1, A3, A4, A5, A6, A9, A12 and A13). Many interventions were normal clinical functions (to assess, to assist, to help). These clinical function statements did not reflect any active treatment interventions to improve specific presenting psychiatric symptoms or problems. These deficiencies resulted in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to interdisciplinary treatment.

Findings include:

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans and/or most recent update in parentheses): A1 (5/25/16), reviewed 8/5/16; A3 (7/20/16), reviewed 8/5/16; A4 (7/25/16), reviewed 8/10/16; A5 (8/2/16); A6 (8/5/16); A9 (8/7/16); A12 (8/10/16) and A13 (8/10/16). The listing of generic routine discipline functions and tasks does not disclose a patient specific focus for the interventions.

I. Patient A1

For problem: "Danger to self/suicidal ideation. " The MTP had the following deficient intervention statements by various treatment staff:

Nursing Intervention: "To assist pt (patient) to learn to practice skills to manage symptoms and seek assistance." "To assist patient to learn about benefits, risks and side effects of medication." "To engage in treatment activities."

Psychiatry Intervention: "Assess response to treatment."

Social Work Intervention: "To help the patient to have better understanding about his/her Mental Illness."

Activity Therapy Intervention: "To learn relaxation techniques and alternate methods of coping (sic)."

Psychology Intervention: "Help the patient to have better understanding about his/her Mental Illness."

II. Patient A3

For problem: "Danger to self/suicidal ideation with plan to stand in front of train," the MTP had the following deficient intervention statements:

Nursing Intervention: "To provide skills to manage his/her symptoms better and also able identify his symptoms (sic), " " To learn importance of taking his medication side effects and benefit of his medication." "To provide activities, also engage patient in treatment plan."

Psychiatry Intervention: "Assess response to treatment."

Social Work Intervention: "Patient will obtain services needed for continuity of care following D/C (discharge)."

Activity Therapy Intervention: "Learn relaxation skills and techniques to improve ability to cope with life stressors." "Connect socially with peers in a therapeutic environment to improve communication skills."

Psychology Intervention: "Patient will learn positive ways to manage SI (suicide ideation) symptoms."

III. Patient A4

For problem: "Alteration in thought process."

Nursing Intervention: "To help patient understand benefits, risks and side effects of medication." "To assist patient to learn skills and awareness of symptoms and to seek assistance for treatment."

Psychiatry Intervention: "Assess response to treatment."

Social Work Intervention: "Explore housing options and possible before, if his cousin's house is not available." "Help the Pt (patient) to cope with his depression, paranoia, hearing voices and substance abuse."

Activity Therapy Intervention: "Learn relaxation skills and techniques in order to more effectively cope with symptoms and life stressors."

Psychology Intervention: "Will assist in dealing with negative thoughts and learn debate them with healthy ones (sic)." "Will assist and identify coping skills to deal with negative thoughts and feelings."

IV. Patient A5

For problem: "Alteration in thought process."

Nursing Intervention: "Assist Pt (patient) to learn and understand benefits, risks, side effects of medications." "Provide medication education."

Psychiatry Intervention: "To assess progress and adjust meds (medications) as needed."

Social Work Intervention: "Pt (patient) will obtain and monitor services needed for stabilization and continuity of care." " Pt (patient) will learn positive ways to control aggression." "Pt (patient) will develop understanding of challenges of MI (Mental Illness) and how to avoid crisis."

Activity Therapy Intervention: "Identify leisure interests to support recovery and prevent relapse." "Improve ability to communicate and relate to others without becoming inappropriate or aggressive."

Psychology Intervention: No intervention identified.

V. Patient A6

For problem: "Inability to care for self."

Nursing Intervention: "Assist Pt (patient) to identify and verbalize symptoms of psychiatric disorder."

Psychiatry Intervention: "Assess response to treatment."

Social Work Intervention: "Explore his/her aftercare alternatives and possible refer to get housing." "Meet with Pt (patient) 2 times per week to discuss possible coping strategies."

Activity Therapy Intervention: "Improve interpersonal communication skills."

Psychology Intervention: "Will assist in identifying coping skills to deal with suicidal thoughts and feelings."

VI. Patient A9

For problem: "Potential for suicide."

Nursing Intervention: "To assist Pt (patient) to learn and practice skills and to appropriate(ly) seek assistance from treatment provider to manage symptoms and illness {sic}." "To promote participation in self care and collaboration in treatment process." "To help patient understand benefits, risk(s), and side effects of medications." "To engage Pt (patient) in treatment activities to provide med (medication) education to increase awareness of behavior that promote healthy lifestyle."

Psychiatry Intervention: " Assess response to treatment." "Assess risk of harm."

Social Work Intervention: "Client will ID (identify) positive behavioral changes achieved through above placement and use of O/P (outpatient) community treatment to sustain and further recovery."{sic}

Activity Therapy Intervention: "Learn relaxation skills to cope effectively with stress."

Psychology Intervention: None identified.

VII. Patient A12

For problem: "Danger to self/hearing voices telling him/her to hurt himself/herself."

Nursing Intervention: "To assist Pt (patient) to learn importance of symptom management, also to practice skills to manage symptoms." "To teach patient importance of taking medication, side effect, and to be compliant with medication." "To engage patient in activities and treatment plan."

Psychiatry Intervention: "Monitor progress and adjust meds (medication) as needed."

Social Work Intervention: "Client will dialogue with other patients to gain understanding of alternatives to assault and positive skills in addressing personal needs."

Activity Therapy Intervention: "Learn relaxation skills to cope with stress." "Identify personal leisure skills to more effectively cope with stress."

Psychology Intervention: None identified.

VIII. Patient A13

For problem: "Bizarre behavior, disorganized and flight of ideas."

Nursing Intervention: "To teach Pt (patient) importance of managing symptoms, " " Teach patient importance of taking medication, side effects, benefits of medications."

Psychiatry Intervention: "Assessment, symptom evaluation."

Social work Intervention: No intervention identified.

Activity therapy Intervention: "Improve ability to relate and communicate with others without acting bizarre or responding to internal stimuli."

Psychology Intervention: No intervention identified.

B. Interviews

I. In an interview on 8/17/16 at 1:05 p.m., with the Director of Nursing (Pavilion 4), the MTPs were discussed. "I agree with you, the goals and interventions need to be better. I am aware of that, and we are working on it."

II. In an interview on 8/17/16 at 11:22 a.m., the Director of Social Work acknowledged that the goals and interventions were not individualized. "We are currently working on it."

III. In an interview on 8/16/16 at 2:00 p.m., with the clinical director, the MTPs were reviewed. The clinical director stated that the MTPs need improving.

Based on medical record review and staff interview it was determined that for five (5) of eight (8) patients there were standing prn (as necessary) physician Orders written that instructed nursing staff to administer one (1) or two (2) different medications for patient issues such as "anxiety" and/or "psychosis." This failure to describe behaviorally symptoms of the patient compels nursing staff to determine what medication is appropriate. This results in the nursing staff having to function outside their scope of practice. (Patients A1, A3, A4, A6 and A12).

The findings include:

I. Medical Record Review:

A parameter to examine the use of standing prn physician Orders was established. For the period 8/14/2016 and 8/15/2016, i. e. for 2 days, the MAR (Medication Administration Record) was reviewed with RN#1. All eight (8) patients in the random sample were reviewed.

1. Patient A1: On 8/14/2016, chlorpromazine (Thorazine) 50 mg po (by mouth) was given 2 times for "anxiety" by nursing staff. On 8/15/2016 again chlorpromazine 50 mg po was given 2 times (per MAR) for "anxiety". The physician Order for this usage was written on 8/5/2016 as "chlorpromazine 50 mg po g6h (every 6 hours) prn agitation."

2. Patient A3: On 8/14/2016, hydroxyzine (Atarax) 50 mg po and olanzapine (Zyprexa) 10 mg po were given by nursing staff for what the MAR described as "anxiety". On 8/15/2016 again this combination of an antipsychotic and antianxiety medication was administered by nursing staff for what the MAR described as "anxiety". The physician Order for this guidance was written on 8/10/2016 as two (2) separate physician Orders both to be given "q6h prn agitation". It was unclear if they were to be used separately or in combination as this was one (1) physician Order, and there were no behavioral prompts to guide nursing staff.

3. Patient A4: On 8/14/2016, olanzapine 10 mg po and lorazepam (Ativan) 2 mg were both administered per MAR for "(increased) anxiety". On 8/15/2016 olanzipine 10mg was administered per MAR for "(increased) agitation". The physician Order was written 8/11/2016 for "olanzipine 10mg po q6h prn agitation" and "lorazapam 2mg po q4h prn anxiety". There were no behavioral guidelines for nursing staff; rather it was left to 3 different shifts of nursing staff to determine what the patient's symptoms represented, and which medication to utilize.

4. Patient A6: While there was no occurrence of usage of prn medications during the 8/14 and 8/15/2016 period, there was a standing physician Order dated 8/8/2016 for "olanzipine 10mg po q6h prn psychosis/agitation". This had been administered on 8/8/2016, 8/11/2016 x2, and 8/12/2016 per MAR for "anxiety".

5. Patient A12: On 8/14/2016 lorazepam 1 mg po was administered on 2 separate occasions and on 2 occasions on 8/15/2016 for "anxiety" per MAR. The physician Order written 8/10/2016 stated "lorazepam 1 mg po x3 daily prn anxiety". No behavioral guidelines were written to clarify what "anxiety" meant.

II. Staff Interview:

On 8/18/2016 at 9:30 AM, the clinical director was interviewed. The focus was on the standing prn physician Orders using antianxiety and/or antipsychotic medications which left the nursing staff to diagnose and differentiate what was occurring and what medication to administer. The clinical director stated that these types of standing prn physician Orders were unacceptable.

Based on medical record review and staff interview it was determined that the facility failed to ensure for eight (8) of eight (8) patients (Patients A1, A3, A4, A5, A6, A9, A12 and A13) the following monitoring of staff functions:

1. Clinical Director failed to monitor the quality of Psychiatric Evaluations for the presence of assessment of patient assets. (See, B117 for details) and monitor Master Treatment Plans to ensure patient short term goals were measurable (See, B121 for details) and ensure Master Treatment Plans described individualized, not generic discipline functions (See, B122 for details) and that there were not standing prn Orders that necessitated nursing staff to have to function outside nursing scope of practice (Refer to B125). (Refer to B144)

2. Director of Social Work failed to assure that Psychosocial Assessments contained a description of the anticipated role of the social service staff in discharge planning. (Refer to B108)

3. Director of Nursing failed to ensure that active treatment interventions to be implemented by Registered nurses were individualized and contained a specific purpose and/or focus based on the needs for each patient. (Refer to B122)

4 The facility failed to provide a therapeutic activity program that ensured an adequate number of qualified therapists to provide comprehensive therapeutic activities for eight (8) of eight (8) active sample patients (A1, A3, A4, A5, A6, A9, A12 and A13). No staff was available to provide or oversee services on afternoons, evenings or weekends. (Refer to B158)

Based on medical record review and staff interview it was determined that the clinical director failed to monitor for eight (8) of eight (8) patients (Patients A1, A3, A4, A5, A6 A9, A12 and A13) the following areas of staff performance:

A. Psychiatric Evaluations included patient assets in descriptive, not interpretive fashion:

Based on medical record review and staff interview it was determined that for seven (7) of eight (8) patients their Psychiatric Evaluation failed to describe in descriptive not interpretive fashion patient assets. This failure results in the treatment team members not being aware of what personal attributes, interests, etc. might be utilized in therapeutic endeavors. (Patients A3, A4.A5, A6, A9, A12 and A13).

The findings include---

I. Medical Record Review:

1. PatientA3: The Psychiatric Evaluation dated 7/20/2016 described as the patient's assets " states he wants help, generally healthy. No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

2. Patient A4: The Psychiatric Evaluation dated 7/25/2016 described patient's assets as "good health, history of treatment." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

3. Patient A5: The Psychiatric Evaluation dated 8/01/2016 described the patient's assets as "good health, history of treatment." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

4. Patient A6: The Psychiatric Evaluation dated 8/04/2016 described the patient's assets as "healthy, wants help." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

5. Patient A9: The Psychiatric Evaluation dated 8/07/2016 described as the patient's assets "wants treatment." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

6. Patient A12: The Psychiatric Evaluation dated 8/10/2016 stated as patient assets "wants treatment." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

7. Patient A13: The Psychiatric Evaluation dated 8/10/2016 stated as patient assets "healthy. has family." No description of inherent or personal attributes, interests, or other strengths that might, hopefully, be utilized in therapeutic endeavors were mentioned.

II. Staff Interview:

On 8/18/2016 at 9:15 AM the facility's clinical director was interviewed. The clinical director was shown the findings described in Section I., above. The clinical director stated that these evaluations were inadequate in describing individualized, personal or inherent patient assets.

B. Master Treatment Plans contained patient short term goals that were measurable. (See B121 for details) and that Master Treatment Plans disclosed individualized interventions and not generic discipline functions. (See, B122 for details)

C. Use of standing prn physician Orders were written in a manner that required nursing staff to have to identify what patient behaviors necessitated their use, and which medication and/or medications to select.

Based on medical record review and staff interview it was determined that for five (5) of eight (8) patients there were standing prn (as necessary) Orders written that instructed nursing staff to administer 1 or 2 different medications for patient issues such as "anxiety" and/or "psychosis." This failure to describe behaviorally symptoms of the patient compels nursing staff to determine what medication is appropriate. This results in the nursing staff having to function outside their scope of practice. (Patients A1, A3, A4, A6 and A12).

The findings include----

I. Medical Record Review:

A parameter to examine the use of standing prn physician Orders was established. For the period 8/14/2016 and 8/15/2016 i.e. for 2 days, the MAR (Medication Administration Record) was reviewed with RN#1. All eight (8) patients in the random sample were reviewed.

1. Patient A1: On 8/14/2016, chlorpromazine (Thomasine) 50 mg po (by mouth) was given 2 times for "anxiety" by nursing staff. On 8/15/2016 again chlorpromazine 50 mg po was given 2 times (per MAR) for "anxiety". The physician Order for this usage was written on 8/5/2016 as "chlorpromazine 50 mg po g6h (every 6 hours) prn agitation."

2. Patient A3: On 8/14/2016, hydroxyzine (Atarax) 50 mg po and olanzapine (Zyprexa) 10 mg po was given by nursing staff for what the MAR described as "anxiety". On 8/15/2016 again this combination of an antipsychotic and antianxiety medication was administered by nursing staff for what the MAR described as "anxiety". The physician Order for this guidance was written on 8/10/2016 as 2 separate Orders both to be given "q6h prn agitation". It was unclear if they were to be used separately or in combination as this was 1 Order, and there were no behavioral prompts to guide nursing staff.

3. Patient A4: On 8/14/2016, olanzapine 10 mg po and lorazepam (Ativan) 2 mg were both administered per MAR for "(increased) anxiety". On 8/15/2016 olanzapine 10mg was administered per MAR for "(increased) agitation". The physician Order was written 8/11/2016 for "olanzipine 10mg po q6h prn agitation" and "lorazapam 2mg po q4h prn anxiety". There were no behavioral guidelines for nursing staff; rather it was left to 3 different shifts of nursing staff to determine what the patient's symptoms represented, and which medication to utilize.

4. Patient A6: While there was no occurrence of usage of prn medications during the 8/14 and 8/15/2016 period, there was a standing physician Order dated 8/8/2016 for "olanzapine 10mg po q6h prn psychosis/agitation". This had been administered on 8/8/2016, 8/11/2016 x2, and 8/12/2016 per MAR for "anxiety".

5. Patient A12: On 8/14/2016 lorazepam 1 mg po was administered on 2 separate occasions and on 2 occasions on 8/15/2016 for "anxiety" per MAR. The physician Order written 8/10/2016 stated "lorazepam 1 mg po x3 daily prn anxiety". No behavioral guidelines were written to clarify what "anxiety" meant.

II. Staff Interview:

On 8/18/2016 at 9:30 AM the clinical director was interviewed. The focus was on the ambiguous standing prn physician Orders using antianxiety and/or antipsychotic medications which left the nursing staff to diagnose and differentiate what was occurring and what medication to administer. The clinical director stated that these types of standing prn Orders were unacceptable.

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

I. Ensure that active treatment interventions to be implemented by Registered Nurses were individualized and contained a specific purpose and/or focus based on needs for each eight (8) of eight (8) active sample patients (A1, A3, A4, A5, A6, A9, A12 and A13). This deficiency resulted in treatment plans that failed to reflect a comprehensive and individualized nursing approach to treatment. (Refer to B122)

II. Ensure the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A3, A4, A5, A6, A9, A12 and A13) identified short-term treatment goals that were observable and measurable addressing the individual patient presenting problems and needs. (Refer toB121)

B. Interview

I. In an interview on 8/17/16 at 1:05 p.m., with the Director of Nursing (Pavilion 4), the MTPs were discussed. "I agree with you, the goals and interventions need to be better. I am aware of that, and we are working on it."

Based on medical record review and staff interview it was determined that the Director of Social Work failed to monitor the quality of the Psychosocial Assessments for four (4) of eight (8) sample patients (Patients A3, A6, A12 and A13).

The findings include--

I. Medical Record Review:

1. Patient A3: The Psychosocial Assessment dated 7/22/2016 had no description of what the anticipated role for social service staff toward discharge planning would be. This Psychosocial Assessment was incomplete at the 72 hour deadline established by facility policy. There was no notation on the Psychosocial Assessment that any further attempts to obtain information had been made to complete the assessment.

2. Patient A6: The Psychosocial Assessment dated 8/8/2016 had no description of what the anticipated role for social service staff toward discharge planning would be.

3. Patient A 12: The Psychosocial Assessment dated 8/11/2016 stated "will seek o/p (out-patient) tx (treatment) resources for linkage." No further explanation was given for what "resources" were to be explored.

4. Patient A13: The Psychosocial Assessment dated 8/11/2016 had no description of what the anticipated role for social service staff toward discharge planning would be.

Staff Interview:

On 8/17/2016 at 10:40 AM the Director of Social Services was interviewed. The Director was shown the findings described in Section I, above. The Director stated that individualized discharge planning efforts were not described. The Director, also, stated that the Psychosocial Assessment of Patient A3 was incomplete.

This Standard was not met as evidenced by:
Based on observations, interview, and record review, the facility failed to provide a therapeutic activity program that ensured an adequate number of qualified therapists to provide comprehensive therapeutic activities for eight (8) of eight (8) active sample patients (A1, A3, A4, A5, A6, A9, A12 and A13). No staff was available to provide or oversee services on evenings or weekends. In addition, the Director of Therapeutic activities position was vacant. The Clinical Director was overseeing this discipline with a Lead Activity therapist (Activity Therapy Supervisor), an Activity Therapy Coordinator (for scheduling) and two Activity Therapists for 6 sites (Pavilions).

Findings include:

A. Document Review

I. There was no Activity Therapy Assessment done to ensure appropriate input into the formulation of the Master Treatment Plan (MTP) for eight (8) of eight (8) sample patients.

II. A review of the "Group Schedule" for Pavilion 4 revealed that therapeutic activities were scheduled for four core groups on the unit in a 5-dayworkweek. There were no therapeutic activities offered after 4:00 p.m. during the week and no therapeutic activities offered on Saturdays and Sundays.

III. There was no record to identify if planned therapeutic activities were held or not held.

IV. Afternoon, evening and weekend activities were assigned to nursing staff (Mental Health Technicians). This failed practice can result in patients not receiving structured activity therapy groups to assist them in meeting their treatment goals.

B. Observation

I. On 8/16/16 at 10:30 a.m. Activity Therapy was scheduled to conduct a class. After waiting for 5-10 minutes, the Activity Therapist who had been scheduled did not arrive and the nursing staff (Mental Health Technicians) then stepped in to conduct the class.

II. On 8/17/16 at 10:30 a.m., Activity Therapy conducted a "Relaxation" group, which was a yoga group with an attendance of 5 patients. It required patients standing on one foot balancing with hands clasped in prayer form in front of their chest without regard to age or medication side effects such as dizziness, tremor, muscle stiffness, etc.

C. Interview

I. In an interview on 8/17/16 at 2:00 p.m. with the Clinical Director; she stated, "I understand how important it is for Activity Therapy to be here. We are short of AT staff."

II. In an interview on 8/18/16 at 9:10 a.m. with the Lead Activity Therapist he stated that he is assigned to covers Pavilion 3, and that he also fills in wherever there is an absence of AT staff from the other Pavilions.