HospitalInspections.org

Based on record review and interview the facility failed to provide:

l. Treatment plans that identified patient-related short-term goals (STGs) stated in observable, measurable and behavioral terms for eight (8) out of eight (8) sampled patients (A1, A2, A3, A4, A5, A6, A7, and A8). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs and prolonged hospitalization. (B121)

ll. Individualized interventions to address specific treatment needs for eight (8) out of eight (8) sampled patients (A1, A2, A3, A4, A5, A6, A7, and A8). Listed interventions on the Master Treatment Plans were routine, generic discipline functions rather than individualized interventions. These deficiencies result in lack of guidance to staff in providing individualized, coordinated treatment in the least restrictive environment, and can result in prolonged hospitalizations for patients. (B122)

Based on record review and interview the facility failed to provide Master Treatment Plans (MTP) that identified patient related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). In addition, many Master Treatment Plans contained similarly worded short-term goals for patients, which were not measurable outcome behaviors. This deficient practice hinders the treatment team's ability to measure individualized behavior changes in the patient and may contribute to failure to the team to modify Master Treatment Plan in response to patient needs.

Findings include:

A. Record Reviews:

1. Patient A1 was admitted 11/29/2016. The psychiatric evaluation dated 11/29/2016 identified psychiatric diagnosis as "Unspecified Psychosis." The Master Treatment Plan (MTP) dated 11/29/2016 identified Short Term Goals (STG) for:

Problem: Danger to Others/Agitated and delusional:

a. Nursing STG stated "Patient will verbalize orientation to person, place, time and situation with in 10 day of inpatient treatment"
b. Psychiatry STG stated "Patient will be oriented x3 and able to manage taking medications and some self-care"
c. Social Work STG stated "Patient will identify two coping strategies with SW (social work) weekly to deal with acute MI (mental illness)-psychotic [sic] delusional"
d. Activity Therapy STG stated "Patient will identify 3 leisure activities to participate to cope with life stressors"
e. Psychology STG stated "Patient will verbalize 2 examples of good coping to deal with [sic]thought and feeling"

2. Patient A2 was admitted 12/9/2016. The psychiatric evaluation dated 12/9/2016 identified psychiatric diagnosis as "Major Depression, recurrent, severe, w/o (without) psychotic feats (features); Opiate dep (dependency); THC (marijuana) abuse." The Master Treatment Plan (MTP) dated 12/9/2016 identified Short Term Goals (STG) for:

Problem: Danger to Self/suicidal ideation:

a. Nursing STG stated "Patient will verbalize his/her feelings and concerns each shift 5 minutes 1:1 interaction with staff"
b. Psychiatry STG stated "Patient's to respond no further thoughts of harming self [sic] at least 3 days prior to d/c (discharge)"
c. Social Work STG stated "Patient will verbalize 4 coping skills to be utilized in managing depression to avoid SI (suicidal ideation) or other related crisis; At least 4 days prior to discharge"
d. Activity Therapy STG stated "Patient will identify 3 relaxation techniques to practice to develop sober coping skills for life stressors, depression and/or anxiety and prevent further mental health crisis"
e. Psychologist STG stated, "Patient will [sic] 2 examples of [sic] coping and [sic] [sic] negative thoughts and feelings"

Problem: Substance Abuse:

a. No Nursing STG was identified
b. Psychiatry STG stated "Patient to be able to [sic] [sic] plans of staying sober at least 2 days prior to d/c (discharge)"
c. Social Work STG stated "Patient will verbalize recovery plan for SA (substance abuse) Tx (treatment) at least 4 days prior to discharge"
d. Activity Therapy STG stated "Patient will identify 3 leisure activities to engage in while sober, in order to develop positive recreational activities to cope with triggers to use drugs and life stressors."

3. Patient A3 was admitted 12/7/2016. The psychiatric evaluation dated 12/7/2016 identified psychiatric diagnosis as "Schizoaffective Disorder." The Master Treatment Plan (MTP) dated 12/7/2016 identified Short Term Goals (STG) for:

Problem: Delusional, Paranoid, [sic]

a. Nursing STG stated, "Patient will comply with medication and verbalize the benefits of taking psycho (psychiatric) medications within 3-5 day of hospitalization"
b. Psychiatry STG stated "Patient to be lucid, [sic] compliant with meds (medications) at least 3 days prior to d/c (discharge)"
c. Social Work STG stated "Patient will learn to cope with his/her paranoid delusional problems from weekly group therapy and individualized therapy"
d. Activity Therapy STG stated "Patient will [sic] and engage in AT (activity therapy) groups without responding to internal stimuli at least 3 days prior to discharge"
e. Psychologist STG stated, "Patient will [sic] 2 examples of [sic] coping to [sic] [sic] stressful situation"

4. Patient A4 was admitted 12/2/2016. The psychiatric evaluation dated 12/2/2016 identified psychiatric diagnosis as "Schizoaffective Disorder, Bipolar type, severe; R/O (rule out) secondary to traumatic brain injury." The Master Treatment Plan (MTP) dated 12/2/2016 identified Short Term Goals (STG) for:

Problem: Alteration in thought process:

a. Nursing STG stated, "Patient will be free from hearing voices and will be able to differentiate [sic] delusional thinking and reality"
b. Psychiatry STG stated, "O/E (on examination) Patient will report no AH (auditory hallucinations) x 3 days"
c. Social Work STG stated, "Patient will identity [sic] weekly to deal with hearing voices"
d. Activity Therapy STG stated, "Patient will identify 2 relaxation techniques to practice to cope more effectively with stress "

Problem: Substance abuse:

a. No Nursing STG was identified
b. Psychiatry STG stated, "Patient will be able to state a concrete plan for staying sober"
c. Social Work STG stated, "To learn negative facts [sic] [sic][sic] learn negative [sic] of substance abuse (SA) [sic]"
d. Activity Therapy STG stated, "Patient will identify 3 leisure activities to participate in to cope with triggers to use and maintain sobriety post d/c (discharge)"

5. Patient A5 was admitted 12/10/2016. The psychiatric evaluation dated 12/10/2016 identified psychiatric diagnosis as "Adjustment disorder unspecified." The Master Treatment Plan (MTP) dated 12/10/2016 identified Short Term Goals (STG) for:

Problem: Danger to Self/Suicide with Plan

a. Nursing STG stated, "Patient will report to staff that s/he is not feeling suicidal with plan to shoot himself/herself at least 3 days prior to d/c (discharge)"
b. Psychiatry STG stated, "Patient to gain coping skills to be independent and [sic] no further SI (suicide ideation) at least 3 days prior to d/c"
c. Social Work STG stated, "Patient will verbalize 4 coping skills to be utilized managing anxiety and depression [sic] SI (suicidal ideation) and other related crisis at least 4 days prior to discharge"
e. Activity Therapy STG stated, "Identify 2 relaxation techniques and 2 leisure activities to engage in safety and effectively cope with life stressors"
d. Psychology STG stated, "Patient will identify 2 examples of good coping and [sic]"


6. Patient A6 was admitted 12/10/2016. The psychiatric evaluation dated 12/10/2016 identified psychiatric diagnosis as " R/O (rule out) Schizophrenia; Alcohol Abuse. " The Master Treatment Plan (MTP) dated 12/10/2016 identified Short Term Goals (STG) for:

Problem: Danger to Self:

a. Nursing STG stated, "Patient will verbalize 3 coping skills to be utilized in managing his/her life style"
b. Psychiatry STG stated, "O/E (on examination) patient will no longer be disorganized or internally preoccupied"
c. Social Work STG stated, "Patient will identify at least 2 coping skills with SW (social work) weekly meeting to deal with depressive symptoms"
d. Activity Therapy STG stated, "Patient will engage and focus in AT (activity therapy) groups without responding to internal stimuli or engaging in paranoid/bizarre behavior at least 3 days prior to discharge"

Problem: Alcohol use disorder, mild

a. No Nursing STG was identified
b. Psychiatry STG stated, "Patient will be able to commit to a concrete plan to stay sober"
c. Social Work STG stated, "Patient will gain insight and motivation from MISA/HAS (Mental Illness Substance Abuse/Healthcare Alternative Systems) problems from substance abuse treatment"
d. Activity Therapy STG stated, "Patient will identify 3 sober leisure interests to participate in alternative to using ETOH (alcohol) and as a healthy method of coping with triggers to drink ETOH (alcohol)"

7. Patient A7 was admitted 12/1/2016. The psychiatric evaluation dated 12/1/2016 identified psychiatric diagnosis as "Major Depression disorder, recurrent, severe without psychotic features." The Master Treatment Plan (MTP) dated 12/1/2016 identified Short Term Goals (STG) for:

Problem: Depression with Suicide Ideation

a. Nursing STG stated, "Patient will verbalize feelings and concerns to staff each shift for 10 days and will contract for safety [sic]"
b. Psychiatry STG stated, "Resolutions of suicidal ideation and mood dysregulation and euthymic affect"
c. Social Work STG stated, "Free of SI (suicidal ideation) and [sic] remission depression 15 consecutive days"
d. Activity Therapy STG stated, "Patient will identify 3 relaxation techniques to practice to cope more effectively with difficult stressful situations and feelings"
e. Psychology STG stated, "Patient will [sic] 2 examples of good coping and [sic] with negative thought and feeling"

8. Patient A8 was admitted 12/5/2016. The psychiatric evaluation dated 12/5/2016 identified psychiatric diagnosis as "Unspecified Mood Disorder." The Master Treatment Plan (MTP) dated 12/5/2016 identified Short Term Goals (STG) for:

Problem: Mood disorder

a. Nursing STG stated, "Patient will identify 2 stressors that lead to relapse and suicide ideation at 3 days prior to discharge"
b. Psychiatry STG stated, "O/E (on examination) patient will have euthymic mood and affect and no SI (suicidal ideation)"
c. Social Work STG stated, "Client will remain free of SI (suicidal ideation) x 7 consecutive days and will report remission on depression"
d. Activity Therapy STG stated "Patient will identify 2 relaxation techniques to practice in order to improve his/her ability to cope with life stressors and/or depression"
e. Psychology STG stated, "Patient will verbalize 2 examples of good coping to deal with negative thoughts and feelings"

Problem: Substance Abuse

a. No Nursing STG was identified
b. Psychiatry STG stated, "Patient will endorse the need for sobriety at some point prior to discharge"
c. Social Work STG stated, "Client will reframe from drugs [sic] drugs to [sic] prevent relapse and reoccurring depression"
d. Activity Therapy STG stated, "Patient will identify 2 sober leisure activities to participate in to promote a healthy lifestyle and maintain sobriety"

B. Interview

1. On 12/12/2016 at 1:30 PM, interviews were held with facility Administrator, Quality Management Coordinator from Illinois central office, Directors of Social Work, Quality Management, and Nursing to review treatment planning process. Facility representatives present, attempted to read the treatment plans to surveyor and acknowledged legibility was problematic and they were unable to read portions of the short-term goals and interventions.

2. On 12/13 at 2:20 PM, interviews were held with Director of Nursing (DON) about the treatment plans. DON stated the goals were not written in observable or measurable and stated "I agree with you."

3. On 12/13/2016 at 1 PM, interviews were held with Medical Director and Laura Godinez, Quality Management Coordinator from Illinois central office was present. The Medical Director agreed the goals were not written in observable or measurable terms and stated "we can be more specific."

4. On 12/13/2016 at 2 PM, interviews were held with Director of Social Work and reviewed the short-term goals written by social workers. Director of Social Work agreed the STGs were written in vague terms. Additionally, Social Worker Director attempted to read some of the written goals and had difficulty reading the writing and acknowledged portions of the treatment plans were illegible.

Based on record review and interview the facility failed to develop and Record individualized treatment interventions with specific purpose based on the presenting psychiatric problems for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Listed interventions were routine, generic discipline functions rather than individualized interventions. These deficiencies result in lack of guidance to staff in providing individualized, coordinated treatment and can result in prolonged hospitalizations for patients.

A. Record Review

Review of the sample patients' Master Treatment Plans (MTPs) revealed that the plans included lists of routine generic discipline functions listed as individualized interventions for eight (8) out of eight (8) sample patients. The facility failed to develop treatment plans that identified clearly delineated interventions to address specific patient problems. Instead, interventions on plans included the following:

1. Patient A1-MTP dated 11/29/16

Problem: "Danger to others/Agitated and delusional"

a. Nursing Interventions stated, "Assist patient to learn and practice skills by appropriately seek [sic] from treatment [sic] to manage symptoms and illness" "To engage patient in treatment [sic]" "To promote medication education"
b. Psychiatry intervention stated, "Attempt to engage patient in treatment"
c. Activity Therapy Interventions stated, "Identify and improve leisure skills to cope with life stressors"


2. Patient A2-MTP dated 12/9/2016

Problem: "Danger to self/suicidal ideation"

a. Nursing Interventions stated, "To assist patient to learn to practice skills to manage symptoms and to seek assistance" "To engage patient in treatment activities" "To provide medication education"
b. Psychiatry Interventions stated "Patient to be monitored for symptoms and medication adjustment"

Problem: "Substance Abuse"

a. Nursing Interventions, no nursing interventions were listed
b. Psychiatry Interventions stated "Patient to be monitored for symptoms and medication adjustment"

3. Patient A3-MTP dated 12/7/2016

Problem "Delusional, Paranoid/responding to internal stimuli"

a. Nursing Interventions stated, "Assist patient learn to practice skills to manage symptoms and seek assistance" "Engage patient in treatment activities of healthy lifestyle"
b. Psychiatry Interventions stated, "To assess symptoms and adjust medications as needed."
c. Activity Therapy Intervention stated, "Identify and improve leisure skills and interest to cope with life stressors"

4. Patient A4-MTP dated 12/2/2016

Problem "Alteration in Thought Process"

a. Nursing Interventions stated, "To assist patient to learnt to [sic] ability to manage sx (symptoms) and seek assistance" "To engage patient in treatment activities"
b. Psychiatry Interventions stated, "Assess response to treatment"
c. Social Work Interventions stated, "Meet with patient 2 x per week to discuss possible coping strategies [sic] to his/her MI (mental illness) and substance abuse"


Problem "Substance Abuse"

a. Nursing Interventions, no nursing interventions were listed
b. Psychiatry Interventions stated, "educate regarding substance use"

5. Patient A5-MTP dated 12/10/2016

Problem "Danger to self/suicidal with plan"

a. Nursing Interventions stated, "To educate patient to learn skills to manage his/her illness and symptoms better" "To educate patient about importance of taking [medication] as prescribed" "Engage patient with treatment activities as scheduled"
b. Psychiatry Interventions stated, "To evaluate need for [sic] medications" "To monitor [sic] assessment of other symptoms that may need interventions"
c. Social Work Interventions stated, "Patient will have services needed to manage symptoms to avoid crisis and have long term stabilization" "Patient will learn affect ways to manage [sic] or symptoms to avoid [sic] crisis."
d. Activity Therapy Interventions stated, "Identify and improve leisure skills to safety and effectively cope with life stressors"

6. Patient A6-MTP dated 12/10/2016

Problem "Danger to Self"

a. Nursing Interventions stated, "Provide medication teaching, encourage patient to engage in treatment activities and groups"
b. Psychiatry Interventions stated, "Supportive therapy and medication management"

Problem "Alcohol Use Disorder, Mild"

a. Nursing Interventions, no nursing interventions were listed
b. Psychiatry Interventions stated, "Educate re (regarding) substance abuse"
c. Social Work Interventions stated, "Meet with patient 2 x per week to discuss possible coping strategies [sic] to his/her MI (mental illness) and substance abuse"

7. Patient A7-MTP dated 12/1/2016

Problem "Depression with SI (suicidal ideation)"

a. Nursing Interventions stated, "Assist patient to learn and practice self-help skills to better manage symptoms"
b. Psychiatry Interventions stated, "Supportive therapy and medication management"
c. Social Work Interventions stated, "[sic] connect o/p (outpatient) resources"
c. Activity Therapy Interventions stated, "Learn ways to relax and cope with stress"

8. Patient A8-MTP dated 12/8/2016

Problem "Mood D/O (disorder)"

a. Nursing Interventions, "To engage patient in treatment activities to provide mediation education"
b. Psychiatry Interventions stated, "assess response to treatment, assess risk of harm"
c. Social Worker Interventions stated, "Client will ID (identify) O/P (outpatient) resources [sic]"

Problem "Substance abuse"
a. Nursing Interventions, no nursing interventions were listed
b. Psychiatry Interventions stated, "educate re: (regarding) substance use"

B. Interviews

1. On 12/13/2016 at 2:20 PM, interviews were held with Director of Nursing (DON) about the treatment plans. DON agreed the interventions were lists of routine generic discipline functions and not individualized interventions. On 12/14/2016 at 11:30 AM, interviews were held with the DON about no nursing treatment interventions for patients with substance abuse and she stated "Social Work takes care of that and it is not nursing."

2. On 12/13/2016 at 1 PM, interviews were held with Medical Director and Laura Godinez, Quality Management Coordinator from Illinois central office was present. The Medical Director agreed the interventions were vague and not individualized. The Medical Director attempted to read the interventions of selected treatment plans and acknowledged portions of the treatment plan were illegible.

3. On 12/13/2016 at 2 PM, interviews were held with Director of Social Work and reviewed the interventions written by social workers. Director of Social Work agreed the interventions were written in general and vague terms and routine for social workers.

Based on record review and interviews the Medical Director failed to ensure the quality and appropriateness of services provided by the medical staff.

l. Treatment plans that failed to identify patient-related short-term goals (STGs) stated in observable, measurable and behavioral terms for eight (8) out of eight (8) sampled patients (A1, A2, A3, A4, A5, A6, A7, and A8). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs and prolonged hospitalization. (See B121)

ll. Individualized interventions that failed to address specific treatment needs for eight (8) out of eight (8) sampled patients (A1, A2, A3, A4, A5, A6, A7, and A8). Listed interventions on the Master Treatment Plans were routine, generic discipline functions rather than individualized interventions. These deficiencies result in lack of guidance to staff in providing individualized, coordinated treatment in the least restrictive environment, and can result in prolonged hospitalizations for patients. (See B122)

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

I. Ensure the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) identified short-term goals that were individualized and measurable based on identified patient needs. This failure hampered nursing staffs' ability to provide structured, focused treatment and can result in prolonged hospital stay for patients. (B121)
A. Record Review

1. Patient A1 was admitted 11/29/2016. The psychiatric evaluation dated 11/29/2016 identified psychiatric diagnosis as "Unspecified Psychosis." The Master Treatment Plan (MTP) dated 11/29/2016 identified Short Term Goals (STG) for:

Problem: Danger to Others/Agitated and delusional:

Nursing STG stated "Patient will verbalize orientation to person, place, time and situation with in 10 day of inpatient treatment"

2. Patient A2 was admitted 12/9/2016. The psychiatric evaluation dated 12/9/2016 identified psychiatric diagnosis as "Major Depression, recurrent, severe, w/o (without) psychotic feats (features); Opiate dep (dependency); THC (marijuana) abuse." The Master Treatment Plan (MTP) dated 12/9/2016 identified Short Term Goals (STG) for:

Problem: Danger to Self/suicidal ideation:

Nursing STG stated "Patient will verbalize his/her feelings and concerns each shift 5 minutes 1:1 interaction with staff"

Problem: Substance Abuse:

No Nursing STG was identified

3. Patient A3 was admitted 12/7/2016. The psychiatric evaluation dated 12/7/2016 identified psychiatric diagnosis as "Schizoaffective Disorder." The Master Treatment Plan (MTP) dated 12/7/2016 identified Short Term Goals (STG) for:

Problem: Delusional, Paranoid, [sic]

Nursing STG stated, "Patient will comply with medication and verbalize the benefits of taking psycho (psychiatric) medications within 3-5 day of hospitalization"

4. Patient A4 was admitted 12/2/2016. The psychiatric evaluation dated 12/2/2016 identified psychiatric diagnosis as "Schizoaffective Disorder, Bipolar type, severe; R/O (rule out) secondary to traumatic brain injury." The Master Treatment Plan (MTP) dated 12/2/2016 identified Short Term Goals (STG) for:

Problem: Alteration in thought process:

Nursing STG stated, "Patient will be free from hearing voices and will be able to differentiate [sic] delusional thinking and reality"


Problem: Substance abuse:

No Nursing STG was identified

5. Patient A5 was admitted 12/10/2016. The psychiatric evaluation dated 12/10/2016 identified psychiatric diagnosis as "Adjustment disorder unspecified." The Master Treatment Plan (MTP) dated 12/10/2016 identified Short Term Goals (STG) for:

Problem: Danger to Self/Suicide with Plan

Nursing STG stated, "Patient will report to staff that s/he is not feeling suicidal with plan to shoot himself/herself at least 3 days prior to d/c (discharge)"

6. Patient A6 was admitted 12/10/2016. The psychiatric evaluation dated 12/10/2016 identified psychiatric diagnosis as "R/O (rule out) Schizophrenia; Alcohol Abuse." The Master Treatment Plan (MTP) dated 12/10/2016 identified Short Term Goals (STG) for:

Problem: Danger to Self:

Nursing STG stated, "Patient will verbalize 3 coping skills to be utilized in managing his/her life style"

Problem: Alcohol use disorder, mild

No Nursing STG was identified

7. Patient A7 was admitted 12/1/2016. The psychiatric evaluation dated 12/1/2016 identified psychiatric diagnosis as "Major Depression disorder, recurrent, severe without psychotic features." The Master Treatment Plan (MTP) dated 12/1/2016 identified Short Term Goals (STG) for:

Problem: Depression with Suicide Ideation

Nursing STG stated, "Patient will verbalize feelings and concerns to staff each shift for 10 days and will contract for safety [sic]"

8. Patient A was admitted 12/5/2016. The psychiatric evaluation dated 12/5/2016 identified psychiatric diagnosis as "Unspecified Mood Disorder." The Master Treatment Plan (MTP) dated 12/5/2016 identified Short Term Goals (STG) for:

Problem: Mood disorder

Nursing STG stated, "Patient will identify 2 stressors that lead to relapse and suicide ideation at 3 days prior to discharge"

Problem: Substance Abuse

a. No Nursing STG was identified

II. Ensure that active treatment interventions to be implemented by Registered Nurses were individualized and contained a specific purpose and focus based on the needs of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This failure resulted in treatment plans that failed to reflect a comprehensive and individualized nursing approach to treatment. (B122)

A. Record Review

1. Patient A1-MTP dated 11/29/16

Problem: "Danger to others/Agitated and delusional"

Nursing Interventions stated, "Assist patient to learn and practice skills by appropriately seek [sic] from treatment [sic] to manage symptoms and illness" "To engage patient in treatment [sic]" "To promote medication education"


2. Patient A2-MTP dated 12/9/2016

Problem: "Danger to self/suicidal ideation"

Nursing Interventions stated, "To assist patient to learn to practice skills to manage symptoms and to seek assistance" "To engage patient in treatment activities" "To provide medication education"

Problem: "Substance Abuse"

Nursing Interventions, no nursing interventions were listed

3. Patient A3-MTP dated 12/7/2016

Problem "Delusional, Paranoid/responding to internal stimuli"

Nursing Interventions stated, "Assist patient learn to practice skills to manage symptoms and seek assistance" "Engage patient in treatment activities of healthy lifestyle"

4. Patient A4-MTP dated 12/2/2016

Problem "Alteration in Thought Process"

Nursing Interventions stated, "To assist patient to learnt to [sic] ability to manage sx (symptoms) and seek assistance" "To engage patient in treatment activities"

Problem "Substance Abuse"

Nursing Interventions, no nursing interventions were listed

5. Patient A5-MTP dated 12/10/2016

Problem "Danger to self/suicidal with plan"

Nursing Interventions stated, "To educate patient to learn skills to manage his/her illness and symptoms better" "To educate patient about importance of taking [medication] as prescribed" "Engage patient with treatment activities as scheduled"

6. Patient A6-MTP dated 12/10/2016

Problem "Danger to Self"

Nursing Interventions stated, "Provide medication teaching, encourage patient to engage in treatment activities and groups"

Problem "Alcohol Use Disorder, Mild"

Nursing Interventions, no nursing interventions were listed

7. Patient A7-MTP dated 12/1/2016

Problem "Depression with SI (suicidal ideation)"

Nursing Interventions stated, "Assist patient to learn and practice self-help skills to better manage symptoms"

8. Patient A8-MTP dated 12/8/2016

Problem "Mood D/O (disorder)"

Nursing Interventions, "To engage patient in treatment activities to provide mediation education"

Problem "Substance abuse"

Nursing Interventions, no nursing interventions were listed

B. Interview

An interview was conducted with the Director of Nursing 12/14/16 at 11:30 AM. She acknowledged that the nursing staff were not "there yet" in developing Master Treatment Plan short-term and long-term goals that were stated in observable, measurable terms.
She further stated that nurses did not develop Master Treatment goals or interventions for any substance abuse problems that were identified. She stated that the Social Work Department took care of any substance abuse problems that were identified.

Based on observations, record review and interviews the Social Work Director failed to adequately ensure the quality and appropriateness of services provided by the social work staff. Based on record review, the Social Work Director failed to provide:

l. Treatment plans that identified patient-related short-term goals (STGs) stated in observable, measurable and behavioral terms for eight (8) out of eight (8) sampled patients (A1, A2, A3, A4, A5, A6, A7, and A8). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs and prolonged hospitalization.

Findings include:

A. Record Reviews:

1. Patient A1 was admitted 11/29/2016. The psychiatric evaluation dated 11/29/2016 identified psychiatric diagnosis as "Unspecified Psychosis. The Master Treatment Plan (MTP) dated 11/29/2016 identified Short Term Goals (STG) for:

Problem: Danger to Others/Agitated and delusional:

Social Work STG stated "Patient will identify two coping strategies with SW weekly to deal with acute MI (mental illness) -psychotic [sic] delusional"

2. Patient A2 was admitted 12/9/2016. The psychiatric evaluation dated 12/9/2016 identified psychiatric diagnosis as "Major Depression, recurrent, severe, w/o (without) psychotic feats (features); Opiate dep (dependence); THC (marijuana) abuse." The Master Treatment Plan (MTP) dated 12/9/2016 identified Short Term Goals (STG) for:

Problem: Danger to Self/suicidal ideation:

Social Work STG stated "Patient will verbalize 4 coping skills to be utilized in managing depression to avoid SI or other related crisis; At least 4 days prior to discharge"

Problem: Substance Abuse:

Social Work STG stated "Patient will verbalize recovery plan for SA (substance abuse) Tx (treatment) at least 4 days prior to discharge"

3. Patient A3 was admitted 12/7/2016. The psychiatric evaluation dated 12/7/2016 identified psychiatric diagnosis as "Schizoaffective Disorder." The Master Treatment Plan (MTP) dated 12/7/2016 identified Short Term Goals (STG) for:

Problem: Delusional, Paranoid, [sic]

Social Work STG stated "Patient will learn to cope with his/her paranoid delusions problems from weekly group therapy and individualized therapy"

4. Patient A4 was admitted 12/2/2016. The psychiatric evaluation dated 12/2/2016 identified psychiatric diagnosis as "Schizoaffective Disorder, Bipolar type, severe; R/O (rule out) secondary to traumatic brain injury." The Master Treatment Plan (MTP) dated 12/2/2016 identified Short Term Goals (STG) for:

Problem: Alteration in thought process:

Social Work STG stated, "Patient will identity [sic] weekly to deal with hearing voices"

Problem: Substance abuse:

Social Work STG stated, "To learn negative facts [sic] [sic][sic] learn negative [sic] of substance abuse (SA) [sic]"

5. Patient A5 was admitted 12/10/2016. The psychiatric evaluation dated 12/10/2016 identified psychiatric diagnosis as "Adjustment disorder unspecified." The Master Treatment Plan (MTP) dated 12/10/2016 identified Short Term Goals (STG) for:

Problem: Danger to Self/Suicide with Plan

Social Work STG stated, "Patient will verbalize 4 coping skills to be utilized manage anxiety and depression [sic] SI (suicide ideation) and other related crisis at least 4 days prior to discharge"

6. Patient A6 was admitted 12/10/2016. The psychiatric evaluation dated 12/10/2016 identified psychiatric diagnosis as "R/O (rule out) Schizophrenia; Alcohol Abuse." The Master Treatment Plan (MTP) dated 12/10/2016 identified Short Term Goals (STG) for:

Problem: Danger to Self:

Social Work STG stated, "Patient will identify at least 2 coping skills with SW (social work) weekly meeting to deal with depressive symptoms"

Problem: Alcohol use disorder, mild

Social Work STG stated, "Patient will gain insight and motivation from MISA/HAS (Mental Illness Substance Abuse/Healthcare Alternative Systems) problems from substance abuse treatment"

7. Patient A7 was admitted 12/1/2016. The psychiatric evaluation dated 12/1/2016 identified psychiatric diagnosis as "Major Depression disorder, recurrent, severe without psychotic features." The Master Treatment Plan (MTP) dated 12/1/2016 identified Short Term Goals (STG) for:

Problem: Depression with Suicide Ideation

Social Work STG stated, "Free of SI (suicidal ideation) and [sic] remission depression 15 consecutive days"

8. Patient A8 was admitted 12/5/2016. The psychiatric evaluation dated 12/5/2016 identified psychiatric diagnosis as "Unspecified Mood Disorder." The Master Treatment Plan (MTP) dated 12/5/2016 identified Short Term Goals (STG) for:

Problem: Mood disorder

Social Work STG stated, "Client will remain free of SI (suicide ideation) x 7 consecutive days and will report remission of depression"

Problem: Substance Abuse


Social Work STG stated, "Client will reframe from drugs [sic] drugs to [sic] prevent relapse and reoccurring depression"


ll. Individualized interventions to address specific treatment needs for five (5) out of eight (8) sampled patients (A4, A5, A6, A7, and A8). Listed interventions on the Master Treatment Plans were routine, generic discipline functions rather than individualized interventions. These deficiencies result in lack of guidance to staff in providing individualized, coordinated treatment in the least restrictive environment, and can result in prolonged hospitalizations for patients.

Findings include:


A. Record Reviews:


1. Patient A4-MTP dated 12/2/2016

Problem "Alteration in Thought Process"

Social Work Interventions stated, "Meet with patient 2 x per week to discuss possible coping strategies [sic] to his/her MI (mental illness) and substance abuse"

2. Patient A5-MTP dated 12/10/2016

Problem "Danger to self/suicidal with plan"

Social Work Interventions stated, "Patient will have services needed to manage symptoms to avoid crisis and have long term stabilization" "Patient will learn affect ways to manage [sic] or symptoms to avoid [sic] crisis."

3. Patient A6-MTP dated 12/10/2016

Problem "Alcohol Use Disorder, Mild"

Social Work Interventions stated, "Meet with patient 2 x per week to discuss possible coping strategies [sic] to his/her MI (mental illness) and substance abuse"

4. Patient A7-MTP dated 12/1/2016

Problem "Depression with SI (suicidal ideation)"

Social Work Interventions stated, "[sic] connect o/p (outpatient) resources"

5. Patient A8-MTP dated 12/8/2016

Problem "Mood D/O (disorder)"

Social Worker Interventions stated, "Client will ID (identify) O/P (outpatient) resources [sic]"

Based on and record review and interview, the facility failed to provide a therapeutic activity program that ensured an adequate number of qualified therapists to provide comprehensive therapeutic activities for five (5) of eight (8) active sample patients (A1, A2, A4, A5, A6, and A8). No staff was available to provide or oversee services on evenings or weekends.
Findings include:
A. Record Review

1. There was no Activity Therapy Assessment done to ensure objective data was used to formulate the Master Treatment Plan (MTP) for five (5) of eight (8) sample patients (A1, A3, A4, A5, and A8).
2. 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-day work week. There were no therapeutic activities offered after 4:00 PM during the week and no therapeutic activities offered on Saturdays and Sundays.
3. "Engagement Activities" are part of the routine unit activities such as hygiene and passing of medication.
4. 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. Interviews


1. An interview was conducted on 12/13/16 at 1:00 PM with the Clinical Director and the Lead Activity Therapist. Both reported that they were short "at least one" activity therapist.


2. An interview was conducted with the Clinical Director on 12/14/16 at 12:30 PM to discuss the Activity Therapist Assessment Process and the need for change. He agreed that therapeutic assessments need to be completed for each patient.