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A. Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 1 of 2 (Pt#4) clinical records reviewed on the boys adolescent unit, the Hospital failed to ensure the patient received notification of rights.

Findings include:

1. On 4/24/12 at approximately 10:30 AM the Hospital policy titled, "Patient Rights and Responsibilities (revised 1/12)", included, "...8. Admission staff will present verbally and in writing a patient rights to the patient at the time of admission..8.1..will be encouraged to sign...8.2 will receive a written copy of Patients Rights."

2. On 4/23/12 the clinical record of Pt#4 was reviewed. Pt#4 was a 16 year old male admitted on 4/14/12 with a diagnosis of Major Depressive Disorder. The clinical record lacked signed consents by Pt#4, or the Parent/Guardian, including: 1) Consent to Use and Disclose Protected Health Information, 2) Acknowledgement of Receipt of Patient/Family Handbook, and 3) Video Surveillance, Teleconferencing, and Photography consent.

3. The Clinical Nurse Manager verified the findings during an interview on 4/23/12 at approximately 12:30 PM.

B. Based on review of Hospital policy, clinical records, and staff interview it was determined that for 1 of 2 (Pt #4), clinical records reviewed on the boys adolescent unit, the Hospital failed to ensure the patient was notified when rights were being restricted.

Findings include:

1. On 4/24/12 at approximately 10:30 AM, the Hospital Policy titled "Denial (Restriction) of Rights (revised 1/12)" was reviewed, and included, "...3. If at any time a patient's rights are violated, a Restriction of Rights (ROR) forms will be completed and copies distributed..."

2. On 4/23/12 at approximately 11:30 AM, the clinical record of Pt#4 was reviewed. Pt#4 was a 16 year old patient, admitted on 4/14/12, with a diagnosis of Major Depressive Disorder, unspecified. On 4/18/12 clinical documentation included, a physical hold of the patient, for attempts to self injure. Pt#4's clinical record lacked documentation of notification of Restriction of Rights.

3. The Clinical Nurse Manager confirmed this finding on 4/23/12 at approximately 12:30 PM, during an interview.

Based on review of Hospital policy, Psychotropic Medication Request Form, clinical records, and staff interview, it was determined that for 1 of 5 (Pt. #8) clinical records reviewed on the PDD unit, the Hospital failed to obtain informed consent prior to administering psychotropic medications.

Findings include:

1. The Hospital policy titled, "Informed consent for Psychotropic Medication and Ordinary & Routine Medical/Dental Care, reviewed 1/12" was reviewed on 4/24/12 at 9:00 AM. The policy included, "If the patient is a minor, the Nurse will obtain permission from the parent/guardian via phone ... Both the Nurse obtaining consent and the witness will sign and date the consent form that consent was received."

2. The "Psychotropic Medication Request Form, revised 12/16/11," was reviewed on 4/23/12 at 3:00 PM. The form instructions included, "Verbal consent requires signature of Psychiatrist or two signatures if obtained by a nurse."

3. The clinical record of Pt. #8 was reviewed on 4/23/12 at approximately 3:00 PM. Pt. #8 was a 13 year old female admitted on 4/15/12 with the diagnosis of Asperger's. The Psychotropic Medication Request forms for 5 ordered psychotropic medications were signed by the nurse on 4/15/12 with a verbal telephone consent from Pt. #8's mother. The consent form lacked documentation of a witness. Pt. #8 received the psychotropic medications from 4/16/12 to 4/23/12.

4. The PDD Unit Manager confirmed the above finding on 4/23/12 at approximately 3:30 PM, during an interview.

Based on review of Hospital policies and protocols, observation, staff interview, review of clinical records, and family interviews, it was determined that for 121 of 121 inpatients on hospital census as of 4/23/12, the Hospital failed to ensure the patients' privacy was maintained.

Findings include:

1. The Hospital policy entitled, "Video Security Surveillance" (revised 1/12), reviewed on 4/23/12 at approximately 1:00 PM, included, "Silent video security will be utilized in common areas of patient care units as well as exit and entry areas in the facility. Silent video security will be utilized in patient rooms. Security surveillance will not be utilized in patient restrooms at any time.. Silent video Security will be viewed by the Safety Officer to assure correct positioning and functioning of camera equipment..."

2. The Hospital policy entitled, "Denial (Restriction) of Rights" (revised 1/12) was reviewed on 4/23/12 at approximately 2:00 PM, and included, "...If at any time a patient's rights are violated, a Restriction of Rights (ROR) form will be completed..."

3. The Hospital's protocol for "Video Surveillance Cameras" (dated 3/6/10) was reviewed on 4/24/12 at approximately 12:00 PM and included, "...if a guardian refuses to sign the Consent for Video Surveillance form, the staff must initiate the Restriction of Rights Form."

4. Unit tours were conducted on the Hospital's inpatient units (PDD {Autism}, Children, Girls Adolescent/Flex, and Boys Adolescent/Flex) on 4/23/12 and 4/24/12. Video Surveillance cameras were present in the hallways, group rooms, stairwells, quiet rooms, and all patient rooms.

5. An interview was conducted with the Chief Nursing Officer (CNO) on 4/23/12 at approximately 2:00 PM. The CNO stated that the cameras were on at all times, and were viewed in a monitoring room located on the main level of the Hospital in the Nursing Administration Office. The CNO stated that alternating Behavioral Health Technicians (BHT) are assigned to continuously monitor the video screens from 9:00 PM to 7:30 AM.

6. A tour of the camera monitoring room in the Nursing Administration Office was conducted on 4/23/12 at approximately 2:30 PM. There were 8 monitors with screens that were divided into 16 sections that displayed the live video monitoring in real time. These monitors were on a desk that was located in the office, positioned directly in front of (facing) the nursing supervisor's desk. There was an at the secretary's desk facing the monitors, as well, and the monitors were visible from any part of the room. The monitors were all on at the time of the tour, but were not being continuously monitored by staff.

7. An interview was conducted with the Chief Executive Officer (CEO) on 4/24/12 at approximately 9:00 AM. The CEO stated that the cameras were used for patient safety. The CEO stated that the kids are rarely in there rooms during the day. They spend more time in their rooms in the evening and this is the time when there is a higher risk for suicide and sexually acting out. The cameras are continuously monitored by a BHT during the evening and night hours. Certain rooms are tagged as high risk. If the BHT sees anything that looks suspicious, he/she would call the unit and tell the staff to check that room. The CEO stated that if a patient refuses surveillance by camera, then the Hospital would override this and complete a Restriction of Rights form and give a copy to the patient. The CEO stated that the video surveillance consent is reviewed with the patient on admission and the patients are made aware of the location of cameras and informed that no video cameras are located in the bathrooms. The patients are instructed to perform personal hygiene and change clothes in the bathrooms during designated time periods and as needed. The CEO stated that no one has refused to sign consent for video surveillance monitoring.

8. A second interview was conducted with the CEO on 4/25/12 at approximately 9:45 AM. This surveyor asked the CEO why the video surveillance cameras recorded 24 hours a day, but were only monitored by the staff from 9:00 PM through 7:30 AM. The CEO stated that the camera system is motion sensitive for starting and stopping. The CEO stated that the patient rooms are kept securely locked during the day and the patients are not in their rooms during the day. If an unwitnessed incident is reported, then they can go back and look at the surveillance video. The CEO stated that only the staff that was directly involved in an incident can view the video for debriefing.

9. The clinical record of Pt. #15 was reviewed on 4/25/10 at 9:00 AM. Pt. #15 was an 11 year old boy, admitted on 3/30/12, with a diagnosis of Rule Out Depressive Disorder. The clinical record for Pt #15 included a consent for video surveillance that was signed by Pt #15, but not by a parent/guardian.

On 4/25/12 at approximately 10:00 AM, the Father of Pt #15 was interviewed by phone regarding the use of video surveillance cameras. The Father stated that when Pt #15 was admitted to the Hospital he (Father) was informed of the patient being under constant 24 hour surveillance and not informed of the usage of cameras in the patient rooms.

10. The clinical record of Pt. #2 was reviewed on 4/24/10 at approximately 11:00 AM. Pt. #2 was a 12 year old boy, admitted on 3/16/12, with diagnoses of Autism, Self Injury and Intermittent Explosive Disorder. The clinical record for Pt #2 included a consent for video surveillance that was signed by Pt #2's parent.

On 4/25/12 at approximately 10:00 AM, the mother of Pt. #2 was interviewed by phone regarding the use of video surveillance cameras. The mother stated that she had requested for video recording upon admission. She stated that, "For safety, I would rather have the ability to know if my son has been hurt or hurts others. The last facility he was at, did not have cameras and there was no way to follow up on problems."

11. The clinical record for Pt. #21 was reviewed on 4/25/12 at approximately 10:30 AM. Pt. #21, an 8 year old, was admitted on 4/16/12, with a diagnosis of Mood Disorder. The clinical record contained a "video surveillance, video teleconferencing and photography consent" form dated 4/16/12 that was not signed by the parent.

On 4/25/12 at approximately 10:10 AM, a telephone interview was conducted with the mother of Pt. #21 regarding the use of video surveillance cameras. The mother stated, "No one informed me that there were cameras. I do not know anything about that."

12. Pt. #32's clinical record was reviewed on 4/25/12 at approximately 10:10 AM. Pt. #32 was a 14 year old female, admitted on 4/23/12, with a diagnosis of Depression. The clinical record for Pt #32 included a consent for video surveillance that was signed by Pt #32, but not by a parent/guardian.

On 4/25/12 at approximately 10:20 AM a telephone interview was conducted with the mother of Pt. #32 regarding the use of video camera in the patients rooms. Pt. #32's mother stated she did not know anything about cameras in the patients' room, and that she was "not keen on a camera in the patient room, because of privacy. I would have been upset if they had told me then." The mother stated that she was informed and consented to the admission and the treatment but did not know about the camera until this interview.

13. An interview was conducted with the Director of Admissions and Records (A & R) on 4/25/12 at approximately 10:45 AM. He stated that at the time of admission, they attempt to contact the patient's parent/guardian by phone (if not present) to obtain consent for admission, which includes the consent for video surveillance. The forms are explained to the patient and the parent/guardian. The explanation of the video surveillance includes that cameras are located throughout the building and in every patient room. They are informed that there are no cameras in the bathrooms. The parent/guardian requests at this time if they would like the original consents mailed to them for signature or held in the A & R Department for signature when they arrive at the Hospital at a later time. A & R keeps the original copies of the consents until signed by parent/guardian. Copies of the consents that have been reviewed and signed by the patient are kept in the chart.

14. The above findings were confirmed with the CEO and CNO during an interview on 4/25/12 at approximately 2:00 PM.

Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 1 of 2 (Pt#4) clinical records reviewed on the boys adolescent unit, the Hospital failed to insure the patient was monitored for safety as ordered.

Findings include:

1. On 4/23/12 at approximately 1:00 PM the Hospital policy titled "Levels of Observation (revised 1/12)" was reviewed and included, " All patients will be routinely observed in compliance with physician orders and prescribed protocol...A specific and dedicated staff will stay within approximately one arms length...on 1:1 observation".

2. On 4/23/12 at approximately 11:00 AM the clinical record of Pt #4 was reviewed. Pt #4 was a 16 year old male admitted on 4/14/12, with a diagnosis of Major Depressive Disorder, unspecified. Clinical documentation included a physician's order dated 4/14/12 that required Pt #4's level of observation was 1:1 monitoring. The Behavioral Health Technician Progress Summaries dated 4/15/12 night shift and 4/16/12 day shift included that Pt #4 was monitored every 15 minutes and lacked documentation of 1:1 monitoring as ordered.

3. On 4/23/12 at approximately 12:30 PM, during an interview, these findings were confirmed with the Clinical Nurse Manager.

Based on review of Hospital policy, clinical record review and staff interview it was determined that for 6 of 10 (Pt. #s 1, 2, 8, 9, 10, 14), clinical records reviewed on the PDD and girls adolescent units, the Hospital failed to ensure the charge nurse reviewed the patient observation rounds each shift as required.

Findings include:

1. The Hospital policy titled, "Patient Observation Policy, revised 1/12" was reviewed on 4/24/12 at 10:00 AM. The policy included, "staff will initial the Patient Observation Rounds form at change of shift to indicated the completion of the handoff procedure.".

2. The clinical record of Pt. #1 was reviewed on 4/23/12 at 10:50 AM. Pt. #1 was a 11 year old male admitted on 4/5/12 with the diagnosis of Oppositional Defiant Disorder. The patient observation rounds dated 4/6/12 - 4/11/12 lacked charge nurse signatures for shift review.

3. The clinical record of Pt. #2 was reviewed on 4/23/12 at 1:30 PM. Pt. #2 was a 12 year old male admitted on 3/16/12 with the diagnosis of Intermittent Explosive Disorder. The patient observation rounds dated 3/31/12, 4/8/12 and 4/15/12 lacked charge nurse signatures for shift review.

4. The clinical record of Pt. #8 was reviewed on 4/23/12 at 3:00 PM. Pt. #8 was a 13 year old female admitted on 4/15/12 with the diagnosis of Asperger's. The patient observation rounds dated 4/17/12 and and 4/18/12 lacked charge nurse signatures for shift review.

5. The clinical record of Pt. #9 was reviewed on 4/23/12 at 3:30 PM. Pt. #9 was a 16 year old male admitted on 4/11/12 with the diagnosis of Autism. The patient observational rounds dated 4/13/12, 4/13/12, 4/17/12 and 4/18/12 lacked charge nurse signatures for shift review.


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6. The clinical record for Pt #10 was reviewed on 4/23/12 at approximately 10:45 AM. Pt #10 was a 14 year old female admitted on 4/13/12 with a diagnosis of Major Depression. The patient observation rounds sheets dated 4/15/12 and 4/16/12 lacked charge nurse signatures for shift review.

7. The clinical record for Pt #14 was reviewed on 4/23/12 at approximately 11:00 AM. Pt #14 was an 11 year old female admitted on 4/16/12 with a diagnosis of Mood Disorder. The patient observation rounds sheets dated 4/17/12 and 4/20/12 lacked charge nurse signatures for shift review.

8. The above findings were confirmed with the CEO during an interview on 4/23/12 at approximately 3:45 PM.

Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 1 of 2 (Pt #3) clinical records reviewed on the boys adolescent unit, the Hospital failed to ensure the multidisciplinary treatment plan was completed per policy.

Findings include:

1. On 4/23/12 at approximately 3:00 PM the policy titled, "Multidisciplinary Treatment Plan" (revised 1/12), was reviewed on 4/23/12 at approximately 10:00 AM included, "...9. signatures of the multidisciplinary treatment team will be obtained at the 72 hour staffing...it is the responsibility of the assigned therapist to obtain the signature of the patient and the family/guardian after their participation in the development of this plan..."

2. On 4/23/12 at approximately 11:30 AM the clinical record of Pt. #3 was reviewed. Pt. #3 was a 10 year old male admitted on 10/18/11 with diagnoses of Disruptive Behavior, Defiant Disorder, and Mood and Conduct Disorder. The Master Treatment Plan dated 10/18/11 was not signed by the Physician until 10/31/11, approximately 9 days after the 72 hour (3 day) deadline. Additionally, the treatment plan lacked the signature of the parent/guardian without identification of reason for lack of signature.

3. On 4/24/12 at approximately 3:30 PM during a meeting with the Clinical Manager these findings were confirmed.

CONDITION: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on April 23 and 24, 2012, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the severity, variety, and number of Life Safety Code deficiencies that were found. Also see A 710

.

STANDARD: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on April 23 and 24, 2012, the surveyor finds that the facility does not comply with NFPA 101 - 2000, the Life Safety Code

See Life Safety Code deficiencies that were cited (K-tags dated 04/24/12). Also see A 700

.

Based on review of Hospital policy, observation and staff interview, it was determined that in 6 of 17 (Rooms-203, 204, 206, 207, 209, 219) in-patient rooms and 1 of 2 Quiet Rooms (West Unit) observed, the Hospital failed to ensure the patient care rooms were maintained in a clean and safe manner.

Findings include:

1. On 4/25/12 at approximately 9:30 AM the Hospital policy titled "Cleaning Schedule" dated 1/08 was reviewed, and included, "Routine and special cleaning will be performed as scheduled...to provide a clean environment for patients, staff and others."

2. On 4/23/12 between 9:30 AM and 12:30 PM a tour was conducted on the adolescent boys unit (west) the following was observed:

- The bathroom toilets in rooms 203, 204, 206, 207, and 209 had exposed, rusted studs at the base of the toilets.

- 1 Quiet Room, had debris and dust accumulation on the floor.

- Patient room #219 had food stuff and an accumulation of debris behind the patient's bed, on the floor.

3. The above findings were confirmed by the Clinical Nurse Manager during an interview on 4/23/12 at approximately 12:30 PM.

Based on interview and record review, the facility failed to ensure that active individualized psychiatric treatment was provided for 3 of 8 active sample patients (A6, D1 and E1) and 3 of 4 patients added to the sample (A2, A3 and A5). These patients were hospitalized by judicial order without specific psychiatric problems or continued to be hospitalized beyond the time that their psychiatric problems were resolved. This failure results in patients remaining hospitalized without defined psychiatric treatment needs that could be addressed. (Refer to B125)

Based on record review and interviews, the hospital failed to ensure that individualized nursing and physician treatment modalities were developed to address the identified needs of 8 of 8 sample patients (A1, A6, C2, D1, E1, F2, G1 and G13). This deficiency results in failure to provide specific guidance for nursing and medical staff to care for each patient based on each patient's individual psychiatric needs. (Refer to B122)

Based on record reviews and interviews, the facility failed to develop Master Treatment Plans for 8 of 8 sample patients (A1, A6, C2, D1, E1, F2, G1 and G13) that clearly delineated nursing and physician interventions to address specific psychiatric problems. Instead, the nursing and physician interventions on the plans were general assessment and monitoring functions, as well as routine milieu and discipline-related practices. This deficiency results in failure to provide specific guidance for staff to provide care for patients based on their individual psychiatric needs.

Findings include:

A. Record Review

1. Patient A1 (MTP review 4/16/12). Two psychiatric problems were identified as "open" on the treatment plan. Problem 1: "Aggression." Goals identified as "on-going" or not yet achieved were: "Patient and Mother to meet biweekly to encourage ongoing communication and for patient to be able to take ownership of any aggressive act during two week period." "Patient will identify one staff per shift to address all concerns." "Patient will attend 4 groups per day for 3 days." "Patient will have no STAT meds or seclusion for 3 days." The only nursing or physician interventions for the problem of "aggression" were: "Initiate precautions, administer meds as ordered, q 15 minute checks." Problem 2: "Suicidal." All goals for this open problem were identified as having been "achieved." The only physician intervention for this problem was "LOS [line of sight] to keep patient safe."

2. Patient A6 (MTP review 4/16/12). One psychiatric problem was identified as "open" on the treatment plan. Problem: "Danger to Others." Goal: "Patient will verbalize understanding of aggressive behaviors x 3 days." Generic nursing interventions were: "Q 15 min checks per order of MD. Aggression Precautions."

3. Patient C2 (MTP 4/18/12). Two psychiatric problems were identified as "open" on the treatment plan. Problem 1: "Danger to Self." Goal 1: "Patient will not attempt to harm self in the next three days." Generic nursing interventions were: "Place on SI [self-injury precaution], E [elopement], 1:1 24 hours [one-to-one observation for 24 hours]." Problem 2: "Danger to Others." Goal: "Patient will not attempt to harm others in the next 3 days." The generic nursing intervention was: "Place on A [assault] precautions."

4. Patient D1 (MTP review 4/9/12). Two psychiatric problems were identified as "open" on the treatment plan. Problem 1: "Aggression." One goal was identified that had not yet been achieved: "Pt. will identify 2 motivations for staying on Level III and getting to court date." Generic physician interventions were: "Medication management 5X week; no meds recommended" and " STAT medication as last resort when pt. is danger to self or others." Generic nursing interventions were: "A prec. [assault precautions]." Problem 2: "Danger to self." One goal was identified that had not yet been achieved: "Pt. will identify 2 interpersonal effectiveness skills to improve communication at home." Generic nursing interventions were: "suicide prec. [precautions], self-injury prec., 1:1 W/A LOS W/S [one-to-one observation, within arm's reach; line-of-sight with suicide precautions]."

5. Patient E1 (MTP review 4/19/12). One psychiatric problem was identified as "open" on the treatment plan. Problem: "Aggression." No current nursing or physician interventions were identified.

6. Patient F2 (MTP 4/12/12). Two psychiatric problems were identified as "open" on the treatment plan. Problem 1: "Danger to self." Two goals were identified as not yet achieved: Goal 1. "Pt. will not harm self for 5 consecutive days." Generic nursing interventions for this goal were: "Administer meds as ordered. Initiate S [suicide] precautions. Initiate SI [self-injurious] precautions. 24 hour unit restriction." Goal 2: "Patient will identify coping skills to utilize in lieu of self-injurious behaviors and head banging." No nursing or medical interventions were applied to this goal. Problem 2: "Danger to Others." One goal was identified as not yet having been achieved: "Pt. will not harm others for 3 consecutive days." Generic nursing interventions to meet this goal were: "Administer meds as ordered. Initiate A [assault] precautions, Q 15 min checks."

7. Patient G1 (MTP review 4/16/12). One psychiatric problem was identified as "open" on the treatment plan. Problem: "Danger to Self." One goal was identified as not yet achieved: "Patient will notify staff when feeling urge to harm self as part of safety contract." Generic nursing and physician interventions were: "Place pt SI [self injurious]. Place pt. on LOS [line-of-sight] 24 hours. Maintain calm and safe environment. Monitor pt for safety and precautions." Two medical problems were identified as "open" on the treatment plan. Problem 1: "Asthma." Goal: "Pt. will verbalize understanding of s/s of exacerbation of asthma and report them accordingly." Generic nursing and physician interventions were: "Vital signs ordered by MD. Vital signs as required for symptom management per RN." Problem 2: "Laceration." Goal: "Pt. will verbalize understanding of s/s of infection and report them accordingly." Generic interventions were: "Vital signs as ordered by the MD; Vital Signs as required for symptom management per RN."

8. Patient G13 (MTP 4/19/12). One psychiatric problem was identified as "open" on the treatment plan. Problem: "Aggression." Goal: "Pt will have no aggression toward others for 3 consecutive days." Generic nursing interventions were: "Pt. will be placed on 'A' [assault] precautions. Pt. will attend groups."

B. Staff Interview

1. In an interview on 4/24/12 at 2p.m. the Clinical Services Director stated, "Some interventions are general. There is a programming page that lists interventions we use. We add that page to the treatment plan, and for the long term patients, we would refer to the general intervention page as the interventions."

2. In an interview on 4/24/12 at 2:30p.m., the Medical Director stated that the treatment plan for Patient D1 was "puzzling" because it was difficult to determine which interventions addressed which patient goals. The Medical Director also acknowledged the lack of specific psychiatrist interventions on patients' treatment plans, addressing the identified problems.

Based on interview and record review, the facility failed to ensure that active individualized psychiatric treatment was provided for 3 of 8 active sample patients (A6, D1 and E1) and 3 of 4 patients added to the sample (A2, A3 and A5). These patients were hospitalized by judicial order without specific psychiatric problems or continued to be hospitalized beyond the time that their psychiatric problems were resolved. This failure results in patients remaining hospitalized without defined psychiatric treatment needs that can be addressed.

Findings include:

A. Specific Patient Findings

1. Patient A2

a. Patient A2 was an adolescent who was ordered by the legal system to be admitted to the facility on 1/19/12 to undergo fitness restoration to stand trial. The "Problem Status" section of the "Multi-Disciplinary Master Treatment Plan" (MTP), originally dated 1/20/12, indicated that the problem of "Danger to self - suicidal" was resolved by 2/15/12, and the problem of "Aggression" was resolved by 4/4/12. The only remaining problem on the psychiatric MTP was "Fitness Restoration legal charges."

b. During an interview on 4/24/12 at 10a.m., the Social Work Manager and Social Work Supervisor noted that Patient A2 did not currently display behavioral or psychiatric problems. They agreed that Patient A2 was fit to return to court, but that it could be up to 21 days before s/he was discharged. They acknowledged that Patient A2 required no active psychiatric interventions at that time.

c. During an interview on 4/24/12 at 11a.m. with MD 2 and Therapist 1, MD 2 stated that Patient A2 responded well to low dose medication and had been "remarkably well" for the previous three to four weeks. They acknowledged that no psychiatric or behavioral problems were being actively treated, but that Patient A2 continued to need to learn legal information to be discharged from the hospital.

2. Patient A3

a. Patient A3 was an adolescent who was ordered by the legal system to be admitted to the facility on 1/19/12 to undergo fitness restoration to stand trial. The "Problem Status" section of the Multi-Disciplinary Master Treatment Plan, originally dated 1/20/12, indicated that the problems of "Danger to others aggression" was initially rated as "severe impairment." On 3/8/12 "aggression" was rated as "moderate impairment" and on 4/2/12 it was only rated as "mild impairment."

b. During an interview with MD 2 and Therapist 1 on 4/24/12 at 11a.m., MD 2 stated that Patient A3 displayed hyperactivity and a lack of focus at the time of admission. MD 2 reported that these symptoms had been controlled with medications. Therapist 1 reported that a case conference was held on 4/18/12, and it was concluded that Patient A3 was "restored." MD 2 stated that a recommendation for the return of Patient A3 to the legal system was dictated on 4/24/12, and that Patient A3 would return for a court hearing within 21 days. MD 2 and Therapist 1 acknowledged that the only "treatment" provided during this period would be to assist Patient A3 to retain the cognitive information s/he had obtained about the legal system.

3. Patient A5

a. Patient A5 was an adolescent who was ordered by the legal system to be admitted to the facility on 2/27/12 in order to undergo fitness restoration to stand trial. The "Problem Status" section of the Multi-Disciplinary Master Treatment Plan, originally dated 2/27/12, indicated that the problem of "Aggression towards others" was initially rated as "moderateimpairment" on 2/27/12. This problem was rated as "moderate impairment" on 3/7/12 and "resolved" on 3/15/12.

b. During an interview on 4/24/12 at 9a.m., MD 1 stated that Patient A5 was admitted with no psychiatric illness. He stated that Patient A5 would not have been hospitalized if s/he had not been referred on a court order. He stated that Patient A5 required no psychotropic medications during this hospitalization. He stated that Patient A5 had cognitive limitations that made learning required legal information difficult for him/her. He stated that the interventions for Patient A5 were education and training about legal issues, not psychiatric interventions.

c. During an interview on 4/24/12 at 10a.m. with the Social Work Manager and Social Work Supervisor, the Social Work Supervisor stated that Patient A5 had cognitive limitations that prevented him/her from learning the necessary legal information in a timely manner, but she hoped Patient A5 would be able to learn the material in the following four to six weeks. The Social Work Supervisor stated that the interventions being provided were only about learning about the legal system. The Social Work Manager and Social Work Supervisor acknowledged that Patient A5 did not have behavioral or psychiatric issues that required hospitalization.

4. Patient A6

a. Patient A6 was an adolescent who was ordered by the legal system to be admitted to the facility on 3/13/12 in order to undergo fitness restoration to stand trial. The "Problem Status" section of the Multi-Disciplinary Master Treatment Plan, originally dated 3/13/12, indicated that the problem of "Danger to others" was initially rated as "severe impairment." This problem was rated as "moderate impairment" on 3/22/12 and as "mild impairment" on 4/16/12.

b. During an interview on 4/24/12 at 11a.m., MD 2 and Therapist 1acknowledged that there were no psychiatric or behavioral issues at the time of admission for Patient A6. MD 2 stated that the patient required no psychotropic medications or other psychiatrist interventions during his/her hospitalization.

5. Patient D1

a. Patient D1 was an adolescent who was ordered by the legal system to be admitted to the facility on 8/24/11 to undergo fitness restoration to stand trial. The "Problem Status" section of the Multi-Disciplinary Master Treatment Plan, originally dated 8/24/11, indicated that the problem of "Aggression" was initially rated as "severe impairment" on 8/25/11. This problem was rated as "moderate impairment" on 9/5/11 and as "mild impairment" on 4/2/12. An additional problem of "self injurious, danger to self" was added on 1/29/12 with a rated severity of "severe impairment." This problem was rated as "moderate impairment" on 2/5/12 and only as "mild impairment" on 3/12/12.

b. During an interview on 4/23/12 at 1p.m., Patient D1 stated, "I get bored in the groups." S/he stated that s/he was familiar with all the groups because s/he had been hospitalized for over eight months, and that because of this, s/he was granted the privilege of being able to leave any group or program halfway through group sessions. S/he stated that the best part of treatment was "going to the gym and going downstairs to eat." Patient D1 stated that his/her understanding was that s/he was only in the hospital because s/he was "waiting for the judge to say I'm ready to go to court."

c. On 4/23/12 at 1:30p.m., RN 1 stated that Patient D1 was "currently stable" but that s/he would remain hospitalized until his/her next court date which was scheduled for June 2012. RN 1 stated that Patient D1 was given the special privilege of being able to leave each treatment group session halfway through the group as a "reward" for going to the first half of the group and for good behavior throughout the day. RN 1 stated that the patient had been in the hospital so long that s/he was familiar with the content of the groups, and his/her "programming is now time-limited."

d. On 4/24/12 at 9a.m., the Director of Clinical Services stated that Patient D1 " would have been discharged the first two weeks s/he was here if s/he had not been admitted for court fitness. S/he was stable at that point in his/her treatment." The Director of Clinical Services also stated that patients who were hospitalized for court fitness "cycle with the milieu," i.e. when the milieu was stable, the patient was stable and when the milieu was "struggling," the patient "struggles."

6. Patient E1

a. Patient E1 was an adolescent who was ordered by the legal system to be admitted to the facility on 12/22/11 to undergo fitness restoration to stand trial. The "Problem Status" section of the Multi-Disciplinary Master Treatment Plan, originally dated 12/22/11, indicated that the problem "Suicidal" was initially rated as "severe impairment" on 12/22/11. This problem was rated as "moderate impairment" on 12/30/12, as "mild impairment" on 1/17/12, and as "resolved" on 2/7/12. An additional problem of "aggression" was rated as "severe impairment" on 12/22/11. This problem was rated as "moderate impairment" on 1/17/12.

b. During an interview on 4/24/12 at 9a.m., MD 1 stated that Patient E1 might never meet the criteria for fitness for trial. He stated that that Patient E1 needed a residential level of care. He stated that Patient E1 would be unable to meet the criteria for fitness for trial and would be hospitalized for up to a year before a determination could be made that the patient could not become fit for trial.

c. During an interview on 4/24/12 at 10a.m., the Social Work Manager and Social Work Supervisor acknowledged that Patient E1 did not currently have psychiatric or behavioral problems to be addressed and only needed to learn the legal material necessary for him/her to be assessed as fit to stand trial.

B. Additional Interviews

1. During an interview on 4/24/12 at 9a.m., MD 1 stated that patients who were admitted by court order for fitness restoration did not necessarily have a psychiatric illness and some remained hospitalized after the resolution of their psychiatric illness until they could understand and cooperate with the legal process. MD 1 stated that some patients might never meet fitness for trial criteria but remained hospitalized by court order. He stated that patients remained hospitalized up to 21 days after the recommendation was made for them to return to court.

2. During an interview on 4/24/12 at 2:30p.m. with MD 2 and Therapist 1, Therapist 1 stated that there were two areas in which patients could be found unfit to stand trial. The first area was behavioral problems that disrupted the court process or ability of the patient to cooperate with legal counsel. The second area was the cognitive ability of the patient to demonstrate a basic understanding of the legal system. MD 1 and Therapist 1 acknowledged that some forensic patients were hospitalized for a deficiency in the knowledge area only, without behavioral or psychiatric issues. MD 1 and Therapist 1 also acknowledged that the behavioral problems of some of the forensic patients resolved but they continued to be hospitalized until the cognitive and knowledge criteria were also met.

3. During an interview on 4/24/2 at 2:30p.m., the Medical Director stated that patients hospitalized for fitness restoration attended so many of the same groups due to their long length of stay, that they became over-familiar with the content of the groups. He stated that the level of clinical care needed for many of the patients admitted for fitness restoration was residential rather than acute psychiatric inpatient. He stated that the legal system did not allow a more appropriate level of care due to the security requirements of the court order.

C. Policy Review

The facility policy "Court Fitness Restoration," dated 11/99, states, "Patients requiring inpatient fitness restoration services will be sent to [the facility]...with a court order...The presiding judge makes the final decision related to the patient's fitness (to stand trial). Once a patient is ordered to be fit by the presiding judge, he/she will be discharged from the hospital on his/her court date."

Based on interview and record review, it was determined that the Medical Director failed to:

I. Ensure that individualized nursing and physician treatment modalities were developed to address the identified needs of 8 of 8 sample patients (A1, A6, C2, D1, E1, F2, G1 and G13). This deficiency results in failure to provide specific guidance for medical staff to care for each patient based on each patient's individual psychiatric needs. (Refer to B118)

II. Ensure that the Master Treatment Plans for 8 of 8 sample patients (A1, A6, C2, D1, E1, F2, G1 and G13) clearly delineated physician interventions to address specific psychiatric problems. The physician interventions on the plans were absent or were general assessment and monitoring functions or routine milieu and discipline-related practices. This deficiency results in failure to provide specific guidance for staff to care for each patient based on each patient ' s individual psychiatric needs.

Findings include:

A. Record Review

1. Patient A1 (MTP review 4/16/21). Two psychiatric problems are identified as "open" on the treatment plan. Problem 1: "Aggression." Goals identified as "on-going" or not yet achieved were: "Patient and Mother to meet biweekly to encourage ongoing communication and for patient to be able to take ownership of any aggressive act during two week period"; "Patient will identify one staff per shift to address all concerns"; "Patient will attend 4 groups per day for 3 days" and "Patient will have no STAT meds or seclusion for 3 days." The identified "physician interventions" for the problem of "aggression" were "Initiate precautions, administer meds as ordered, q 15 minute checks." Problem 2: "Suicidal" All goals for this open problem were identified as having been "achieved." The physician intervention for this problem was "LOS [line of sight] to keep patient safe."


2. Patient A6 (MTP reviewed 4/16/12). One psychiatric problem was identified as "open" on the treatment plan. Problem: "Danger to Others." Goal: "Patient will verbalize understanding of aggressive behaviors x 3 days." The listed generic interventions for the physician were: "Q 15 min checks per order of MD. Aggression Precautions."

3. Patient C2 (MTP 4/18/12). Two psychiatric problems were identified as "open" on the treatment plan. Problem 1: "Danger to Self." Goal 1: "Patient will not attempt to harm self in the next three days." Problem 2: "Danger to Others." Goal: "Patient will not attempt to harm others in the next 3 days." No psychiatrist interventions were listed for these problems.

4. Patient D1 (MTP review 4/9/12). Two psychiatric problems were identified as "open" on the treatment plan. Problem 1: "Aggression." One goal was identified that had not yet been achieved: "Pt. will identify 2 motivations for staying on Level III and getting to court date." Generic physician interventions were: "Medication management 5X week; no meds recommended" and "STAT medication as last resort when pt. is danger to self or others." Problem 2: "Danger to self." One goal was identified that had not yet been achieved: "Pt. will identify 2 interpersonal effectiveness skills to improve communication at home." No psychiatrist interventions were listed for this problem.

5. Patient E1 (MTP review 4/19/12). One psychiatric problem was identified as "open" on the treatment plan. Problem: "Aggression." No current physician interventions were identified.

6. Patient F2 (MTP 4/12/12). Two psychiatric problems were identified as "open" on the treatment plan. Problem 1: "Danger to self." Two goals were identified as not yet achieved: Goal 1. "Pt. will not harm self for 5 consecutive days." Generic physician interventions were: "Administer meds as ordered. Initiate S [suicide] precautions. Initiate SI [self-injurious] precautions. 24 hour unit restriction." Goal 2: "Patient will identify coping skills to utilize in lieu of self-injurious behaviors and head banging." No medical interventions were applied to this goal. Problem 2: "Danger to Others." One goal was identified as not yet having been achieved: "Pt. will not harm others for 3 consecutive days." Generic physician interventions to meet this goal were: "Administer meds as ordered. Initiate A [assault] precautions, Q 15 min checks."

7. Patient G1 (MTP review 4/16/12). One psychiatric problem was identified as "open" in the treatment plan. Problem: "Danger to Self." One goal was identified as not yet achieved: "Patient will notify staff when feeling urge to harm self as part of safety contract." Generic physician interventions were: "Place pt SI [self injury precautions]. Place pt. on LOS [line-of-sight] 24 hours. Maintain calm and safe environment. Monitor pt for safety and precautions." Two medical problems were identified as "open" in the treatment plan. Problem 1: "Asthma." Goal: "Pt. will verbalize understanding of s/s of exacerbation of asthma and report them accordingly." Generic physician interventions were: "Vital signs ordered by MD. Vital signs as required for symptom management per RN." Problem 2: "Laceration." Goal: "Pt. will verbalize understanding of s/s of infection and report them accordingly." Generic physician interventions were: "...Vital Signs as required for symptom management per RN."

8. Patient G13 (MTP 4/19/12). One psychiatric problem was identified as "open" in the treatment plan. Problem: "Aggression." Goal: "Pt will have no aggression toward others for 3 consecutive days." No psychiatrist interventions were listed.

B. Staff Interview

During an interview on 4/24/12 at 2:30p.m., the Medical Director stated that the treatment plan for Patient D1 was "puzzling" because it was difficult to determine which interventions addressed which patient goals. The Medical Director also acknowledged the lack of specific psychiatrist interventions on patients' treatment plans, addressing the identified problems.

III. Ensure that active individualized psychiatric treatment was provided for 3 of 8 active sample patients (A6, D1 and E1) and 3 of 4 patients added to the sample (A2, A3 and A5). These patients were hospitalized by judicial order without specific psychiatric problems or continued to be hospitalized beyond the time that their psychiatric problems were resolved. This failure results in patients remaining hospitalized without defined psychiatric treatment needs that can be addressed. (Refer to B125)

Based on record review and interviews, the Director of Nursing failed to ensure that nursing interventions on the Master Treatment Plans of 8 of 8 sample records (A1, A6, C2, D1, E1, F2, G1 and G13) were individualized and specific to patient needs. The nursing interventions for the listed problems were absent or were stated as generic role functions. This deficiency results in failure to provide specific guidance for nursing staff to care for each patient based on each patient's individual psychiatric nursing needs.

Findings include:

A. Record Review

1. Patient A1 (MTP review 4/16/12). The only nursing interventions for the identified problem of "aggression" were: "Initiate precautions, administer meds as ordered, q 15 minute checks."

2. Patient A6 (MTP review 4/16/12). The only nursing interventions for the problem of "danger to others" were: "Q 15 min checks per order of MD. Aggression Precautions,"

3. Patient C2 (MTP 4/18/12). The only nursing interventions for the problem of "danger to self" were: "Place on SI [self-injury precautions], E [elopement precautions], 1:1 24 hours [one-to-one observation for 24 hours]." The only nursing intervention for the problem of "danger to others" was: "Place on A [assault] precautions."

4. Patient D1 (MTP review 4/9/12). The only nursing intervention for the problem "danger to others" was "A prec. [assault precautions]." The only nursing interventions for the problem "danger to self" were: "suicide prec. [precautions], self-injury prec., 1:1 W/A LOS W/S [one-to-one observation, within arm's reach; line-of-sight with suicide precautions]."

5. Patient E1 (MTP review 4/19/12). No current nursing interventions were listed for the problem of "aggression."

6. Patient F2 (MTP 4/12/12). The only nursing interventions for the problem of "danger to self" were "Administer meds as ordered. Initiate S [suicide] precautions. Initiate SI [self-injurious] precautions. 24 hour unit restriction." The only nursing interventions for the problem "danger to others" were: "Administer meds as ordered. Initiate A [assault] precautions, Q 15 min checks."

7. Patient G1 (MTP review 4/16/12). The only nursing interventions for the problem "Asthma" was: "Vital signs ordered by MD. Vital signs as required for symptom management per RN." The only nursing interventions for the problem "Laceration" were: "Vital signs as ordered by the MD; Vital Signs as required for symptom management per RN."

8. Patient G13 (MTP 4/19/12). The only nursing intervention for the problem "danger to others" was: "Pt. will be placed on 'A' [assault] precautions. Pt. will attend groups."

B. Staff Interview

1. On 4/24/12, at 2p.m. the Clinical Services Director stated, "Some interventions are general. There is a programming page that lists interventions we use. We add that page to the treatment plan, and for the long term patients, we would refer to the general intervention page as the interventions."