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Based on observation, staff interview, document and record review, the hospital's Governing Body failed to ensure the hospital's operation was conducted in an effective, safe, and organized manner by: 1. Failing to ensure the physical environment was safe for the care and treatment of patients; 2. Failing to incorporate risk assessment findings from 07/2018 into the quality assessment and performance improvement (QAPI) program so it reflected the safety of all patients; 3. Failing to ensure medical staff bylaws include all required elements; 4. Failing to ensure the hospital had an ongoing infection control program; 5. Failing to ensure hospital personnel were trained, and had documentation of required health information; and 6. Failing to ensure the hospital was in compliance with 42 CFR 482.60, Condition of Participation: Special Provisions Applying to Psychiatric Hospitals, 42 CFR 482.61, Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals and 42 CFR 482.62, Condition of Participation: Special Staff Requirements for Psychiatric Hospitals.

These deficient practices have the potential to cause patients to receive care in an unsafe environment which could lead to patient harm.

Finding Include:

The hospital failed to ensure all personnel had current Basic Life Support (BLS) certification. (Refer to A-0023).

The hospital failed to maintain an environment free from ligature (hanging) hazards, for patients assessed at risk for harm to self or others. The hospital has a current census of seventeen, and of those, five have been assessed at risk for suicide (Patients 3, 13, 14, 16, and 17). Specifically, three patients assessed at risk for suicide were left unattended (Patients 3, 13, and 16), nine patients assessed as having assaultive/aggressive precautions had access to items that could be used to harm self or others (Patients 3, 11, 12, 13, 14, 16, 17, 18, and 19), eight of ten patients assessed as a suicide risk or placed on assaultive/violence precautions (Patients 6, 11, 14, 16, 17, 18, 19, and 20) did not have fifteen minute checks completed as ordered, and five of five patients with suicide precautions did not have their suicide precaution orders renewed or discontinued during their stay (Patients 3, 13, 14, 16, and 17). (Refer to A-0144).

The hospital failed to ensure development of an effective Quality Assessment Performance Improvement Plan that identifies high risk, high-volume problem prone areas including identified ligature risked and infection control practices specifically by not including ligature risks identified in a risk assessment and infection control issues in its ongoing quality improvement program (Refer to A-0283).

The hospital's Governing Body failed to ensure quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety by not including ligature risked identified in a risk assessment and infection control issues in its ongoing quality improvement program. (Refer to A-0309).

The hospital failed to ensure the medical staff Bylaws included a requirement for a History and Physical (H&P) to be documented in the medical record less than 30 days before admission or within 24 hours after admission. (Refer to A-0358).

The hospital failed to ensure expired supplies were removed from patient use, failed to ensure that staff members (Staff J, RN) properly donned personal protective equipment (PPE) when providing wound care for one of one patients (Patient 25) and when passing medications for seven of seven patients (Patient 16, 17, 18, 22, 25, 26, and 27), failed to ensure one of one flushable basins and three of three observed air vents were clean, failed to ensure initial health examinations were completed for four of ten personnel records reviewed (Staff I, J, L, and Q), failed to ensure periodic health evaluations were completed for four of ten personnel records reviewed (Staff C, K, O, and P) , failed to ensure tuberculin (TB) skin tests or chest x-rays were completed for four of ten personnel records reviewed (Staff I, J, L, and Q) during new hire orientation; failed to ensure a TB test was provided annually for one of ten personnel files reviewed (Staff K); and failed to ensure immunization history for eight of ten personnel records reviewed (Staff C, I, J, K, L, M, N, and Q). (Refer to A-0749).


The facility failed to ensure the availability of a physician to provide psychiatric treatment and ensure oversight of the treatment and care of geriatric patients 50 years and older at the frequency, level, and intensity necessary for psychiatric hospitalization. Specifically, there was no physician on-site to provide, direct, review, and supervision psychiatric treatment. Instead, the only physician contact with patients for psychiatric care was via electronic telecommunication (a telemedicine process) once a week for approximately five to ten minutes per patient. Without consistent on-site supervision and direction of each patient's treatment, the patients' recovery may be compromised, potentially delaying their timely discharge. (Refer to B-0099)


The facility failed to ensure an adequate number of clinical staff to complete comprehensive assessments, provide ongoing active treatment, and document progress for the geriatric patient population served. In addition, Directors of Services failed to assure all care was appropriately completed and documented. Specifically, the facility failed to:

I. Provide an onsite physician responsible for psychiatric care and treatment of acutely ill geriatric patients and provide consistent oversight and supervision of psychiatric treatment on a regular basis. Instead, a psychiatrist saw patients for approximately five to ten minutes once per week via electronic telecommunication (a telemedicine process). This failure potentially delays the treatment of acutely mentally ill geriatric patients with appropriate psychiatric treatment and psychotropic medications. (Refer to B-0142).

II. Employ a Director of Nursing (DON) with a Master's Degree in Psychiatric Nursing, or alternatively assure the DON had necessary consultation with a qualified Psychiatric nurse or ongoing training. The DON did not have documented evidence of supervisory consultation from a nurse with a Master's degree in Psychiatric/Mental Health Nursing nor alternatively, did she have ongoing training in psychiatric/mental health nursing. This failure results in the facility not having a qualified nursing director to manage and monitor psychiatric/mental health nursing care of the patients. (Refer to B-0147).

III. Ensure that nurses documented verbal orders accurately on the form titled "Admit Orders / Preliminary Plan of Care." Specifically, telephone orders were recorded as being ordered by the psychiatrist when they were orders received from the APRN for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). This deficient practice results in the lack of appropriate monitoring of medication orders resulting in falsified medical documentation. (Refer to B-0148).

IV. Provide an adequate number of Registered Nurses (RNs) to implement active treatment interventions, supervise paraprofessional staff, and monitor patients. The facility's staffing of RNs results in the lack of active treatment provided by registered nurses and limited direction and supervision of paraprofessional staff in the provision of psychiatric nursing care. (Refer to B-0150).

V. Ensure the availability of services by a licensed psychologist for the geriatric patients in its care. This deficiency potentially results in patients not receiving the full array of diagnostic and intervention services when needed, and patients' needs not being met in a timely manner. (Refer to B-0151).

VI. Employ a sufficient number of qualified therapeutic rehabilitation (TR) staff to plan and implement a structured therapeutic rehabilitation program especially after hours and on weekends for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). This failure results in patients not receiving active treatment at the intensity and frequency necessary for psychiatric hospital treatment, potentially delaying recovery. (Refer to B-0158).

The facility failed to:

I. Ensure that the psychosocial assessment contained a comprehensive statement of conclusions and recommendations that included the social evaluation of psychiatric issues, anticipated role of the social worker in treatment during hospitalization, and projected steps in discharge planning for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A14). This failure hampers the ability of the treatment team to formulate appropriate social service interventions for patients. (Refer to B-0108)

II. Ensure that a neurological examination was completed for three (3) of nine (9) active sample patients (A1, A2, and A13.) For an additional three (3) active sample patients (A6, A9, and A15), the neurological document failed to include any information to verify the specific testing performed. This failure to document a neurological examination with specific testing compromises the identification of pathology for geriatric patients, which may be pertinent to their current mental illness and compromises future comparative re-examination to assess the patient's response to treatment interventions. (Refer to B-0109)

III. Ensure that psychiatric evaluations were performed by a physician and contained all the necessary information to justify the patients' diagnoses and planned treatment for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). Instead, psychiatric evaluations for these patients were completed by an Advanced Practice Registered Nurse without comprehensive information and documented physician review. The failure to have the psychiatric evaluation completed with detailed information and provided under the direction of a physician potentially compromises the formulation of an accurate diagnostic view of the patient, thereby limiting the team's ability to develop a meaningful plan of care to meet the patient's individual psychiatric needs. (Refer to B-0110)

IV. Ensure that the psychiatric evaluations for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) included comprehensive information regarding an estimate of intellectual functioning, memory functioning, and orientation. Lack of this necessary clinical information can negatively affect decision-making on the need of geriatric patients for further evaluation. (Refer to B-0116)

V. Include an inventory of each patient's personal assets such as accomplishments, skills, or interests written in descriptive and non-interpretative fashion for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). This deficiency results in a lack of necessary information to guide in developing a plan of treatment for the patient. (Refer to B-0117)

VI. Develop and document comprehensive Master Treatment Plans (MTPs) for nine (9) of nine (9) sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). Instead, MTPs were completed separately by each discipline using a preprinted document with treatment goals and interventions assigned by discipline. The physician and APRN were not involved in the development of the Master Treatment Plan. These deficient practices reflect a failure of collaborative input by all team members resulting in the potential to compromise patients' opportunity to receive appropriate treatment measures. (Refer to B-0118-I)

VII. Provide comprehensive Master Treatment Plans (MTPs) that were individualized and included all required components for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). The MTPs were missing the following components:

A. Behaviorally descriptive strength statements and disability statements (called problems by the facility) to be used as the basis for developing treatment plans. (Refer to B-0119).

B. Observable and measurable goals based on each patient's presenting psychiatric symptoms and needs. (Refer to B-0121)

C. Individualized active treatment interventions with a method of delivery, frequency of contact and focus of treatment based on each patient's presenting psychiatric symptoms and needs. (Refer to B-0122).

D. Both the name and discipline of the staff responsible and accountable for each of the interventions identified in the Master Treatment Plan. (Refer to B-0123)

Failure to develop Master Treatment Plans with all the required components hampers the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's treatment needs not being met.

VIII. Ensure that the physician responsible for psychiatric treatment wrote progress notes as stipulated by facility policy for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) and five (5) non-sample active patients selected for review of physician progress notes (A4, A7, A11, A12, and A16). Instead, the APRN recorded and signed progress noted without documented physician review. These notes failed to include the progress or lack of progress related to the presenting psychiatric symptoms and rationale for medication orders and changes. The absence of comprehensive documentation of each patient's progress prevented an up to date picture of pertinent changes in the patient's psychiatric condition or response to changes in the medication. (Refer to B-0126)

IX. Ensure that discharge summaries were completed according to the facility's policy in providing timely discharge summary for three (3) of five (5) sampled discharged patients (D1, D3, and D4). This deficiency results in a failure to communicate in a timely manner psychiatric assessments and discharge plans to providers providing follow-up care. (Refer to B-0133)

Based on observation, staff interview and document review the hospital failed to maintain an environment free from ligature (hanging) hazards, for patients assessed at risk for harm to self or others. The hospital has a current census of seventeen, and of those, five have been assessed at risk for suicide. Specifically, three patients assessed at risk for suicide were left unattended (Patients 3, 13, and 16), nine patients assessed as having assaultive/aggressive precautions had access to items that could be used to harm self or others (Patients 3, 11, 12, 13, 14, 16, 17, 18, and 19), eight of ten patients assessed as a suicide risk or placed on assaultive/violence precautions (Patients 6, 11, 14, 16, 17, 18, 19, and 20) did not have fifteen minute checks completed as ordered, and five of five patients with suicide precautions did not have their suicide precaution orders renewed or discontinued during their stay (Patients 3, 13, 14, 16, and 17).

Refer to A-0144 for further details.

Findings Include:

Review of an undated document titled, "Patient Handbook" showed: ..."The hospital program has been set up to provide a safe environment where you can heal from recent life events and recover from your symptoms. Keeping the program safe and comfortable requires a cooperative relationship between all staff and patients on the program." Review of the Patient Rights contained in the handbook showed: ..."As a patient you have the right to:" ..."Be treated with consideration, dignity, and respect with care provided in a safe environment free from any form of abuse, neglect, exploitation, or harassment."

Review of a hospital policy titled, "Risk Assessment Program" effective 09/2016 and revised 09/2016, showed: "The performance improvement program for the Safety/Environment of Care Committee is designed to monitor the level of safety compliance at the hospital, and to identify any situations that detract from the goal of providing a safe and secure environment for patients, employees, medical staff and visitors. Any risks that are identified through proactive risk assessments, environmental tours, performance measure monitoring, etc., will be evaluated, and have procedures and controls put into place to reduce to the lowest possible point the adverse impact on the safety and health of patients, personnel, medical staff, and visitors of the hospital. For those cases, where appropriate and deemed necessary, the failure mode effects and analysis process will be undertaken."

Review of a hospital notebook labeled "Risk assessment 07/2018" on 04/30/19 at 9:00 AM showed the hospital conducted a facility wide risk assessment and identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles.

During an interview on 04/30/19 at 12:15 PM, Staff A, Registered Nurse (RN) Director of Nursing (DON), stated that she didn't know why the Governing Body didn't initiate a plan to fix the ligature risks. She stated that she still wondered how the hospital opened with those in place. When asked about the Risk Assessment 2018 notebook she stated that she thought a guy from corporate did that risk assessment in July of 2018, but I don't recall the issues being brought up during the Governing Body meetings.

Observations made during the hospital tour on 04/22/19 between 10:45 AM until 11:50 AM showed multiple ligature risks and items accessible to patients that could be used for self-harm or harm to others. These ligature risks and items accessible to patients could be used for self-harm or harm to others include the following:

Door handles of the Entrance/Exit Double Doors, have open push arms not flush with the glass doors, hinges at the top of both doors near the walls. A patient could loop a cord or other similar item around these door handles to hang themselves.

Six exit signs with large round lights on each side. A patient could loop a cord or other similar item around these exit signs to hang themselves.

Two sets double fire doors have elbow hinges at the top of both doors near the walls leaving a gap in the hinge, at the top backside of both fire doors, there are magnets that protrude out, the handles on the back side of the door are not flush with the door, latch bars that are not flush and runs vertically on each door and has a flat surface that protrudes out at the top of the door. A patient could loop a cord or other similar item around the elbow hinges, magnets, handles, and latch bars of the fire doors to hang themselves.

Eight locked doors with exterior hinges that protrude out. A patient could loop a cord or other similar item around the exterior hinges of these locked doors to hang themselves.

A water fountain with spout. A patient could loop a cord or other similar item around the spout of the water fountain to hang themselves.

Four chairs located in the hallway and 12 chairs in the dining room that are light enough to be picked up and thrown. A patient could use these chairs as a weapon to assault other patients, staff, or visitors.

Blunt solid wood handle on fire extinguisher box. A patient could loop a cord or other similar item around the wood handle to hang themselves.

An exit door at the east end of the hall between patient rooms 111 and 112 has a push arm that is not flush with the door. A patient could loop a cord or other similar item around the push arm of the exit door to hang themselves.

The top casing of the fire doors in the north hall by the nurse's station has a bar that protrudes out. A patient could loop a cord or other similar item around the bar of the fire door to hang themselves.

The shower room has two square light switch boxes, a locked, plastic storage cabinet with a break in the plastic that could be used to harm self, and a large metal cabinet with a square top. The tub has Hot and Cold-water handles, faucet and hand bar, a square wall mounted timer and laundry basket with metal wire framing and soap dispenser and paper towel dispensers. A patient could loop a cord or other similar item around the light switch boxes, the top of the large metal cabinet, the tub's hot and cold fixtures, the tub's faucet, tub's hand bar, the timer, the laundry baskets's metal frame, the soap dispenser, and the paper towel dispenser of the shower room to hang themselves. A patient could also use the break in the locked, plastic storage cabinet to cut themselves.

Observation in the dining room showed four tables light enough to be picked up and thrown, a wall mounted television, square ice machine, soap dispenser hanging on the wall, faucets, and the lower cabinets had five looping handles. A patient could loop a cord or other similar item around the wall mount of the TV, the ice machine, the soap dispenser, and the handles of the lower cabinets to hang themselves. A patient could use the tables as a weapon to assault other patients, staff, or visitors.

Eight of nine patient bathrooms had paper towel and soap dispensers hanging on the walls. A patient could loop a cord or other similar item around the paper towel and soap dispensers of these bathrooms to hang themselves.

Patient rooms 101, 107A, 107B, 110B, and 112A all had broken metal bells with sharp edges attached to the bedside tables that creates a self-injury hazard. A patient could use the sharp metal edges to cut themselves.


Review of a hospital policy titled, "Suicide Precautions," effective 09/2016 and revised 12/2016, showed, "To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients." ... "All patients placed on suicide precautions will be assigned an acuity level based upon the severity of the suicidal thoughts, plan or behavior." The levels are as follows: "Every 15-minute observation, Line of sight observation and one-to-one observation at all times.

Review of a hospital policy titled, "Assessment for Suicidal Ideation," effective 09/2016 and revised 12/2016, showed: "To ensure safety, prevent injury and maintain a therapeutic relationship with all patients." "Upon admission to the facility, every patient will be evaluated for suicidal ideation." ..."All patients admitted to the program following any suicide attempt will be considered high-risk, kept on suicide precautions and assessed every 24 hours." ..."This is an ongoing assessment since patients in a behavioral health setting may regress at any time. Orders for suicide precautions will be renewed every 24 hours and discontinued only by order of the physician."

Review of current medical records for Patient 3, 13, 14, 16 and 17, who were placed on suicide precautions, lacked evidence of renewed or discontinued suicide precautions orders throughout their hospital stay.

Failure of the hospital to follow their policy to assess a patient's risk for suicide every twenty four hours and for the physician to write continued orders for suicide precautions or discontinue suicide precautions has the potential for a patient, whose suicidal thoughts may have increased and who may need closer observation including either "line of sight" or 1:1 observation, instead of 15 minute observations, to have an opportunity to injure themselves.


During an observation in the dining room, on 04/22/19 at 1:18 PM, four patients (Patients 3, 13, 16 and an unidentified female patient) were sitting in chairs unattended by any hospital staff. At 1:26 PM (about 8 minutes later), Patient 15 approached in the hall just outside of the dining room followed by unidentified MHT staff, the unidentified MHT staff asked Staff N, MHT if he could help in the dining room. Staff N went into the dining room with the patients and escorted them out.

Review of the records for Patient 3, 13, and 16 showed the hospital had placed them on suicide and assaultive/aggressive precautions. The dining room had tables and chairs that were lightweight and could be used by one of the patients as a weapon to injure another patient, staff member, or visitor. The dining room also contained items that one of the patients could have used to hang themselves by looping a cord or other similar item around it including the wall mount of the TV, the ice machine, the soap dispenser, and the handles of the lower cabinets. Staff left patients (suicidal/assaultive/aggressive) unattended in the dining room for about 8 minutes in an environment that included hanging risks and items that could be used to harm others. This situation placed patients at risk for harming themselves or others.

During an interview on 04/22/19 at 11:25 Staff A, RN DON stated that it is the expectation that staff should never leave patients alone in the shower room, group activity room or the dining room.


Review of Patient 3's current medical record on 04/24/19 showed she was admitted on 03/26/19 with a diagnosis of delusional disorder and anxiety, the psychiatric diagnosis showed major depressive disorder and schizoaffective disorder. Review of the psychiatric evaluation dated 03/28/19 showed the chief complaint of paranoid/somatic delusions with physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." Review of the admission orders dated 03/26/19 showed she was placed on Assaultive/Violence and Suicide Precaution, Level 1, every 15-minute observation. The record lacked the required every 24 hour assessment and evidence of renewed or discontinued suicide precaution orders throughout their hospital stay

During an interview on 04/22/19 at 1:20 PM, in the dining room, Patient 3 stated that she goes to the bathroom by herself and staff do not go with her. Even though eight of the nine patient bathrooms had paper towel and soap dispensers that a patient could use to loop a cord or other similar item around to hang themselves, the patient reports that staff allow her to go to the bathroom unattended, thus giving the patient opportunity to injure herself.


Review of Patient 6's discharged medical record showed a picture of Patient 6 at admission, sitting in a chair with a sling on her left arm with straps that extend from her left elbow and shoulder area up around both sides of her neck. Patient 6 was admitted on 10/19/18 with a diagnosis of severe Major Depressive disorder. Review of the psychiatric evaluation dated 10/19/18 showed she was admitted because she attempted to wrap a cord around her neck as a suicidal gesture. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." Review of the Nursing Admission Assessment dated 10/19/18 showed, ..."Assistive Devices: ...other LUE (left upper extremity) sling. The Suicide Risk Level Screen showed that she was a high risk for suicide. The document comments regarding risk level and precautions showed: Pt. attempted suicide in last 72 hours by trying to use cords and gait belt and took a bottle of pills when she was younger.

Even though the hospital assessed her as a high risk for suicide and that she attempted suicide by trying to use cords and a gait belt to hang herself, the staff left her with an arm sling which had long straps that could easily be used to hang herself.

The admission orders showed: "Precautions: Suicide", with "Observation: every (Q) 15 minutes and 1:1" both marked. A physician's order dated 10/20/18 showed, "Change Pt (patient) order to now, line of sight only, for hx (history) of suicidal ideation and intent. Review of the "Close Observation" forms dated 10/19/18 through 11/02/18 showed the following:

Level 1 - observation every 15-minutes: 10/21/18, 10/22/18, 10/28/18, 10/29/18, 10/30/18, 11/01/19 and 11/02/19.
Level II - Line of Sight: 10/19/18 and 10/25/18.
Level III - One to One: 10/20/18 and 10/21/18.
"Close Observation" forms with no level of observation mark: 10/23/18, 10/24/18, 10/26/18, 10/27/18 and 10/31/18.

Review of the "Close Observation" forms dated 10/19/18 through 11/02/18 showed missed 15-minute observations on 10/29/18 beginning at 4:30 AM, she was observed in her room awake, the next observation was documented at 5:15 AM in her room asleep, forty-five minutes later. She was observed in the day room on 10/29/18 at 2:30 PM and the next observation was at 3:00 PM in the day room, thirty minutes later. On 10/30/18 at 6:15 AM, she was observed in her room awake, the next documented observation was at 7:00 AM, in her room awake, thirty minutes later. On 10/31/18 at 1:45 PM she was observed in the day room, the next documents observation was at 3:00 PM in the day room, one hour and fifteen minutes later. Hospital staff failed to conduct line of sight observations of Patient 6 on ten of twelve days even though there was no physician's order to stop the line of site observations ordered on 10/20/19. The staff's failure to observe the patient with "line of sight" placed this suicidal patient at risk for harming herself.


Review of Patient 11's discharged medical record on 04/26/19 showed he was admitted on 04/08/19 with a diagnosis of delusion disorder and anxiety. Review of the psychiatric evaluation dated 04/09/19 showed the chief complaint of physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/08/19 showed he was placed on Assaultive/Violence precautions with every 15-minute observation. Review of the "Close Observation" form dated 04/11/19 showed missed 15-minute observations beginning at 5:00 PM, he was observed in the day room, the next observation was documented at 7:19 PM when he was in the hall, two hours and 19 minutes later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 11.


Review of Patient 13's current medical record showed he was admitted on 04/12/19 with a diagnosis of Major depressive disorder and delusional disorder. Review of the psychiatric evaluation dated 04/13/19 showed a chief complaint of suicidal ideation with no plan. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/12/19 showed he was placed on Assaultive/Violence and Suicide Precaution Level 1, every 15 minutes observation. The record lacked the required every 24 hour assessment and evidence of renewed or discontinued suicide precaution orders throughout their hospital stay.


Review of Patient 14's current medical record on 04/30/19 showed she was admitted on 04/18/19 with a diagnosis of delusional disorder and schizophrenia. Review of the psychiatric evaluation dated 04/19/19 showed a chief complaint of delusions. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders showed she was placed on Assaultive/Violence and Suicide precaution, Level 1, every 15 minutes observation. Review of the "Close Observation" form dated 04/23/19 showed missed 15-minute observations beginning at 5:45 PM when she was in her room sleeping, the next observation documented was at 7:19 PM, one hour and 34 minutes later. Review of the "Close Observation" form dated 04/26/19 showed missed 15-minute observations beginning at 1:06 PM when she was observed in her room awake, the next documented 15-minute observation was at 1:43 PM when she was observed in the hall 37 minutes later. The staff's failure to perform 15 minute checks of this assaultive/violent/suicidal patient places Patient 14 at risk for injuring himself or others.


Review of Patient 16's current medical record showed he was admitted on 04/21/19 with a diagnosis of Major Depressive Disorder, Alzheimer and anxiety. Review of the psychiatric evaluation dated 04/22/19 showed a chief complaint of suicide attempt by hanging times two on 04/21/19. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/21/19 showed he was placed on Assaultive/Violence and Suicide Precaution Level 1, every 15 minutes observation. Review of the "Close Observation" form dated 04/24/19 showed missed 15-minute observations beginning at 6:45 PM, when he was observed in his room awake, the next observation documented was at 7:45 PM when he was in the hall, one hour later. The staff failed to complete every 15 minute checks for an hour, giving the patient opportunity to harm himself or others. The record lacked the required every 24 hour assessment and evidence of renewed or discontinued suicide precaution orders throughout their hospital stay.

During an interview on 04/22/19, at 1:18 PM, in the dining room, Patient 16 stated that it was a nice day and he got good care. He stated he didn't know why he was here. Observation showed that he had on a long sleeve brown sweater. Patient 16 had attempted suicide by using shirt sleeves on 04/21/19. The hospital allowed the patient to wear an article of clothing that he could use to hang himself.

During an interview on 04/22/19 at 3:15 PM, Staff I, RN, stated that all patients are on 15-minute observation and more often if needed, she stated that even though not all patients are assessed as suicidal, they might not tell you and you may not know, so they are all on 15-minute checks. She stated that Patient 16 was admitted last night, 04/21/19, after attempting suicide twice that day, she stated that he used his sleeves once and a mini blind cord the second time. She stated that he has Alzheimer and does not remember attempting suicide.


Review of Patient 17's current medical record on 04/22/19 showed he was admitted on 04/18/19 with a diagnosis of delusional disorder and schizoaffective disorder. Review of the psychiatric evaluation dated 04/19/19 showed a chief complaint of refusing medications and physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The close observation forms dated 04/18/19 through 04/24/19 showed he was on Assaultive/Violence and Suicide precautions, Level 1, Observation every 15-minutes. Review of the "Close Observation" forms dated 04/24/18 showed missed 15-minute observations beginning at 6:45 PM when he was observed sleeping in his room and was next observed awake in his room at 7:30 PM, 45 minutes later. On 04/25/19 at 3:15 AM Patient 17 was observed asleep in his room and next observed at 4:00 AM, 45 minutes later. The staff's failure to perform 15 minute checks of this assaultive/violent/suicidal patient places Patient 17 at risk for injuring himself or others.


Review of Patient 18's current medical record on 04/27/19 showed she was admitted on 04/18/19 with a diagnosis of delusional disorder and schizophrenia. Review of the psychiatric evaluation dated 04/09/19 showed a chief complaint of delusions and physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The undated admission orders showed she was placed on Assaultive/Violence precautions and Observation every 15-minutes. Review of three undated "Close Observation" forms showed missed 15-minute observations beginning at 4:15 AM and the next observation was documented at 4:45 AM, 30 minutes later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 18.


Review of Patient 19's current medical record on 04/27/19 showed he was admitted on 04/16/19 with a diagnosis of delusional disorder and anxiety. Review of the psychiatric evaluation dated 04/18/19 showed a chief complaint of physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation. The admission orders dated 04/16/18 showed he was placed on Assaultive/Violence precautions with every 15-minute observation. Review of a "Close Observation" form dated 04/23/19 showed missed observations beginning at 5:45 PM when he was in the day room and the next observation was at 7:19 PM in the hall, one hour and 19 minutes later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 19.


Review of Patient 20's current medical record on 04/27/19, showed he was admitted on 04/10/19, with a diagnosis of delusional disorder and anxiety. Review of the psychiatric evaluation dated 04/11/19, showed a chief complaint of physical aggression and paranoia. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/10/19, showed he was placed on Assaultive/Violence precautions and Observation every 15-minutes. Review of a "Close Observation" form dated 04/11/19, showed missed observations beginning at 6:45 PM when he was in his room sleeping and the next documented observation was at 7:19 PM when he was in the hall, 34 minutes later. Review of a "Close Observation" form dated 04/24/19, showed missed observations when he was observed in the day room a 6:45 PM, the next observation documented was at 7:45 PM, one hour later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 20.

During an interview on 04/24/19 at 3:15 PM, Staff K, Interim DON, stated that the CNA/MHT is supposed to do 15-minute checks and then the nurse is supposed to do a walk around every hour. There shouldn't be any times that are not documented with a location and a signature.

Based on observation, document review and staff interview the hospital failed to ensure development of an effective Quality Assessment Performance Improvement Plan that identifies high risk, high-volume problem prone areas including identified ligature risked and infection control practices.

This systemic failure has the potential to adversely affect all patient by putting them at risk for infections, self-harm and harm to others.

Findings Include:

Review of a hospital policy titled, "Risk Assessment Program" effective 09/2016 and revised 09/2016, showed: "The performance improvement program for the Safety/Environment of Care Committee is designed to monitor the level of safety compliance at the hospital, and to identify any situations that detract from the goal of providing a safe and secure environment for patients, employees, medical staff and visitors. Any risks that are identified through proactive risk assessments, environmental tours, performance measure monitoring, etc., will be evaluated, and have procedures and controls put into place to reduce to the lowest possible point the adverse impact on the safety and health of patients, personnel, medical staff, and visitors of the hospital. For those cases, where appropriate and deemed necessary, the failure mode effects and analysis process will be undertaken."

Review of a hospital notebook labeled "Risk Assessment 07/2018" on 04/30/19 at 9:00 AM showed the hospital conducted a facility wide risk assessment and identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles.

During an interview on 04/30/19 at 12:15 PM, Staff A, Registered Nurse (RN) Director of Nursing (DON), stated that she didn't know why the Governing Body didn't initiate a plan to fix the ligature risks. She stated that she still wondered how the hospital opened with those in place. When asked about the Risk Assessment 2018 notebook she stated that she thought a guy from corporate did that risk assessment in July of 2018, but I don't recall the issues being brought up during the Governing Body meetings.

Review of a hospital document titled "Black-Ops Operations and Quality, Total Quality Management System" (BTQM)" Black-Ops TQM Systems Plan" dated April 2019 showed: "Operations, quality and performance management is the practice of actively using hospital data to improve the health of patients, who require care and treatment services. A Total Quality Management (TQM) system is defined by the activities and methods that help the hospital meet its goals in the most effective and efficient manner possible. In order to achieve desired patient outcomes, the hospital focuses on improving the safety, quality and efficiency of the services, care and treatment provided. The best way to achieve desired patient outcomes is by measuring the performance of processes that support the services, and then using that data to make improvements."

Review of the plans Annual Performance Improvement Projects does not include the identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles found on the facility wide risk assessment dated 07/2018.

Review of the Quality Assessment Performance Improvement Meeting minutes dated 10/25/18, 11/15/18, 12/21/18, 01/18/19, 02/14/19, and 03/15/19 showed no discussion of the identified ligature risks in the hospital.

Document review of the hospitals policy titled, "Infection Prevention and Control Program" showed, "The facilities Infection Prevention and Control Plan ensures that this organization develops, implements and maintains and active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers, and to optimize use of resources".

Review of the hospital's "Infection Control" Binder on 04/30/2019 showed the infection control officer, Director of Nursing (DON), failed to complete employee health program information which was to include immunization and exposure information, Behavioral Health Facility Surveillance information which was to include information on Hospital Acquired Infections and Community Acquired Infections, employee education including hand hygiene, isolation precautions, prevention of urinary tract infections, cleaning techniques and other infection control education offerings, the Antibiotic and Organism Yearly Summary, the QAPI monitoring for basic disinfection, hand hygiene, patient identifiers, and the Infection control tracking reports for February 2019, March 2019, and April 2019.

Review of the hospitals QAPI report on 04/30/19 showed during the 02/14/19 and 03/15/19 meetings no infection control information was reported.

During an interview on 04/30/2019 at 12:00 PM, Staff A, DON, stated the she quit working at the hospital in February 2019 and Staff K, RN, was to be her replacement. Staff A stated that Staff K was also supposed to take over the infection control officer duties. Staff A stated, "I don't know why there is no documentation for February, March, and April". Staff A stated, "It is too much for someone to be the DON and the infection control officer".

Based on observation, record review, and interview, the facility failed to ensure the availability of a physician to provide psychiatric treatment and ensure oversight of the treatment and care of geriatric patients 50 years and older at the frequency, level, and intensity necessary for psychiatric hospitalization. Specifically, there was no physician on-site to provide, direct, review, and supervision psychiatric treatment. Instead, the only physician contact with patients for psychiatric care was via electronic telecommunication (a telemedicine process) once a week for approximately five to ten minutes per patient. Without consistent on-site supervision and direction of each patient's treatment, the patients' recovery may be compromised, potentially delaying their timely discharge. (Refer to B99)

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

I. Ensure that the psychosocial assessment contained a comprehensive statement of conclusions and recommendations that included the social evaluation of psychiatric issues, anticipated role of the social worker in treatment during hospitalization, and projected steps in discharge planning for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A14). This failure hampers the ability of the treatment team to formulate appropriate social service interventions for patients. (Refer to B108)

II. Ensure that a neurological examination was completed for three (3) of nine (9) active sample patients (A1, A2, and A13.) For an additional three (3) active sample patients (A6, A9, and A15), the neurological document failed to include any information to verify the specific testing performed. This failure to document a neurological examination with specific testing compromises the identification of pathology for geriatric patients, which may be pertinent to their current mental illness and compromises future comparative re-examination to assess the patient's response to treatment interventions. (Refer to B109)

III. Ensure that psychiatric evaluations were performed by a physician and contained all the necessary information to justify the patients' diagnoses and planned treatment for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). Instead, psychiatric evaluations for these patients were completed by an Advanced Practice Registered Nurse without comprehensive information and documented physician review. The failure to have the psychiatric evaluation completed with detailed information and provided under the direction of a physician potentially compromises the formulation of an accurate diagnostic view of the patient, thereby limiting the team's ability to develop a meaningful plan of care to meet the patient's individual psychiatric needs. (Refer to B110)

IV. Ensure that the psychiatric evaluations for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) included comprehensive information regarding an estimate of intellectual functioning, memory functioning, and orientation. Lack of this necessary clinical information can negatively affect decision-making on the need of geriatric patients for further evaluation. (Refer to B116)

V. Include an inventory of each patient's personal assets such as accomplishments, skills, or interests written in descriptive and non-interpretative fashion for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). This deficiency results in a lack of necessary information to guide in developing a plan of treatment for the patient. (Refer to B117)

VI. Develop and document comprehensive Master Treatment Plans (MTPs) for nine (9) of nine (9) sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). Instead, MTPs were completed separately by each discipline using a preprinted document with treatment goals and interventions assigned by discipline. The physician and APRN were not involved in the development of the Master Treatment Plan. These deficient practices reflect a failure of collaborative input by all team members resulting in the potential to compromise patients' opportunity to receive appropriate treatment measures. (Refer to B118-I)

VII. Provide comprehensive Master Treatment Plans (MTPs) that were individualized and included all required components for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). The MTPs were missing the following components:

A. Behaviorally descriptive strength statements and disability statements (called problems by the facility) to be used as the basis for developing treatment plans. (Refer to B119).

B. Observable and measurable goals based on each patient's presenting psychiatric symptoms and needs. (Refer to B121)

C. Individualized active treatment interventions with a method of delivery, frequency of contact and focus of treatment based on each patient's presenting psychiatric symptoms and needs. (Refer to B122).

D. Both the name and discipline of the staff responsible and accountable for each of the interventions identified in the Master Treatment Plan. (Refer to B123)

Failure to develop Master Treatment Plans with all the required components hampers the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's treatment needs not being met.

VII. Ensure that the physician responsible for psychiatric treatment wrote progress notes as stipulated by facility policy for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) and five (5) non-sample active patients selected for review of physician progress notes (A4, A7, A11, A12, and A16). Instead, the APRN recorded and signed progress noted without documented physician review. These notes failed to include the progress or lack of progress related to the presenting psychiatric symptoms and rationale for medication orders and changes. The absence of comprehensive documentation of each patient's progress prevented an up to date picture of pertinent changes in the patient's psychiatric condition or response to changes in the medication. (Refer to B126)

VIII. Ensure that discharge summaries were completed according to the facility's policy in providing timely discharge summary for three (3) of five (5) sampled discharged patients (D1, D3, and D4). This deficiency results in a failure to communicate in a timely manner psychiatric assessments and discharge plans to providers providing follow-up care. (Refer to B133)

Based on observation, document review, and interview, the facility failed to ensure an adequate number of clinical staff to complete comprehensive assessments, provide ongoing active treatment, and document progress for the geriatric patient population served. In addition, Directors of Services failed to assure all care was appropriately completed and documented. Specifically, the facility failed to:

I. Provide an onsite physician responsible for psychiatric care and treatment of acutely ill geriatric patients and provide consistent oversight and supervision of psychiatric treatment on a regular basis. Instead, a psychiatrist saw patients for approximately five to ten minutes once per week via electronic telecommunication (a telemedicine process). This failure potentially delays the treatment of acutely mentally ill geriatric patients with appropriate psychiatric treatment and psychotropic medications. (Refer to B142).

II. Employ a Director of Nursing (DON) with a Master's Degree in Psychiatric Nursing, or alternatively assure the DON had necessary consultation with a qualified Psychiatric nurse or ongoing training. The DON did not have documented evidence of supervisory consultation from a nurse with a Master's degree in Psychiatric/Mental Health Nursing nor alternatively, did she have ongoing training in psychiatric/mental health nursing. This failure results in the facility not having a qualified nursing director to manage and monitor psychiatric/mental health nursing care of the patients. (Refer to B147).

III. Ensure that nurses documented verbal orders accurately on the form titled "Admit Orders / Preliminary Plan of Care." Specifically, telephone orders were recorded as being ordered by the psychiatrist when they were orders received from the APRN for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). This deficient practice results in the lack of appropriate monitoring of medication orders resulting in falsified medical documentation. (Refer to B148).

IV. Provide an adequate number of Registered Nurses (RNs) to implement active treatment interventions, supervise paraprofessional staff, and monitor patients. The facility's staffing of RNs results in the lack of active treatment provided by registered nurses and limited direction and supervision of paraprofessional staff in the provision of psychiatric nursing care. (Refer to B150).

V. Ensure the availability of services by a licensed psychologist for the geriatric patients in its care. This deficiency potentially results in patients not receiving the full array of diagnostic and intervention services when needed, and patients' needs not being met in a timely manner. (Refer to B151).

VI. Employ a sufficient number of qualified therapeutic rehabilitation (TR) staff to plan and implement a structured therapeutic rehabilitation program especially after hours and on weekends for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). This failure results in patients not receiving active treatment at the intensity and frequency necessary for psychiatric hospital treatment, potentially delaying recovery. (Refer to B158).

Based on personnel file review, staff interview, and job description review, the hospital failed to ensure five of ten personnel had current Basic Life Support (BLS) certificates (Staff J, K, N, O, and Q). This deficient practice has the potential to place patients at risk for receiving ineffective cardiopulmonary resuscitation (CPR).

Findings Include:

Review of hospital documents titled "Job Description" with revision date of 10/01/17 showed: "Job Title: Director of Nursing" (DON) "Certifications, Licenses and/or Registrations Required: Cardiopulmonary Resuscitation (CPR)." "Job Title: Registered Nurses" (RN) "Certifications, Licenses and/or Registrations Required: Cardiopulmonary Resuscitation (CPR)." "Job Title: Licensed Practical Nurses" (LPN) "Certifications, Licenses and/or Registrations Required: Cardiopulmonary Resuscitation (CPR)." "Job Title: Mental Health Technician" (MHT) "Certifications, Licenses and/or Registrations Required: Cardiopulmonary Resuscitation (CPR)."

Review of Staff J, RN's personnel file showed no evidence of BLS certification.

Review of Staff K, RN, interim DON's personnel file showed an expired BLS certification.

Review of Staff N, MHT's personnel file showed no evidence of BLS certification.

Review of Staff O, MHT's personnel file showed her BLS certification expired 07/2018.

Review of Staff Q, MHT's personnel file showed no evidence of BLS certification.

During an interview on 04/30/19 at 9:00 AM, Staff S, Human Resource Director (HR) stated that staff should not be allowed to work on the floor if they do not have their CPR completed. She stated that they should not be working without it and that some staff have told her they have it and will email it to me, but she has not received them.

During an interview on 04/30/19 at 10:15 AM Staff B, Chief Executive Officer stated that he wasn't aware of Staff not having current CPR certification and he had not restricted any staff from working because of it.

Based on staff interview and document review the facility failed to ensure they investigated and responded to patient grievances in a timely manner for three of five grievances (Patients 21, 22, and 23) dated from 04/2018 to 04/2019.

This deficient practice had the likelihood to cause patient concerns to be unresolved.

Findings Include:

Document review of hospital policy titled, "Complaint and Grievance Procedures for Inpatient Mental Health" revised on 12/16 showed, "This facility shall respond to any such concern in a reasonable, consistent and timely fashion". The policy showed staff are to notify the patient and the patient's family/legally responsible person by written notice of the grievance determination.

Patient 21's complaint & grievance form completed on 02/12/19 showed the patient reported that night shift staff was abusive to him and hurt his neck, he stated they talk about him and are disrespectful.

The complaint & grievance form lacked evidence the hospital investigated the grievance.


Patient 22's complaint & grievance form completed on 08/09/18 showed the patient reported he was discharged without his teeth.

The complaint & grievance form lacked evidence the hospital investigated the grievance


Patient 23's complaint & grievance form completed on 04/17/18 showed the patient reported a staff member was "very nasty and rude" and delayed smoke break because she was asked many times.

The complaint & grievance form lacked evidence the hospital investigated the grievance


During an interview on 04/20/19 at 10:15 AM, Staff B, CEO, stated that he did not know why Patient 21, 22, and 23's complaint & grievance forms were not complete and stated that a patient's reported concern is only a grievance if it takes longer than 24-hours to resolve.

Based on document review and staff interview the hospital failed to provide written notification to complainants in response to grievances for thee of five grievances (Patients 21, 22, and 23) reviewed from 04/2018 to 04/2019.


Failure of the hospital to provide written notice of the outcome of their grievance investigation, and steps taken on behalf of the patient or the patient's family to investigate the grievance violates their right to be informed of how the hospital investigated and resolved the grievance.

Findings Include:

Document review of hospital policy titled, "Complaint and Grievance Procedures for Inpatient Mental Health" revised on 12/16 showed, "This facility shall respond to any such concern in a reasonable, consistent and timely fashion". The policy showed staff are to notify the patient and the patient's family/legally responsible person by written notice of the grievance determination.

Patient 21's complaint & grievance form completed on 02/12/19 showed the patient reported that night shift staff was abusive to him and hurt his neck, he stated they talk about him and are disrespectful. The date of resolution was not documented.

The complaint & grievance form lacked evidence the hospital provided written notification of the resolution to the patient and the patient's family/legally responsible person.

Patient 22's complaint & grievance form completed on 08/09/18 showed the patient reported he was discharged without his teeth. The date of resolution was not documented.

The complaint & grievance form lacked evidence the hospital provided written notification of the resolution to the patient and the patient's family/legally responsible person.

Patient 23's complaint & grievance form completed on 04/17/18 showed the patient reported a staff member was "very nasty and rude" and delayed the smoke break because she was asked many times. The date of resolution was not documented.

The complaint & grievance form lacked evidence the hospital provided written notification of the resolution to the patient and the patient's family/legally responsible person.

During an interview on 04/20/19 at 10:15 AM, Staff B, CEO, stated that he did not know why Patient 21, 22, and 23 did not receive a letter indicating the resolution of their concerns and stated that a patient's reported concern is only a grievance if it takes longer than 24-hours to resolve. Staff B stated that if they resolved it in less than 24-hours they do not have to send a letter. Staff B did stated he did not have any additional documentation showing when or if Patient 21, 22, or 23's grievances had been resolved.

Based on observation, staff interview and document review the hospital failed to ensure five of seventeen current patients assessed at risk for suicide (Patients 3, 13, 14, 16 and 17) and one of ten discharged patient records reviewed at risk for suicide (Patient 6) were safe from ligature (hanging) hazards and items likely to cause harm, failed to follow procedure by leaving three of five patients (Patient 3, 13, and 16) assessed at risk for suicide unattended by staff in the dining room; failed to ensure nine patients assessed as having aggressive behaviors and placed on Assaultive/Aggressive precautions (Patients 3, 11, 12, 13, 14, 16, 17, 18, and 19) did not have access to items that could be used to cause harm to self or others, failed to observe eight of eleven patients (Patient 6, 11, 14, 16, 17, 18, 19, and 20) placed on Suicidal precautions and Assaultive/Violence precautions every 15-minutes as ordered and failed to renew or discontinue suicide precaution orders for five of five current patients (Patients 3, 13, 14, 16 and 17) assessed at risk for suicide on admission.

An Immediate Jeopardy (IJ - represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.) was identified on 04/23/19 at 9:00 AM as a result of the hospital's failure to ensure all patients were cared for in a safe setting and free from ligature (hanging) hazards and items likely to cause harm to self and others.

The hospital submitted a plan of removal on 04/25/19 and was it accepted at 4:41 PM before exiting the survey.

The plan of removal included: Leadership will educate all Charge Nursing staff about each identified ligature risk area. Training acknowledgement forms will be completed prior to start of check shift. ...Charge Nursing staff will educate all licensed practical nurses (LPNs) and mental health technicians (MHT) staff on all identified ligature risk areas. At 6:45 PM on 04/24/19 Charge Nurse will train the oncoming charge nurse and nursing staff on ligature risks. This will continue each shift at 6:45 AM and 6:45 PM until all staff shifts have cycled through. Charge nurse will supervise the rotation of all staff throughout the building with special attention to all areas of ligature risks that have been identified. This will be done by 1 MHT positioned in each hallway in order for all areas to be covered as patient coverage is warranted. The 1 MHT's responsibilities will be to monitor ligature risk areas. If the MHT gets called away from the hallway the MHT will notify the charge nurse or LPN one of them will cover until the MHT can return. All employed employees will be trained by their next shift. All contract employees will be trained before they work their next shift. Staff will be re-educated about Freedom Policy to never have a patient be unattended in the dining room/noisy activity room. The charge nurse will monitor this on the cameras to ensure compliance. If the charge nurse has to step away the LPN will monitor the cameras. All LPN's and RN's will be trained prior to their next shift worked by leadership or trained charge nurse. All nursing staff will be trained by their next shift. MHT's will walk the hallways to do random 15-minute room checks on all patients in their rooms. These checks will be randomized and documented on the 15 minutes or less chart check. All patients will be monitored in high risk areas the same way unless ordered by the physician. Training will begin at 6:45 PM on 04/24/19 by Chief Executive Officer (CEO). All patients will be on line of sight while in the shower area until immediate ligature risks are resolved.

Findings Include:

Review of an undated document titled, "Patient Handbook" showed: ..."The hospital program has been set up to provide a safe environment where you can heal from recent life events and recover from your symptoms. Keeping the program safe and comfortable requires a cooperative relationship between all staff and patients on the program." Review of the Patient Rights contained in the handbook showed: ..."As a patient you have the right to:" ..."Be treated with consideration, dignity, and respect with care provided in a safe environment free from any form of abuse, neglect, exploitation, or harassment."

Review of a hospital policy titled, "Risk Assessment Program" effective 09/2016 and revised 09/2016, showed: "The performance improvement program for the Safety/Environment of Care Committee is designed to monitor the level of safety compliance at the hospital, and to identify any situations that detract from the goal of providing a safe and secure environment for patients, employees, medical staff and visitors. Any risks that are identified through proactive risk assessments, environmental tours, performance measure monitoring, etc., will be evaluated, and have procedures and controls put into place to reduce to the lowest possible point the adverse impact on the safety and health of patients, personnel, medical staff, and visitors of the hospital. For those cases, where appropriate and deemed necessary, the failure mode effects and analysis process will be undertaken."

Review of a hospital notebook labeled "Risk assessment 07/2018" on 04/30/19 at 9:00 AM showed the hospital conducted a facility wide risk assessment and identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles.

During an interview on 04/30/19 at 12:15 PM, Staff A, Registered Nurse (RN) Director of Nursing (DON), stated that she didn't know why the Governing Body didn't initiate a plan to fix the ligature risks. She stated that she still wondered how the hospital opened with those in place. When asked about the Risk Assessment 2018 notebook she stated that she thought a guy from corporate did that risk assessment in July of 2018, but I don't recall the issues being brought up during the Governing Body meetings.

Observations made during the hospital tour on 04/22/19 between 10:45 AM until 11:50 AM showed multiple ligature risks and items accessible to patients that could be used for self-harm or harm to others. These ligature risks and items accessible to patients could be used for self-harm or harm to others include the following:

Door handles of the Entrance/Exit Double Doors, have open push arms not flush with the glass doors, hinges at the top of both doors near the walls. A patient could loop a cord or other similar item around these door handles to hang themselves.

Six exit signs with large round lights on each side. A patient could loop a cord or other similar item around these exit signs to hang themselves.

Two sets double fire doors have elbow hinges at the top of both doors near the walls leaving a gap in the hinge, at the top backside of both fire doors, there are magnets that protrude out, the handles on the back side of the door are not flush with the door, latch bars that are not flush and runs vertically on each door and has a flat surface that protrudes out at the top of the door. A patient could loop a cord or other similar item around the elbow hinges, magnets, handles, and latch bars of the fire doors to hang themselves.

Eight locked doors with exterior hinges that protrude out. A patient could loop a cord or other similar item around the exterior hinges of these locked doors to hang themselves.

A water fountain with spout. A patient could loop a cord or other similar item around the spout of the water fountain to hang themselves.

Four chairs located in the hallway and 12 chairs in the dining room that are light enough to be picked up and thrown. A patient could use these chairs as a weapon to assault other patients, staff, or visitors.

Blunt solid wood handle on fire extinguisher box. A patient could loop a cord or other similar item around the wood handle to hang themselves.

An exit door at the east end of the hall between patient rooms 111 and 112 has a push arm that is not flush with the door. A patient could loop a cord or other similar item around the push arm of the exit door to hang themselves.

The top casing of the fire doors in the north hall by the nurse's station has a bar that protrudes out. A patient could loop a cord or other similar item around the bar of the fire door to hang themselves.

The shower room has two square light switch boxes, a locked, plastic storage cabinet with a break in the plastic that could be used to harm self, and a large metal cabinet with a square top. The tub has Hot and Cold-water handles, faucet and hand bar, a square wall mounted timer and laundry basket with metal wire framing and soap dispenser and paper towel dispensers. A patient could loop a cord or other similar item around the light switch boxes, the top of the large metal cabinet, the tub's hot and cold fixtures, the tub's faucet, tub's hand bar, the timer, the laundry baskets's metal frame, the soap dispenser, and the paper towel dispenser of the shower room to hang themselves. A patient could also use the break in the locked, plastic storage cabinet to cut themselves.

Observation in the dining room showed four tables light enough to be picked up and thrown, a wall mounted television, square ice machine, soap dispenser hanging on the wall, faucets, and the lower cabinets had five looping handles. A patient could loop a cord or other similar item around the wall mount of the TV, the ice machine, the soap dispenser, and the handles of the lower cabinets to hang themselves. A patient could use the tables as a weapon to assault other patients, staff, or visitors.

Eight of nine patient bathrooms had paper towel and soap dispensers hanging on the walls. A patient could loop a cord or other similar item around the paper towel and soap dispensers of these bathrooms to hang themselves.

Patient rooms 101, 107A, 107B, 110B, and 112A all had broken metal bells with sharp edges attached to the bedside tables that creates a self-injury hazard. A patient could use the sharp metal edges to cut themselves.


Review of a hospital policy titled, "Suicide Precautions," effective 09/2016 and revised 12/2016, showed, "To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients." ... "All patients placed on suicide precautions will be assigned an acuity level based upon the severity of the suicidal thoughts, plan or behavior." The levels are as follows: "Every 15-minute observation, Line of sight observation and one-to-one observation at all times.

Review of a hospital policy titled, "Assessment for Suicidal Ideation," effective 09/2016 and revised 12/2016, showed: "To ensure safety, prevent injury and maintain a therapeutic relationship with all patients." "Upon admission to the facility, every patient will be evaluated for suicidal ideation." ..."All patients admitted to the program following any suicide attempt will be considered high-risk, kept on suicide precautions and assessed every 24 hours." ..."This is an ongoing assessment since patients in a behavioral health setting may regress at any time. Orders for suicide precautions will be renewed every 24 hours and discontinued only by order of the physician."

Review of current medical records for Patient 3, 13, 14, 16 and 17, who were placed on suicide precautions, lacked evidence of renewed or discontinued suicide precautions orders throughout their hospital stay.

Failure of the hospital to follow their policy to assess a patient's risk for suicide every twenty four hours and for the physician to write continued orders for suicide precautions or discontinue suicide precautions has the potential for a patient, whose suicidal thoughts have increased and who may need closer observation including either "line of sight" or 1:1 observation, instead of 15 minute observations, to have a greater opportunity to injure themselves.


During an observation in the dining room, on 04/22/19 at 1:18 PM, showed four patients (Patients 3, 13, 16 and an unidentified female patient) sitting in chairs unattended by staff. At 1:26 PM, Patient 15 approached in the hall just outside of the dining room followed by unidentified MHT staff, the unidentified MHT staff asked Staff N, MHT if he could help in the dining room. Staff N went into the dining room with the patients and escorted them out.

Review of the records for Patient 3, 13, and 16 showed the hospital had placed them on suicide and assaultive/aggressive precautions. The dining room had tables and chairs that were lightweight and could be used by one of the patients as a weapon to injure another patient, staff member, or visitor. The dining room also contained items that one of the patients could have used to hang themselves by looping a cord or other similar item around it including the wall mount of the TV, the ice machine, the soap dispenser, and the handles of the lower cabinets. Staff left patients (suicidal/assaultive/aggressive) unattended in the dining room for about 8 minutes in an environment that included hanging risks and items that could be used to harm others. This situation placed patients at risk for harming themselves or others.

During an interview on 04/22/19 at 11:25 Staff A, RN DON stated that it is the expectation that staff should never leave patients alone in the shower room, group activity room or the dining room.


Review of Patient 3's current medical record on 04/24/19 showed she was admitted on 03/26/19 with a diagnosis of delusional disorder and anxiety, the psychiatric diagnosis showed major depressive disorder and schizoaffective disorder. Review of the psychiatric evaluation dated 03/28/19 showed the chief complaint of paranoid/somatic delusions with physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." Review of the admission orders dated 03/26/19 showed she was placed on Assaultive/Violence and Suicide Precaution, Level 1, every 15-minute observation.

During an interview on 04/22/19 at 1:20 PM, in the dining room, Patient 3, who was placed on suicide precautions, stated that she goes to the bathroom by herself and staff do not go with her. Even though eight of the nine patient bathrooms had paper towel and soap dispensers that a patient could use to loop a cord or other similar item around to hang themselves, the patient reports that staff allow her to go to the bathroom unattended, thus giving the patient an opportunity to injure herself.


Review of Patient 6's discharged medical record showed a picture of Patient 6 at admission, sitting in a chair with a sling on her left arm with straps that extend from her left elbow and shoulder area up around both sides of her neck. Patient 6 was admitted on 10/19/18 with a diagnosis of severe Major Depressive disorder. Review of the psychiatric evaluation dated 10/19/18 showed she was admitted because she attempted to wrap a cord around her neck as a suicidal gesture. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." Review of the Nursing Admission Assessment dated 10/19/18 showed, ..."Assistive Devices: ...other LUE (left upper extremity) sling. The Suicide Risk Level Screen showed that she was a high risk for suicide. The document comments regarding risk level and precautions showed: Pt. attempted suicide in last 72 hours by trying to use cords and gait belt and took a bottle of pills when she was younger.

Even though the hospital assessed her as a high risk for suicide and that she attempted suicide by trying to use cords and a gait belt to hang herself, the staff left her with an arm sling which had long straps that could easily be used to hang herself.

The admission orders showed: "Precautions: Suicide", with "Observation: every (Q) 15 minutes and 1:1" both marked. A physician's order dated 10/20/18 showed, "Change Pt (patient) order to now, line of sight only, for hx (history) of suicidal ideation and intent. Review of the "Close Observation" forms dated 10/19/18 through 11/02/18 showed the following:

Level 1 - observation every 15-minutes: 10/21/18, 10/22/18, 10/28/18, 10/29/18, 10/30/18, 11/01/19 and 11/02/19.
Level II - Line of Sight: 10/19/18 and 10/25/18.
Level III - One to One: 10/20/18 and 10/21/18.
"Close Observation" forms with no level of observation mark: 10/23/18, 10/24/18, 10/26/18, 10/27/18 and 10/31/18.

Review of the "Close Observation" forms dated 10/19/18 through 11/02/18 showed missed 15-minute observations on 10/29/18 beginning at 4:30 AM, she was observed in her room awake, the next observation was documented at 5:15 AM in her room asleep, forty-five minutes later. She was observed in the day room on 10/29/18 at 2:30 PM and the next observation was at 3:00 PM in the day room, thirty minutes later. On 10/30/18 at 6:15 AM, she was observed in her room awake, the next documented observation was at 7:00 AM, in her room awake, thirty minutes later. On 10/31/18 at 1:45 PM she was observed in the day room, the next documents observation was at 3:00 PM in the day room, one hour and fifteen minutes later. Hospital staff failed to conduct line of sight observations of Patient 6 on ten of twelve days even though there was no physician's order to stop the line of site observations ordered on 10/20/19. The staff's failure to observe the patient with line of site placed this suicidal patient at risk for harming themselves.


Review of Patient 11's discharged medical record on 04/26/19 showed he was admitted on 04/08/19 with a diagnosis of delusion disorder and anxiety. Review of the psychiatric evaluation dated 04/09/19 showed the chief complaint of physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/08/19 showed he was placed on Assaultive/Violence precautions with every 15-minute observation. Review of the "Close Observation" form dated 04/11/19 showed missed 15-minute observations beginning at 5:00 PM, he was observed in the day room, the next observation was documented at 7:19 PM when he was in the hall, two hours and 19 minutes later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 11.


Review of Patient 13's current medical record showed he was admitted on 04/12/19 with a diagnosis of Major depressive disorder and delusional disorder. Review of the psychiatric evaluation dated 04/13/19 showed a chief complaint of suicidal ideation with no plan. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/12/19 showed he was placed on Assaultive/Violence and Suicide Precaution Level 1, every 15 minutes observation. The record lacked the required every 24 hour assessment and evidence of renewed or discontinued suicide precaution orders throughout their hospital stay.


Review of Patient 14's current medical record on 04/30/19 showed she was admitted on 04/18/19 with a diagnosis of delusional disorder and schizophrenia. Review of the psychiatric evaluation dated 04/19/19 showed a chief complaint of delusions. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders showed she was placed on Assaultive/Violence and Suicide precaution, Level 1, every 15 minutes observation. Review of the "Close Observation" form dated 04/23/19 showed missed 15-minute observations beginning at 5:45 PM when she was in her room sleeping, the next observation documented was at 7:19 PM, one hour and 34 minutes later. Review of the "Close Observation" form dated 04/26/19 showed missed 15-minute observations beginning at 1:06 PM when she was observed in her room awake, the next documented 15-minute observation was at 1:43 PM when she was observed in the hall 37 minutes later. The staff's failure to perform 15 minute checks of this assaultive/violent/suicidal patient places Patient 14 at risk for injuring himself or others.


Review of Patient 16's current medical record showed he was admitted on 04/21/19 with a diagnosis of Major Depressive Disorder, Alzheimer and anxiety. Review of the psychiatric evaluation dated 04/22/19 showed a chief complaint of suicide attempt by hanging times two on 04/21/19. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/21/19 showed he was placed on Assaultive/Violence and Suicide Precaution Level 1, every 15 minutes observation. Review of the "Close Observation" form dated 04/24/19 showed missed 15-minute observations beginning at 6:45 PM, when he was observed in his room awake, the next observation documented was at 7:45 PM when he was in the hall, one hour later. The staff's failure to perform 15 minute checks of this assaultive/violent/suicidal patient places Patient 16 at risk for injuring himself or others.

During an interview on 04/22/19, at 1:18 PM, in the dining room, Patient 16 stated that it was a nice day and he got good care. He stated he didn't know why he was here. Observation showed that he had on a long sleeve brown sweater. Patient 16 had attempted suicide by using shirt sleeves on 04/21/19. The hospital allowed the patient to wear an article of clothing that he could use to hang himself.

During an interview on 04/22/19 at 3:15 PM, Staff I, RN, stated that all patients are on 15-minute observation and more often if needed, she stated that even though not all patients are assessed as suicidal, they might not tell you and you may not know, so they are all on 15-minute checks. She stated that Patient 16 was admitted last night, 04/21/19, after attempting suicide twice that day, she stated that he used his sleeves once and a mini blind cord the second time. She stated that he has Alzheimer and does not remember attempting suicide.


Review of Patient 17's current medical record on 04/22/19 showed he was admitted on 04/18/19 with a diagnosis of delusional disorder and schizoaffective disorder. Review of the psychiatric evaluation dated 04/19/19 showed a chief complaint of refusing medications and physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The close observation forms dated 04/18/19 through 04/24/19 showed he was on Assaultive/Violence and Suicide precautions, Level 1, Observation every 15-minutes. Review of the "Close Observation" forms dated 04/24/18 showed missed 15-minute observations beginning at 6:45 PM when he was observed sleeping in his room and was next observed awake in his room at 7:30 PM, 45 minutes later. On 04/25/19 at 3:15 AM Patient 17 was observed asleep in his room and next observed at 4:00 AM, 45 minutes later. The staff's failure to perform 15 minute checks of this assaultive/violent/suicidal patient places Patient 17 at risk for injuring himself or others.


Review of Patient 18's current medical record on 04/27/19 showed she was admitted on 04/18/19 with a diagnosis of delusional disorder and schizophrenia. Review of the psychiatric evaluation dated 04/09/19 showed a chief complaint of delusions and physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The undated admission orders showed she was placed on Assaultive/Violence precautions and Observation every 15-minutes. Review of three undated "Close Observation" forms showed missed 15-minute observations beginning at 4:15 AM and the next observation was documented at 4:45 AM, 30 minutes later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 18.


Review of Patient 19's current medical record on 04/27/19 showed he was admitted on 04/16/19 with a diagnosis of delusional disorder and anxiety. Review of the psychiatric evaluation dated 04/18/19 showed a chief complaint of physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation. The admission orders dated 04/16/18 showed he was placed on Assaultive/Violence precautions with every 15-minute observation. Review of a "Close Observation" form dated 04/23/19 showed missed observations beginning at 5:45 PM when he was in the day room and the next observation was at 7:19 PM in the hall, one hour and 19 minutes later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 19.


Review of Patient 20's current medical record on 04/27/19, showed he was admitted on 04/10/19, with a diagnosis of delusional disorder and anxiety. Review of the psychiatric evaluation dated 04/11/19, showed a chief complaint of physical aggression and paranoia. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/10/19, showed he was placed on Assaultive/Violence precautions and Observation every 15-minutes. Review of a "Close Observation" form dated 04/11/19, showed missed observations beginning at 6:45 PM when he was in his room sleeping and the next documented observation was at 7:19 PM when he was in the hall, 34 minutes later. Review of a "Close Observation" form dated 04/24/19, showed missed observations when he was observed in the day room a 6:45 PM, the next observation documented was at 7:45 PM, one hour later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 20.

During an interview on 04/24/19 at 3:15 PM, Staff K, Interim DON, stated that the CNA/MHT is supposed to do 15-minute checks and then the nurse is supposed to do a walk around every hour. There shouldn't be any times that are not documented with a location and a signature.

Based on observation, document review and staff interview the hospital quality assessment performance improvement program failed to identify, act, and focus on identified high risk, high-volume problem prone areas by not including ligature risked identified in a risk assessment and infection control. This deficient practice has the potential to adversely affect all patient by putting them at risk for infections, self-harm and harm to others because of missed opportunities for improvement and change in care practices.

Findings Include:

Review of a hospital policy titled, "Risk Assessment Program" effective 09/2016 and revised 09/2016, showed: "The performance improvement program for the Safety/Environment of Care Committee is designed to monitor the level of safety compliance at the hospital, and to identify any situations that detract from the goal of providing a safe and secure environment for patients, employees, medical staff and visitors. Any risks that are identified through proactive risk assessments, environmental tours, performance measure monitoring, etc., will be evaluated, and have procedures and controls put into place to reduce to the lowest possible point the adverse impact on the safety and health of patients, personnel, medical staff, and visitors of the hospital. For those cases, where appropriate and deemed necessary, the failure mode effects and analysis process will be undertaken."

Review of a hospital notebook labeled "Risk Assessment 07/2018" on 04/30/19 at 9:00 AM showed the hospital conducted a facility wide risk assessment and identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles.

During an interview on 04/30/19 at 12:15 PM, Staff A, Registered Nurse (RN) Director of Nursing (DON), stated that she didn't know why the Governing Body didn't initiate a plan to fix the ligature risks. She stated that she still wondered how the hospital opened with those in place. When asked about the Risk Assessment 2018 notebook she stated that she thought a guy from corporate did that risk assessment in July of 2018, but I don't recall the issues being brought up during the Governing Body meetings.

Review of a hospital document titled "Black-Ops Operations and Quality, Total Quality Management System" (BTQM)" Black-Ops TQM Systems Plan" dated April 2019 showed: "Operations, quality and performance management is the practice of actively using hospital data to improve the health of patients, who require care and treatment services. A Total Quality Management (TQM) system is defined by the activities and methods that help the hospital meet its goals in the most effective and efficient manner possible. In order to achieve desired patient outcomes, the hospital focuses on improving the safety, quality and efficiency of the services, care and treatment provided. The best way to achieve desired patient outcomes is by measuring the performance of processes that support the services, and then using that data to make improvements."

Review of the plans Annual Performance Improvement Projects does not include the identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles found on the facility wide risk assessment dated 07/2018.

Review of the Quality Assessment Performance Improvement Meeting minutes dated 10/25/18, 11/15/18, 12/21/18, 01/18/19, 02/14/19, and 03/15/19 showed no discussion of the identified ligature risks in the hospital.

Document review of the hospitals policy titled, "Infection Prevention and Control Program" showed, "The facilities Infection Prevention and Control Plan ensures that this organization develops, implements and maintains and active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers, and to optimize use of resources".

Review of the hospital's "Infection Control" Binder on 04/30/2019 showed the infection control officer, Director of Nursing (DON), failed to complete employee health program information which was to include immunization and exposure information, Behavioral Health Facility Surveillance information which was to include information on Hospital Acquired Infections and Community Acquired Infections, employee education including hand hygiene, isolation precautions, prevention of urinary tract infections, cleaning techniques and other infection control education offerings, the Antibiotic and Organism Yearly Summary, the QAPI monitoring for basic disinfection, hand hygiene, patient identifiers, and the Infection control tracking reports for February 2019, March 2019, and April 2019.

Review of the hospitals QAPI report on 04/30/19 showed during the 02/14/19 and 03/15/19 meetings no infection control information was reported.

During an interview on 04/30/2019 at 12:00 PM, Staff A, DON, stated the she quit working at the hospital in February 2019 and Staff K, RN, was to be her replacement. Staff A stated that Staff K was also supposed to take over the infection control officer duties. Staff A stated, "I don't know why there is no documentation for February, March, and April". Staff A stated, "It is too much for someone to be the DON and the infection control officer".

Based on observation, document review and staff interview the hospital's Governing Body failed to ensure quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety by not including ligature risked identified in a risk assessment and infection control in ongoing quality improvement program. This deficient practice has the potential to place all patients at risk for infections, self-harm and harm to others because of missed opportunities for improvement and change in care practices.

Findings Include:

Review of a hospital document titled "Black-Ops Operations and Quality, Total Quality Management System" (BTQM)" Black-Ops TQM Systems Plan" dated April 2019 showed: "Operations, quality and performance management is the practice of actively using hospital data to improve the health of patients, who require care and treatment services. A Total Quality Management (TQM) system is defined by the activities and methods that help the hospital meet its goals in the most effective and efficient manner possible. In order to achieve desired patient outcomes, the hospital focuses on improving the safety, quality and efficiency of the services, care and treatment provided. The best way to achieve desired patient outcomes is by measuring the performance of processes that support the services, and then using that data to make improvements."

Review of a hospital policy titled, "Risk Assessment Program" effective 09/2016 and revised 09/2016, showed: "The performance improvement program for the Safety/Environment of Care Committee is designed to monitor the level of safety compliance at the hospital, and to identify any situations that detract from the goal of providing a safe and secure environment for patients, employees, medical staff and visitors. Any risks that are identified through proactive risk assessments, environmental tours, performance measure monitoring, etc., will be evaluated, and have procedures and controls put into place to reduce to the lowest possible point the adverse impact on the safety and health of patients, personnel, medical staff, and visitors of the hospital. For those cases, where appropriate and deemed necessary, the failure mode effects and analysis process will be undertaken."

Review of a hospital notebook labeled "Risk Assessment 07/2018" on 04/30/19 at 9:00 AM showed the hospital conducted a facility wide risk assessment and identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles.

Observations made during the hospital tour on 04/22/19 between 10:45 AM until 11:50 AM showed multiple ligature risks and items accessible to patients that could be used for self-harm or harm to others. These ligature risks and items accessible to patients could be used for self-harm or harm to others include the following:

Door handles of the Entrance/Exit Double Doors, have open push arms not flush with the glass doors, hinges at the top of both doors near the walls. A patient could loop a cord or other similar item around these door handles to hang themselves.

Six exit signs with large round lights on each side. A patient could loop a cord or other similar item around these exit signs to hang themselves.

Two sets double fire doors have elbow hinges at the top of both doors near the walls leaving a gap in the hinge, at the top backside of both fire doors, there are magnets that protrude out, the handles on the back side of the door are not flush with the door, latch bars that are not flush and runs vertically on each door and has a flat surface that protrudes out at the top of the door. A patient could loop a cord or other similar item around the elbow hinges, magnets, handles, and latch bars of the fire doors to hang themselves.

Eight locked doors with exterior hinges that protrude out. A patient could loop a cord or other similar item around the exterior hinges of these locked doors to hang themselves.

A water fountain with spout. A patient could loop a cord or other similar item around the spout of the water fountain to hang themselves.

Four chairs located in the hallway and 12 chairs in the dining room that are light enough to be picked up and thrown. A patient could use these chairs as a weapon to assault other patients, staff, or visitors.

Blunt solid wood handle on fire extinguisher box. A patient could loop a cord or other similar item around the wood handle to hang themselves.

An exit door at the east end of the hall between patient rooms 111 and 112 has a push arm that is not flush with the door. A patient could loop a cord or other similar item around the push arm of the exit door to hang themselves.

The top casing of the fire doors in the north hall by the nurse's station has a bar that protrudes out. A patient could loop a cord or other similar item around the bar of the fire door to hang themselves.

The shower room has two square light switch boxes, a locked, plastic storage cabinet with a break in the plastic that could be used to harm self, and a large metal cabinet with a square top. The tub has Hot and Cold-water handles, faucet and hand bar, a square wall mounted timer and laundry basket with metal wire framing and soap dispenser and paper towel dispensers. A patient could loop a cord or other similar item around the light switch boxes, the top of the large metal cabinet, the tub's hot and cold fixtures, the tub's faucet, tub's hand bar, the timer, the laundry baskets's metal frame, the soap dispenser, and the paper towel dispenser of the shower room to hang themselves. A patient could also use the break in the locked, plastic storage cabinet to cut themselves.

Observation in the dining room showed four tables light enough to be picked up and thrown, a wall mounted television, square ice machine, soap dispenser hanging on the wall, faucets, and the lower cabinets had five looping handles. A patient could loop a cord or other similar item around the wall mount of the TV, the ice machine, the soap dispenser, and the handles of the lower cabinets to hang themselves. A patient could use the tables as a weapon to assault other patients, staff, or visitors.

Eight of nine patient bathrooms had paper towel and soap dispensers hanging on the walls. A patient could loop a cord or other similar item around the paper towel and soap dispensers of these bathrooms to hang themselves.

Patient rooms 101, 107A, 107B, 110B, and 112A all had broken metal bells with sharp edges attached to the bedside tables that creates a self-injury hazard. A patient could use the sharp metal edges to cut themselves.

During an interview on 04/30/19 at 12:15 PM, Staff A, Registered Nurse (RN) Director of Nursing (DON), stated that she didn't know why the Governing Body didn't initiate a plan to fix the ligature risks. She stated that she still wondered how the hospital opened with those in place. When asked about the Risk Assessment 2018 notebook she stated that she thought a guy from corporate did that risk assessment in July of 2018, but I don't recall the issues being brought up during the Governing Body meetings.


Document review of the hospitals policy titled, "Infection Prevention and Control Program" showed, "The facilities Infection Prevention and Control Plan ensures that this organization develops, implements and maintains and active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers, and to optimize use of resources".

Review of the hospital's "Infection Control" Binder on 04/30/2019 showed the infection control officer, Director of Nursing (DON), failed to complete employee health program information which was to include immunization and exposure information, Behavioral Health Facility Surveillance information which was to include information on Hospital Acquired Infections and Community Acquired Infections, employee education including hand hygiene, isolation precautions, prevention of urinary tract infections, cleaning techniques and other infection control education offerings, the Antibiotic and Organism Yearly Summary, the QAPI monitoring for basic disinfection, hand hygiene, patient identifiers, and the Infection control tracking reports for February 2019, March 2019, and April 2019.

Observation on 04/22/19 at 10:45 AM showed a room labeled Oxygen Room which revealed an open Yankauer suction tip (airway suction device) connected to suction tubing, expired culture swabs, expired Foley catheter (devise used to remove urine from the bladder) insertion tray, fabric gait belts, a flushable basin with a greenish substance staining the basins bottom and there was no personal protective equipment (PPE), i.e. gowns, gloves, masks or goggles at the basin for staff use near the basin. There were also numerous air vents located in patient rooms and storage rooms that showed a buildup of dust/dirt.

Observation on 04/29/19 at 2:45 PM in the dining room showed Staff J, RN passing medications. Staff J put on gloves without washing her hands, poured water in a small cup, removed medications from a bin in the medication cart, she went to Patient 16, gave him the medication, took the cup back, opened the medication cart drawer, threw the cup away and removed her gloves, she then put on another pair of gloves without washing her hands. Patient 18 then came to the cart, Staff J pour water, removed medication from a bin in the medication cart, handed the medication and water to Patient 18, Staff J removed her gloves, put on a new pair without washing her hands and was going to give Patient 22 his medication but had to return to the medication room for additional medications. She removed the gloves and did not wash her hands. On her way to the medication room Staff J was approached by Staff Q, MHT, who had Patient 25 with her. Staff Q pointed out areas on Patient 25's arms that were actively bleeding. Staff J, RN touched both of Patient 25's arms, without washing her hands, to examine the areas that were bleeding. Staff J then went into the medication room, collected skin cleansing solution, non-adhesive bandages, gauze, wrap and tape from a cabinet just inside the door without washing her hands. Staff J did not wash her hands prior to putting on gloves, she then cleaned the wounds with the cleansing solution and gauze, removed her gloves, did not wash hands or put on gloves to apply the bandages to Patient 25's arms.

Review of the hospitals QAPI report on 04/30/19 showed during the 02/14/19 and 03/15/19 meetings no infection control information was reported.

During an interview on 04/30/2019 at 12:00 PM, Staff A, DON, "I don't know why there is no documentation for February, March, and April."

Based on staff interview, record review, document and policies and procedures review the hospital failed to ensure the medical staff Bylaws included a requirement for a History and Physical (H&P) to be documented in the medical record less than 30 days before admission or within 24 hours after admission.

This deficient practice has the potential to cause a disruption in the continuity of care for 11 of 20 patients (Patients 2, 3, 5, 9-11, 14-15, and 18-20) admitted between 09/01/18 to 04/22/19 which could lead to poor patient outcomes.

Findings Include:

Document review of the hospital's "Medical and Professional Staff Organization Bylaws," adopted on 12/12/16, showed the hospital failed to include a provision requiring H&Ps to be completed and documented in the medical record less than 30 days prior to admission or within 24 hours after admission.

Patient 2's medical record review showed he was admitted on 03/28/19 and a H&P transcription was not completed for placement in the medical record until 04/01/19 which is greater than 24-hours after admission.

Patient 3's medical record review showed he was admitted on 03/26/19 and a H&P transcription was not completed for placement in the medical record until 03/28/19 which is greater than 24-hours after admission.

Patient 5's medical record review showed he was admitted on 09/24/18 and a H&P was signed and dated 09/28/18 which is greater than 24-hours after admission.

Patient 9's medical record review showed he was admitted on 02/08/19 and a H&P transcription was not completed for placement in the medical record until 02/10/19 which is greater than 24-hours after admission.

Patient 10's medical record review showed he was admitted on 03/22/19 and a H&P transcription was not completed for placement in the medical record until 03/24/19 which is greater than 24-hours after admission.

Patient 11's medical record review showed he was admitted on 04/08/19 and a H&P transcription was not completed for placement in the medical record until 04/10/19 which is greater than 24-hours after admission.

Patient 14's medical record review showed he was admitted on 04/18/19 and a H&P transcription was not completed for placement in the medical record until 04/22/19 which is greater than 24-hours after admission.

Patient 15's medical record review showed he was admitted on 04/19/19 and a H&P transcription was not completed for placement in the medical record until 04/22/19 which is greater than 24-hours after admission.

Patient 18's medical record review showed he was admitted on 04/18/19 and a H&P transcription was not completed for placement in the medical record until 04/22/19 which is greater than 24-hours after admission.

Patient 19's medical record review showed he was admitted on 04/16/19 and a H&P transcription was not completed for placement in the medical record until 04/18/19 which is greater than 24-hours after admission.

Patient 20's medical record review showed he was admitted on 04/10/19 and a H&P transcription was not completed for placement in the medical record until 04/12/19 at 11:23 AM which is greater than 24-hours after admission.

During an interview on 04/30/19 at 1:15 PM, Staff R, Medical Records, stated the expectation is that the providers must complete the history and physicals within 24-hours of the patient's admission. Staff R further stated that the providers complete the H&P and then it is sent for dictation prior to being placed into the medical record.

Based on interview, record review and policy review the hospital failed to ensure nursing staff develops, and keeps current, a nursing care plan for 10 of 14 patients (Patients 1, 2, 3, 4, 5, 6, 7, 10, 13, and 14). The hospital's failure to ensure nursing staff develops, and keeps current, a nursing care plan for each patient has the potential for patients to fail to have accurate assessments and interventions to meet their health care and recovery needs resulting in falls, harm, injury, poor discharge planning and poor health outcomes.

Findings Include:

Document review of the Hospital's policy titled, "Plan of Care," dated 11/16, showed ...every patient shall have an individualized comprehensive plan of care ...the needs, strengths, preferences and goals of the patient are identified based on the screening and assessment, and are used in the plan for care, treatment of services ...the plan for care includes goals expressed in a manner that captures the patient's words or ideas, build on the patient's strengths, and supports the transition to community integration as a need during assessment ...objectives include identified steps to achieve goals, are sufficiently specific to assess the progress of the individual served, are in terms that provide indices of progress ...goals and objectives will be reevaluated and as necessary, revised based on changes in the patient's condition, problems, needs and responses to care, treatment and services.

Document review of the Master Treatment Plan of Care showed:

Patient 1's treatment team goals were to verbalize need to request assistance to prevent falls within seven days, demonstrate proper transfer techniques within seven days, and demonstrate use of call bell within seven days.
Review of medical record failed to show the nursing staff assessed and documented progress toward the goals and intervention. Final documentation failed to show if the goals were met upon discharge.

Patient 2's treatment team goals were to verbalize need to request assistance to prevent falls within seven days, demonstrate proper transfer techniques within seven days, and demonstrate use of call bell within seven days.

Review of medical record failed to show the nursing staff assessed and documented progress toward the goals and intervention. Final documentation shows the goals were deferred.

Patient 3's treatment team goals were to demonstrate proper transfer techniques within seven days and demonstrate use of call bell within seven days.

Review of medical record failed to show the nursing staff assessed and documented progress toward the goals and intervention. Final documentation shows the goals were deferred.

Patient 4's treatment team goal was to have no falls as evidenced by providing insight on fall precautions by 12/02/19.

Review of medical record failed to show the nursing staff assessed and documented progress toward the goals and intervention. Final documentation failed to show if the goals were met upon discharge.

Patient 5's treatment team care plan showed falls were listed as a problem upon admission 11/26/19. The facility failed to provide the goals and resolution of goals upon record request.

Patient 6's treatment team goal was patient will remain free from falls or injury while inpatient for seven days. Final documentation failed to show if the goals were met upon discharge.

Patient 7's treatment team goals were to verbalize need to request assistance to prevent falls within seven days, demonstrate proper transfer techniques within seven days, demonstrate use of call bell within seven days, and patient will have no falls during hospital stay for 12 days.
Review of medical record failed to show the nursing staff assessed and documented progress toward the goals and intervention. Final documentation showed the goals were resolved on 10/22/19.

Patient 10's treatment team care plan showed falls were not addressed or included on the care plan after the initial fall assessment upon admission showing she was a fall risk.

Patient 13's treatment team goals failed to be provided by the facility. Her score upon admission showed she was a fall risk.

Patient 14's treatment team goals were to verbalize need to request assistance to prevent falls within seven days and demonstrate use of call bell within seven days.
Review of medical record failed to show the nursing staff assessed and documented progress toward the goals and intervention.

During an interview on 12/23/19 at 4:42 PM, Staff B, Director of Nursing (DON) verified the treatment plans of care failed to be completed on all the patients and the resolutions were not always marked appropriately.

Based on medical record review, policy review and staff interview the hospital failed to ensure that verbal orders were used infrequently for 20 of 20 (Patient 1-20) medical records reviewed.

This deficient practice has the potential to cause a miscommunication which could lead to patient harm.

Finding Include:

Document review of the hospital's policy titled, "Verbal and Written Orders" revised on 11/16 showed, "verbal/telephone orders shall be used infrequently".

Review of Patient 1's discharged medical record on 04/23/19 showed they were admitted on 09/01/18 and discharged on 09/05/18. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of 16 orders with 12 of them documented as verbal orders. (75% of the orders were verbal).

Review of Patient 2's discharged medical record on 04/26/19 showed they were admitted on 03/28/19 and discharged on 04/11/19. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of 11 orders with seven of them documented as verbal orders. (63% of the orders were verbal).

Review of Patient 3's current medical record on 04/24/19 showed they were admitted on 03/26/19. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of 21 orders with 17 of them documented as verbal orders. (81% of the orders were verbal).

Review of Patient 4's discharged medical record on 04/23/19 showed they were admitted on 03/02/19 and discharged on 04/09/19. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of 19 orders with 12 of them documented as verbal orders. (63% of the orders were verbal).

Review of Patient 5's discharged medical record on 04/26/19 showed they were admitted on 09/24/18 and discharged on 10/08/18. Review of documents titled, "Physician's Orders" " and "Admit Orders/ Preliminary Plan of Care" showed a total of four orders with all four of them documented as verbal orders. (100% of the orders were verbal).

Review of Patient 6's discharged medical record on 04/24/19 showed they were admitted on 10/19/18 and discharged on 11/02/18. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of 11 orders with seven of them documented as verbal orders. (64% of the orders were verbal).

Review of Patient 7's discharged medical record on 04/26/19 showed they were admitted on 11/05/18 and discharged on 11/30/18. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of three orders with two of them documented as verbal orders. (66% of the orders were verbal).

Review of Patient 8's discharged medical record on 04/24/19 showed they were admitted on 08/06/18 and discharged on 08/21/18. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of nine orders with eight of them documented as verbal orders. (89% of the orders were verbal).

Review of Patient 9's discharged medical record on 04/26/19 showed they were admitted on 02/08/19 and discharged on 02/20/19. Review of documents titled, " Physician's Orders" and "Admit Orders/Preliminary Plan of Care, showed a total of nine orders with six documented as verbal orders. (66% of the orders were verbal).

Review of Patient 10's discharged medical record on 04/29/19 showed they were admitted on 03/22/19 and discharged on 04/10/19. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of seven orders with five of them documented as verbal orders. (71% of the orders were verbal).

Review of Patient 11's discharged medical record on 04/26/19 showed they were admitted on 04/08/19 and discharged on 04/16/18. Review of documents titled, "Physician's Orders" and "Admit Orders/Preliminary Plan of Care" showed a total of seven orders with five documented as verbal orders. (71% of the orders were verbal).

Review of Patient 12's current medical record on 04/27/19 showed they were admitted on 04/13/19. Review of documents titled, "Physician's Orders" and "Admit Orders/Preliminary Plan of Care" showed a total of eight orders with four documented as verbal orders. (50% of the orders were verbal).

Review of Patient 13's current medical record on 04/30/19 showed they were admitted on 04/12/19. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of ten orders with nine of them documented as verbal orders. (90% of the orders were verbal).

Review of Patient 14's current medical record on 04/30/19 showed they were admitted on 04/18/19. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of nine orders with six of them documented as verbal orders. (67% of the orders were verbal).

Review of Patient 15's current medical record on 04/27/19 showed they were admitted on 04/19/19. Review of documents titled, "Physician's Orders" and "Admit Orders/Preliminary Plan of Care" showed a total of five orders with five documented as verbal orders. (100% of the orders were verbal).

Review of Patient 18's current medical record on 04/27/19 showed they were admitted on 04/18/19. Review of documents titled, "Physician's Orders" and "Admit Orders/Preliminary Plan of Care" showed a total of 15 orders with eight documented as verbal orders. (53% of the orders were verbal).

Review of Patient 19's current medical record on 04/27/19 showed they were admitted on 04/16/19. Review of documents titled, "Physician's Orders" and "Admit Orders/Preliminary Plan of Care" showed a total of four orders with three documented as verbal orders. (75% of the orders were verbal).

Review of Patient 20's current medical record on 04/27/19 showed they were admitted on 04/10/19. Review of documents titled, "Admit Orders/Preliminary Plan of Care" showed a total of 11 orders with eight documented as verbal orders. (72% of the orders were verbal).

During an interview on 04/30/19 at 12:00 PM, Staff A, Director of Nursing (DON), stated, "The providers use a lot of verbal orders". Staff A stated that she believed that The Joint Commission required them to use verbal orders 10% or less. Staff A stated that she doesn't know if anyone had told the providers to limit their use of verbal orders.

During an interview on 04/29/19 at 3:15 PM, Staff D, Advanced Practice Registered Nurse (APRN), stated, "I try to write most of my orders when I am here to reduce verbal orders and I make the nurse read it back to me". Staff D stated that Staff E, Physician, has more verbal orders because he is here through telemedicine and Staff F, Physician, does give a lot of verbal orders as well.

During an interview on 04/30/19 at 1:15 PM, Staff R, Medical Records, stated, "I didn't know there should be a limit on verbal orders. I have not spoken to the providers about it".

Based on staff interview, record review, document and policies and procedures review the hospital failed to ensure verbal orders were completed timely for nine of 10 discharged patients (Patients 1, 2, 4-8, 10, and 11) sampled medical records between 09/01/18 to 04/22/19.

Failure to review, sign, and date verbal orders promptly has the potential to cause errors to remain unidentified which could lead to patient harm.

Findings Include:

Document review of hospital policy titled, "Verbal and Written Orders," revised on 11/16, showed, "Verbal orders, including telephone orders, should include the date and signature of the person recording them. The prescribing or covering practitioner should authenticate the order within 72-hours of the patient's discharge or 30-days, whichever occurs first. Records of patient's discharged should be completed within 30-days following discharge.


Review of Patient 1's discharged medical record on 04/23/19 showed she was admitted on 09/01/18 and discharged on 09/05/18 and the following:

Staff F, Physician gave verbal orders on 09/02/18 for Progesterone (a hormone supplement) with no substitutions. Staff F failed to time and date the order as of 04/23/19 (230 days after discharge).

Staff F, Physician gave a clarification order for Flonase (a nasal spray used to treat allergy symptoms) on 09/02/18 and an order to discontinue loratadine (an allergy medication) and to start Zyrtec (an allergy medication). Staff F signed the order on 09/19/18 which is 14 days after discharge. Staff F failed to ensure verbal orders
Staff U, Physician gave verbal orders on 09/01/19 for admission and preliminary plan of care. Staff U failed to time and date the order as of 04/23/19 (230 days after discharge).


Review of Patient 2's discharged medical record on 04/22/19 showed he was admitted on 03/28/19 and discharged on 04/11/19 showed the following:

Staff H, Advanced Practice Registered Nurse (APRN) gave a verbal order on 04/10/19 to discharge Patient 2 on 04/10/19. The order remained unsigned as of 04/22/19 (11 days after discharge).

Staff E, Physician gave a verbal order on 04/11/19 to discharge Patient 2 on 04/11/19. The order remained unsigned as of 04/22/19 (11 days after discharge).

Staff F, Physician gave a verbal order on 04/10/19 requesting a nursing home placement for Patient 2 on 04/10/19. The order remained unsigned as of 04/22/19 (11 days after discharge).

Staff F, Physician gave a verbal order on 04/03/19 for Flomax (a medication used to treat an enlarges prostate). The order remained unsigned as of 04/22/19 (11 days after discharge).

Staff F, Physician gave a verbal order on 03/28/19 medically clearing Patient 2 for admission. The order remained unsigned as of 04/22/19 (11 days after discharge).


Review of Patient 2's, "Reconcile Home Medication and Physician Order Form," showed Staff H gave a verbal order on 03/28/19 to discontinue the following medications: Hydroxyzine (used to treat itching caused by allergies), Lexapro (used to treat depression and anxiety), and Seroquel (used to treat symptoms of schizophrenia), Alirocumab (used to treat high cholesterol). The order remained unsigned as of 04/22/19 (11 days after discharge).

Review of Patient 2's, "Admit Orders/Preliminary Plan of Care," showed Staff E gave a verbal order for the prescribed plan of care on 03/28/19. Staff E failed to sign the verbal order as of 04/22/19 (11 days after discharge).


Review of Patient 4's discharged medical record on 04/23/19 showed she was admitted on 03/02/19 and discharged on 04/09/19 and the following:

Staff F, Physician gave a verbal order on 03/02/19 to medically clear Patient 4 for admission. Staff F failed to sign the verbal order as of 04/23/19. (14 days after discharge).

Staff F, Physician gave a verbal order on 03/16/19 for Lisinopril (a blood pressure medication). Staff Failed to sign the verbal order as of 04/23/19. (14 days after discharge).

Staff E, Physician gave a verbal order on 03/12/19 for Patient 4's discharge. Staff E failed to sign the verbal order as of 04/23/19 (14 days after discharge).

Staff F, Physician gave a verbal order on 03/08/19 for Diflucan (a medication used to treat yeast infections). Staff F failed to sign the verbal order as of 04/23/19. (14 days after discharge).

Staff F, Physician gave a verbal order on 03/06/19 for a culture of an abdominal wound. Staff F failed to sign the verbal order as of 04/23/19. (14 days after discharge).

Staff F, Physician gave a verbal order on 03/16/19 to discontinue Lisinopril (a medication used to treat high blood pressure). Staff F failed to sign verbal orders order as of 04/23/19. (14 days after discharge).

Staff F, Physician gave a verbal order on 04/09/19 to discharge Patient 4. Staff F failed to sign the order as of 04/23/19. (14 days after discharge).

Staff E, Physician gave a verbal order on 04/09/19 to discharge Patient 4. Staff F failed to sign the order as of 04/23/19. (14 days after discharge).


Review of Patient 5's discharged medical record on 04/22/19 showed he was admitted on 09/24/19 and discharged on 10/08/18 and the following:

Staff F, Physician gave a verbal order on date? for Aspirin 81 milligrams daily. The order was signed and dated on 10/31/18. (23 days after discharge).


Review of Patient 6's discharged medical record on 04/22/19 showed she was admitted on 10/19/18 and discharged on 11/02/18 and the following:

Staff F, Physician gave a verbal order on 10/29/18 for a nicotine patch for Patient 6. Staff F signed the order on 12/12/18. (40 days after discharge).

Staff F, Physician gave a verbal order on 10/30/18 to hold the medication Humalog (insulin used to treat diabetes) on 10/28/18 only. Staff F signed the order on 12/12/18. (40 days after discharge).

Staff F, Physician gave a verbal order on 10/31/18 to give 8 units of Humalog with 16 units as a one-time dose. Staff F signed the order on 12/12/18. (40 days after discharge).


Review of Patient 7's discharged medical record on 04/22/19 showed she was admitted on 11/05/18 and discharged on 11/30/18 and the following:

Staff F, Physician, gave a verbal order for no medication substitutions for Sodium Bicarbonate (a medication used to reduce heartburn). Staff F failed to time and date the order as of 04/22/19. (143 days after discharge).


Review of Patient 8's discharged medical record on 04/22/19 showed she was admitted on 08/06/18 and discharged on 08/21/18 and the following:

Staff F, Physician gave a verbal order on 08/10/19 for performing a straight catheterization to obtain a urine sample on Patient 8. Staff F signed the verbal order on 09/19/18. (31 days after discharge).


Review of Patient 10's discharged medical record on 04/22/19 showed he was admitted on 03/22/19 and discharged on 04/10/19 and the following:

Unidentified Staff on 04/07/19 gave a verbal order for Patient 10's discharge. Unidentified Staff failed to sign the verbal order as of 04/22/19. (12 days after discharge).

Staff H, Advanced Practice Registered Nurse (APRN) gave a verbal order on 04/10/19 to discharge Patient 10. Staff H failed to sign the verbal order as of 04/22/19. (12 days after discharge).

Staff E, Physician gave a verbal order on 03/22/19 to admit Patient 10. Staff H, APRN signed the verbal order and failed to time and date the order as of 04/22/19. (12 days after discharge). Staff E failed to sign the order as of 04/22/19. (12 days after discharge).

Staff F, Physician gave a verbal order on 04/05/19 for laboratory studies. Staff F failed to sign and date the order as of 04/22/19. (12 days after discharge).

Staff H, Advanced Practice Registered Nurse (APRN) gave a verbal order on 03/31/19 to increase Risperdal (a medication used to treat mood disorders). Staff H failed to sign the verbal order as of 04/22/19. (12 days after discharge).


Review of Patient 11's discharged medical record on 04/22/19 showed he was admitted on 04/08/19 and discharged on 04/16/19 and the following:

Staff E, Physician gave a verbal order for Patient 11 to be discharged on 04/16/19. Staff E failed to sign the order as of 04/22/19. (6 days after discharge).

Staff H, Advanced Practice Registered Nurse (APRN) gave a verbal order on 04/10/19 to discontinue two medications, Anbesol (a medication used to treat tooth pain) and Linagliptin (a medication used to treat diabetes) and add two medications, Januvia (a medication used to treat diabetes) and Isosorbide (a medication used to prevent chest pain). Staff H failed to sign the verbal order as of 04/22/19. (6 days after discharge).

Staff E, Physician gave a verbal order for Patient 11's discharge on 04/16/19. Staff E failed to sign the order as of 04/22/19. (6 days after discharge).

During an interview on 04/30/19 at 1:15 PM, Staff A, CEO, stated, "In our policies the providers are required to sign orders within 72 hours after discharge or 30-days whichever comes first".

Based on staff interview, record review, document and policies and procedures review the hospital failed to ensure providers completed a medical history and physical examination (H&P) and placed it in the medical record within 24 hours after admission for 11 of 20 sampled patients (Patient 2, 3, 5, 9-11, 14-15, and 18-20) admitted between 09/01/18 to 04/22/19.

This deficient practice has the potential to cause a disruption in the continuity of care which could lead to poor patient outcomes.

Findings Include:

Document review of hospital's policy titled, "Medical Record Content Policy," revised on 12/16, showed providers are to perform a physical health examination within 24-hours of admission or sooner as appropriate to the physical health needs of the patient.

Document review of the hospital's "Medical and Professional Staff Organization Bylaws," adopted on 12/12/16, showed the hospital failed to include a provision requiring H&P's to be completed and documented in the medical record less than 30 days prior to admission or within 24 hours after admission.

Patient 2's medical record review showed he was admitted on 03/28/19 and a H&P transcription was not completed for placement in the medical record until 04/01/19 which is greater than 24-hours after admission.

Patient 3's medical record review showed he was admitted on 03/26/19 and a H&P transcription was not completed for placement in the medical record until 03/28/19 which is greater than 24-hours after admission.

Patient 5's medical record review showed he was admitted on 09/24/18 and a H&P was signed and dated 09/28/18 which is greater than 24-hours after admission.

Patient 9's medical record review showed he was admitted on 02/08/19 and a H&P transcription was not completed for placement in the medical record until 02/10/19 which is greater than 24-hours after admission.

Patient 10's medical record review showed he was admitted on 03/22/19 and a H&P transcription was not completed for placement in the medical record until 03/24/19 which is greater than 24-hours after admission.

Patient 11's medical record review showed he was admitted on 04/08/19 and a H&P transcription was not completed for placement in the medical record until 04/10/19 which is greater than 24-hours after admission.

Patient 14's medical record review showed he was admitted on 04/18/19 and a H&P transcription was not completed for placement in the medical record until 04/22/19 which is greater than 24-hours after admission.

Patient 15's medical record review showed he was admitted on 04/19/19 and a H&P transcription was not completed for placement in the medical record until 04/22/19 which is greater than 24-hours after admission.

Patient 18's medical record review showed he was admitted on 04/18/19 and a H&P transcription was not completed for placement in the medical record until 04/22/19 which is greater than 24-hours after admission.

Patient 19's medical record review showed he was admitted on 04/16/19 and a H&P transcription was not completed for placement in the medical record until 04/18/19 which is greater than 24-hours after admission.

Patient 20's medical record review showed he was admitted on 04/10/19 and a H&P transcription was not completed for placement in the medical record until 04/12/19 at 11:23 AM which is greater than 24-hours after admission.

During an interview on 04/30/19 at 1:15 PM, Staff R, Medical Records, stated the expectation is that the providers must complete the history and physical within 24-hours of the patient's admission. Staff R further stated that the providers complete the H&P and then it is sent for dictation prior to being placed into the medical record.

Based on staff interview, record review, document and policies and procedures review the hospital failed to ensure to complete medical records within 30 days following discharge for five of 10 discharged patients (Patients 1, and 6-9) sampled medical records between 09/01/18 to 04/22/19.

This deficient practice has the potential to cause a lack of continuity of care for patients discharged from the hospital.


Findings Include:

Document review of the hospital's "Medical and Professional Staff Organization Bylaws," adopted on 12/12/16, showed, "Practitioners must complete their patients' medical records within 30-days of each patients discharge." Medical Records Manager shall notify the practitioner of the delinquency and they will have five days to complete the medical record or they will be automatically suspended.

Document review of hospital policy titled, "Verbal and Written Orders," revised on 11/16, showed, "Verbal orders, including telephone orders, should include the date and signature of the person recording them. The prescribing or covering practitioner should authenticate the order within 72-hours of the patient's discharge or 30-days, whichever occurs first. Records of patient's discharged should be completed within 30-days following discharge".

Review of Patient 1's discharged medical record on 04/23/19 showed she was admitted on 09/01/18 and discharged on 09/05/18 and the following:

Staff F, Physician gave verbal orders on 09/02/18 for Progesterone (a hormone supplement) with no substitutions. Staff F failed to time and date the order within 30-days after discharge.

Staff U, Physician gave verbal orders on 09/01/19 for admission and preliminary plan of care. Staff U failed to time and date the order within 30-days after discharge.


Review of Patient 6's discharged medical record on 04/22/19 showed she was admitted on 10/19/18 and discharged on 11/02/18 and the following:

Staff F, Physician gave a verbal order on 10/29/18 for a nicotine patch for Patient 6. Staff F signed the order on 12/12/18. (40 days after discharge).

Staff F, Physician gave a verbal order on 10/30/18 to hold the medication Humalog (insulin used to treat diabetes) on 10/28/18 only. Staff F signed the order on 12/12/18. (40 days after discharge).

Staff F, Physician gave a verbal order on 10/31/18 to give 8 units of Humalog with 16 units as a one-time dose. Staff F signed the order on 12/12/18. (40 days after discharge).


Review of Patient 7's discharged medical record on 04/22/19 showed she was admitted on 11/05/18 and discharged on 11/30/18 and the following:

Staff F, Physician gave a verbal order on 11/08/18 for no medication substitutions for Sodium Bicarbonate (a medication used to reduce heartburn). Staff F failed to time and date the order within 30-days after discharge. (143 days).


Review of Patient 8's discharged medical record on 04/22/19 showed she was admitted on 08/06/18 and discharged on 08/21/18 and the following:

Staff F, Physician gave a verbal order on 08//10/19 for performing a straight catheterization to obtain a urine sample on Patient 8. Staff F signed the verbal order on 09/19/18. (31 days after discharge).


Review of Patient 9's discharged medical record on 04/22/19 showed he was admitted on 02/08/19 and discharged on 02/20/19 and the following:

Staff H, Advanced Practice Registered Nurse (APRN), gave a verbal order on 02/14/19 to discontinue memantine (a medication used to treat moderate to severe confusion). Staff H failed to time and date the order within 30-days after discharge. (60 days).

Staff H, APRN, gave a verbal order on 02/08/19 for acetaminophen (Tylenol, a medication used to treat pain) and Florinef (a medication used to treat conditions where the body does not produce enough steroids). Staff H failed to time and date the order within 30-days after discharge. (60 days).


During an interview on 04/30/19 at 1:15 PM, Staff R, Medical Records, stated, "In our policies the providers should be suspended if they haven't signed their orders within 30 days. We haven't enforced that here, but we may have to start doing that".

Based on observation, staff interview, and review of the hospital policies and procedures the hospital failed to ensure expired supplies were removed from patient use, failed to ensure that staff members (Staff J, RN) properly donned personal protective equipment (PPE) when providing wound care for one of one patients (Patient 25) and when passing medications for seven of seven patients (Patient 16, 17, 18, 22, 25, 26, and 27), failed to ensure one of one flushable basins and three of three observed air vents were clean, failed to ensure initial health examinations were completed for four of ten personnel records reviewed (Staff I, J, L, and Q), failed to ensure periodic health evaluations were completed for four of ten personnel records reviewed (Staff C, K, O, and P) , failed to ensure tuberculin (TB) skin tests or chest x-rays were completed for four of ten personnel records reviewed (Staff I, J, L, and Q) during new hire orientation; failed to ensure a TB test was provided annually for one of ten personnel files reviewed (Staff K); and failed to ensure immunization history for eight of ten personnel records reviewed (Staff C, I, J, K, L, M, N, and Q).

These deficient practices place all patients and staff at risk of infection, illness, and communicable diseases.

Findings Include:


Document review of the hospitals policy titled, "Infection Prevention and Control Program" showed, "The facilities Infection Prevention and Control Plan ensures that this organization develops, implements and maintains and active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers, and to optimize use of resources".

Review of the hospital's "Infection Control" Binder on 04/30/2019 showed the infection control officer, Director of Nursing (DON), failed to complete employee health program information which was to include immunization and exposure information, Behavioral Health Facility Surveillance information which was to include information on Hospital Acquired Infections and Community Acquired Infections, employee education including hand hygiene, isolation precautions, prevention of urinary tract infections, cleaning techniques and other infection control education offerings, the Antibiotic and Organism Yearly Summary, the QAPI monitoring for basic disinfection, hand hygiene, patient identifiers, and the Infection control tracking reports for February 2019, March 2019, and April 2019.
Review of the hospitals QAPI report on 04/30/19 showed during the 02/14/19 and 03/15/19 meetings no infection control information was reported.


Document review of the hospital's policies and procedures on 04/30/19 showed the hospital failed to provide a policy that directed staff to dispose of expired supplies.

Observation on 04/22/19 at 10:45 AM showed a room labeled Oxygen Room which revealed the following:

1. One open Yankauer (airway suction device) with packaging that states it is a single use sterile item. The Yankauer was open and connected to suction tubing which made it no longer sterile and unable to verify if had been used.

During an interview on 04/22/19 at 10:45 AM, Staff A, DON, stated, "I don't know why someone would have done that. Maybe they thought they were supposed to".

2. One StartSwab II (a culture swab) with an expiration date of 02/01/19

3. One Foley catheter tray (a device used to remove urine from the bladder) with an expiration date of 02/2018.

4. Three fabric gait belts with obvious signs of dirt and wear.

During an interview on 04/22/19 at 10:45 AM, Staff A, DON, stated, "I don't know why those are even up there. Yes, staff must have used those, and they should have thrown them away. We do not launder them we use them on a specific patient and throw them away when they are discharged".


5. One flushable basin with a greenish substance staining the basins bottom, and there was no PPE, i.e. gowns, gloves, masks or goggles at the basin for staff use.

During an interview on 04/22/19 at 10:45 AM Staff B, CEO, stated that he did not know what the greenish substance in the basin was and stated, "I think the housekeepers are responsible for cleaning that, but I am not sure."


6. Air vent located directly outside the Oxygen Room showed to have a buildup of dust/dirt.

During an interview on 04/22/19 at 11:00 AM, Staff A, DON, stated, "that really looks bad and should have been cleaned". Staff A stated that Staff T, Environmental of Care (EOC) Director, is responsible for providing oversight of the housekeeping staff.


Observation on 04/22/19 at 11:00 AM showed a room identified as the Seclusion Room with an air vent containing a buildup of dust/dirt.

Observation on 04/22/19 at 11:15 AM showed a room identified as the Shower Room with an air vent containing a buildup of dust/dirt.

During an interview on 04/30/19 at 8:15 AM Staff T, EOC Director, stated that he does two environmental rounds per day to make sure things are clean. Staff T stated that he just seen the greenish growth in the bottom of the flushable basin the other day and did not know what it was. Staff T stated that the housekeepers should have been cleaning that along with the mental health technicians who use also use the basin. Staff T stated that he had noticed that the vents thought out the hospital were dirty and "he needed to get on that".


Document review of a hospital policy titled, "Hand Hygiene - CDC Guidelines" dated effective 09/2016 and revised 11/2016 showed: "To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections." ..."All staff will use the hand-hygiene techniques, as set forth in the following procedure." ..."Before each patient encounter" ..."After coming in contact with patient intact skin, i.e., taking a patient's blood pressure, pulse, lifting/moving the patient." ..."Always after removing gloves or facemasks." ..."Always follow standard precautions." ...Gloves are to be worn when contact with blood, bodily fluids, mucous membranes, dressings, non-intact skin, etc., is anticipated."

Observation on 04/29/19 at 2:45 PM in the dining room showed Staff J, RN passing medications. Staff J put on gloves without washing her hands, poured water in a small cup, removed medications from a bin in the medication cart, she went to Patient 16, gave him the medication, took the cup back, opened the medication cart drawer, threw the cup away and removed her gloves, she then put on another pair of gloves without washing her hands. Patient 18 then came to the cart, Staff J pour water, removed medication from a bin in the medication cart, handed the medication and water to Patient 18, Staff J removed her gloves, put on a new pair without washing her hands and was going to give Patient 22 his medication but had to return to the medication room for additional medications. She removed the gloves and did not wash her hands. On her way to the medication room Staff J was approached by Staff Q, MHT, who had Patient 25 with her. Staff Q pointed out areas on Patient 25's arms that were actively bleeding. Staff J, RN touched both of Patient 25's arms, without washing her hands, to examine the areas that were bleeding. Staff J then went into the medication room, collected skin cleansing solution, non-adhesive bandages, gauze, wrap and tape from a cabinet just inside the door without washing her hands. Staff J did not wash her hands prior to putting on gloves, she then cleaned the wounds with the cleansing solution and gauze, removed her gloves, did not wash hands or put on gloves to apply the bandages to Patient 25's arms.

During an interview on 04/29/19 at 3:10 PM, Staff J, RN stated that she thought the policy for hand hygiene was to wash between, before and after each patient and stated, "but I don't know their policy."

Continued observation showed that Staff J washed her hands in the dining room sink after she was asked about the hand hygiene policy. She then passed medications to Patients 17, 22, 25, 26 and 27 without washing her hands between each patient.

During an interview on 04/29/19 at 3:20 PM, Staff J, RN, was asked why she didn't perform hand hygiene between each patient she stated that she had not touched the pills with her hands.

During an interview on 04/30/19 at 12:15 PM, Staff A, DON stated that hand hygiene is required to be done between each patient when passing medications and between glove changes.

During an interview on 04/30/2019 at 12:00 PM, Staff A, DON, stated the she quit working at the hospital in February 2019 and Staff K, RN, was to be her replacement. Staff A stated that Staff K was also supposed to take over the infection control officer duties. Staff A stated, "I don't know why there is no documentation for February, March, and April". Staff A stated, "It is too much for someone to be the DON and the infection control officer".



Document review of the hospital's policies and procedures on 04/30/19 showed the hospital failed to provide a policy for initial and periodic health examinations.

Document review of the hospital's policies and procedures on 04/30/19 showed the hospital failed to provide a policy for immunization history of personnel.

Review of hospital documents titled "Job Description" with revision date of 10/01/17 showed: "Job Title: Director of Nursing" (DON) "The employee must provide documentation of a tuberculosis test during new hire orientation and annually thereafter." "Job Title: Registered Nurses" "The employee must provide documentation of a tuberculosis test during new hire orientation and annually thereafter." "Job Title: Licensed Practical Nurses," "The employee must provide documentation of a tuberculosis test during new hire orientation and annually thereafter." "Job Title: Mental Health Technician" "The employee must provide documentation of a tuberculosis test during new hire orientation and annually thereafter."

Review of Staff C, Mental Health Technician's (MHT) personnel file showed a hire date of 05/18/18. There was no evidence of periodic health examination or immunization history in the personnel file.

Review of Staff I, Registered Nurse's (RN) personnel file showed a hire date of 12/27/18. There was no evidence of an initial health examination, immunization history, or TB testing in the personnel file.

Review of Staff J, RN's personnel file showed a hire date of 04/19/19. There was no evidence of an initial health examination, immunization history, or TB (tuberculosis) testing in the personnel file.

Review of Staff K, RN, interim Director of Nursing's (DON) personnel file showed a hire date of 09/27/17. There was no evidence of a periodic health assessment, immunization history, or an annual TB test in the personnel file.

Review of Staff L, Licensed Practical Nurses (LPN) personnel file showed a hire date of 12/04/18. There was no evidence of an initial health examination, immunization history, or a TB test in the personnel file.

Review of Staff O, MHT's personnel file showed a hire date of 01/27/17. There was no evidence of a periodic health assessment or immunization history in the personnel file.

Review of Staff P, MHT's personnel file showed a hire date of 05/17/17. There was no evidence of a periodic health assessment or immunization history in the personnel file.

Review of Staff Q, MHT's personnel file showed a hire date of 04/09/19. There was no evidence of an initial health examination, immunization history, or TB test in the personnel file.

During an interview on 04/30/19 at 9:00 AM, Staff S, Human Resource Director (HR) stated that periodic health assessments are due annually.

During an interview on 04/30/19 at 9:00 AM, Staff S, Human Resource Director (HR) stated that staff need an initial health exam and immunizations record in their personnel file.

During an interview on 04/30/19 at 10:15 AM Staff B, Chief Executive Officer stated that he wasn't aware of the need for immunization records.

Based on observation, medical record review, and interview, the facility failed to ensure that psychiatric patient care was provided, directed and consistently supervised by a physician for nine (9) of nine (9) patients in the active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) and five (5) non-sample active patients (A4, A7, A11, A12, and A16) added to review progress notes. Specifically, the facility had no on-site physician to (1) provide on-site psychiatric treatment and care of patients; (2) complete and review psychiatric evaluations to determine treatment and diagnoses; (3) direct and supervise the development, revision, and modification of treatment plans; and (4) document and review patients' progress. Instead, the only patient contact by a physician for psychiatric treatment was via electronic telecommunication (a telemedicine process) once a week for approximately five (5) to ten minutes per patient. Without the on-site provision of psychiatric care, supervision and direction of the development, review, and update of the patients' treatment plans by a physician, the patients' recovery may be comprised potentially delaying their timely discharge.

Findings include:

1. During an observation on the unit on 4/22/19 at approximately 10:30 a.m., the surveyors asked about the physician responsible for providing psychiatric care. RN1 stated that they contact the physician (the psychiatrist), if needed via phone but usually talked to the Advanced Practice Registered Nurse (APRN) generally via phone.

2. In an interview on 4/22/19 at 12:30 p.m., the Chief Executive Officer (CEO) stated that the physician (psychiatrist), who was also the Medical Director, was available via telemedicine on Tuesdays for the weekly treatment team meeting.

3. Review of the CMS Medical Staffing form prepared by hospital staff and signed 4/24/19 by the Medical Director via DocuSign, noted a total of ".1 [one tenth full-time equivalent] physicians" on staff, which represented telemedicine contact once per week starting at 1:00 each Tuesday and on-call coverage when the APRN was not available. The form also showed a total of ".4 [four-tenths full-time equivalent] Advanced Practice Registered Nurse," which represented on-site coverage two days per week and on-call coverage when assigned. This staffing pattern resulted in five days during the weekdays that there was no on-site physician coverage at the facility, and three weekdays when there was no medical staff coverage for psychiatric care at all.

4. The facility's "Collaborative Practice Agreement for Nurse Practitioner [NP]" signed 10/11/18 by the APRN and 12/11/18 by the Medical Director, stipulated that, " ...The NP is authorized to provide psychiatric and limited medical care under this collaborative practice agreement (CPA) in the inpatient geriatric psychiatric unit ... A collaborating physician, either primary, back-up or on-call, is continuously available to the NP, either in person or by telephone for consultation. The NP will document any consultation with a supervising physician for a specific case in the consumer's medical record." There was no documented evidence that the nurse practitioner received any consultation from the psychiatrist regarding treatment and medications for any of the nine active sample patients.

The facility's "Medical Staff By-Laws" [no date] stipulated, "The word 'physician' shall be defined in accordance with the Centers for Medicare and Medicaid Services in §1861. [42 U.S.C. 1395x] of the Social Security Act as: A doctor of medicine or osteopathy ..." There was nothing in the medical by-laws that addressed the practice of the APRN who was "authorized to provide psychiatric and limited medical care."

5. An observation of the treatment team meeting on 4/23/19 at 1:00 p.m. revealed the following findings:

a. The treatment team meeting was attended primarily by the Interim Director of Nursing, Director of Social Work, Case Manager, and APRN. The psychiatrist was not on-site at the facility but attended via electronic telecommunication (a telemedicine process).

b. The Treatment team meeting included bringing in each patient in the room for a five to ten- minute interview with the psychiatrist who could be seen on a screen. [During the surveyors' observation, the amount of time spent with the patients was five to seven minutes]. The meeting was actually a rounding process where staff reported the patient's progress and discussed possible discharge plans.

c. There were no discussions regarding the development or revisions of the treatment plans, including psychiatric problems, treatment goals, and treatment modalities. Also, there was no discussion regarding the role of specific disciplines in carrying out the plan of care.

d. During the interview on 4/23/19 at 3:05 p.m. with the APRN, the treatment planning process was reviewed. When asked if she or the psychiatrist facilitated a discussion to reach consensus on targeted problems to be addressed and treatment modalities to be offered during the patient' hospital stay, she stated "No. I am a contract employee. I never see the treatment plan, don't sign them, and haven't been asked to sign off on them."

e. During the telephone interview on 4/24/19 at noon with the Medical Director, the treatment planning process was reviewed. When asked about his involvement in developing the treatment plan, he stated that the RN does the treatment plan and he reviews the plan and signs off. When informed that the MTPs did not have a sign off by him, he stated Medical Records staff was responsible for getting the plans to him to sign at home using an electronic signature process ("DocuSign.")

6. This APRN completed and signed all documents that required a physician signature. There was no consistent review by a physician of documents completed by the APRN.

A review of the medical records revealed multiple deficiencies in content, frequency, and authentication by the APRN.

a. The APRN completed and signed the psychiatric evaluations without a physician review for the nine active sample patients. The APRN signed psychiatric evaluations without identifying her credentials or discipline. This signature was in the section for a signature titled "Physician Signature/LIP [Licensed Independent Practitioner]. Therefore, this section contained a signature that did not identify whether the physician or the APRN signed the psychiatric evaluation.

b. The psychiatric evaluation for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) did not include all the necessary information to justify the patients' diagnoses and planned treatment. The psychiatric evaluations were cursory and did not include detailed information on past psychiatric history, substance abuse, and mental status. The psychiatric evaluation also did not include comprehensive information regarding an estimate of intellectual functioning, memory functioning, orientation, and patient assets. Failure to provide this necessary clinical information can negatively affect decision-making regarding the need for further evaluation. (Refer to B110, B116, and B117 for details).

c. The facility did not comply with the policy requirement of documenting daily physician progress notes. The facility's policy titled "Medical Record Content Policy" stipulated that "All entries in the medical record shall be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided ... Physician progress notes shall be documented daily, and as the patient's condition dictates."

d. The APRN completed progress notes without documented physician review for the nine active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) and five non-sample patients (A4, A7, A11, A12, and A16) selected to review physician progress notes.

e. The progress notes written by the APRN failed to consistently document progress or lack of progress related to the presenting psychiatric symptoms that resulted in hospitalization. Entries reflected brief observations and failed to indicate how well the patient was responding to treatment pertaining to presenting psychiatric symptoms or problems. Also, the rationale for medication orders or changes was not included in these notes.

f. The form titled "Psychiatric Physician Progress Note" contained a section for the patient's current mental status, medication changes, anticipated discharge date, and criteria for continued stay. The section of the progress note titled "Physician Signature" was signed by the APRN without identifying that the notes were signed by an APRN, not a physician for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) and two (2) of five (5) non-sample active patients (4 and 11) selected to review physician progress notes. The practice gave the appearance that the physician had signed the forms. (Refer to B126 for details).

h. Another form in the medical record titled, "Medicare Psychiatric Inpatient Admission Status Statement and Physician Certification" required a physician signature. For all of the nine active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15), the APRN signed these forms under the "Required Signature" section on the line for the physician signature without identifying her credentials. This practice again gave the impression that a physician had signed these forms.

6. In a telephone interview with the Medical Director on 4/24/12 at noon, the following information was obtained:

a. The Medical Director confirmed that he did not provide on-site contact with patients.

b. He stated he acts as a backup to the Nurse Practitioner and facility staff was expected to contact him only if they were unable to reach the nurse practitioner. He reported, "They call her first, and I am called if they can't reach her [APRN]." He reported he handled psychiatrist issues only. The facility staff was expected to call the medical physician for physical care issues.

c. When asked about his review of documents and the signatures on the psychiatric evaluation, progress notes, and the other forms requiring a physician signature, he reported he was to countersign these documents. When informed that they were not countersigned, he said that the Medical Records staff was supposed to get them to him.

d. When discussing the history and physical, psychiatric evaluation, and progress notes, he did not dispute the findings regarding the missing components of the psychiatric evaluation and the deficiencies in the progress notes. He stated, "I agree with everything you are saying." (Refer to B110, and B126 for details).

e. When asked about his involvement in developing the treatment plan and determining the target problems, he stated that the RN [on the unit] was responsible for this. He did not dispute the findings that many treatment plans did not have interventions to be implemented by the physician and the interventions identified were routine physician job duties. He also did not dispute the findings that most treatment plans did not have any evidence that they had been reviewed and signed by the physician. (Refer to B118 to B123 for details.)

10. In an interview on 4/24/19 at 8:25 a.m., the Interim Director of Nursing (IDON), the availability of the Medical Director and the APRN was discussed. She acknowledged that not having an on-site psychiatrist and APRN to deal with patient care issues on a regular basis placed significant responsibility on the registered nurse.

Based upon a review of records and staff interview, the facility failed to document psychosocial assessments that included a comprehensive statement of conclusion and recommendations for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A9, A10, A13, and A15). These assessments did not document detailed summarized information or conclusions and recommendations regarding the social evaluation of psychiatric deficits, high-risk psychosocial issues, projected steps for discharge to occur, and the anticipated social work role in treatment during hospitalization. Although social work staff conducted two groups for the geriatric patients (one for patients described as "low functioning" and one as "high functioning: patients, these groups were not included in the psychosocial assessments as anticipated active treatment measures to be used during hospitalization. This failure to comprehensively assess the patient's psychosocial needs potentially results in suboptimal inpatient progress and inadequate discharge care plans.

A. Record review

The "Mental Health/Psychosocial Assessments" for the following patients were reviewed (dates of assessments in parentheses): A1 (4/17/19), Patient A2 (4/7/19), Patient A3 (4/14/19), Patient A6 (4/17/19), Patient A8 (4/14/19), Patient A9 (4/12/19), A10 (4/14/19), A13, (3/14/19), and A15 (4/12/19). This review revealed that:

1. None of the active sample patients had psychosocial assessments that included a sufficient summary or conclusions of social work findings and recommendations that described the social worker's anticipated role in treatment during each patient's hospital stay and projected steps for discharge to occur.

2. The psychosocial assessments contained limited, cursory, and sparse information in the section titled "Integrated Summary," such as the information documented for the following patients:

a. Patient A2: The section titled "Psychological Emotional Behavioral Issues Regarding Admission" stated, "paranoia, pressured speech, is bi-polar [sic] & not taking meds [medications]." There was no description of the patient's paranoia or what medications the patient was not taking. The summary also did not identify any details of high-risk psychosocial issues given the patient's medication non-adherence. Under the section titled "Comorbid Medical / Physical Conditions," the information stated, "Bipolar, paranoia."

b. Patient A6: The section titled "Psychological Emotional Behavioral Issues Regarding Admission" stated, "verbal/physical aggression, memory issues, anxiety/dep [depression]." There was no description of the patient's verbal and physical aggression or under what circumstances these behaviors occurred. Also, there was no description of the patient's memory problems and how they would impact active treatment measures during hospitalization and discharge.

c. Patient A8: The section titled "Psychological Emotional Behavioral Issues Regarding Admission" stated, "suicidal ideation due to severe depression brought on by physical pain 24/7." There was no description of the patient's suicidal ideation or whether the patient had a plan. The summary also did not identify any details of high-risk psychosocial issues given the patient's suicidal ideation associated with physical pain.

d. Patient A10: The section titled "Psychological Emotional Behavioral Issues Regarding Admission" stated, "Severe depression, irritability anger [and] physical aggression [with]/staff. Beginning to struggle [with] memory issues and reports being in pain which makes [her/his] depression worse." There was no description of the patient's depression, anger, and physical aggression or under what circumstances these behaviors occurred. There was no description of the patient's memory problems and how they would impact active treatment measures during hospitalization and discharge planning.

e. Patient A15: The section titled "Psychological Emotional Behavioral Issues Regarding Admission" stated, "Struggle wt [with] depression, has been trying to leave the nursing facility and has been groping peers." There was no description of the patient's depression nor how the depression would impact active treatment measures during hospitalization and anticipated barriers related to discharge.

B. Interview

During interview on 4/23/19 at 11:50 a.m., the Director of Social Work did not dispute the findings that the assessment did not provide comprehensive psychosocial assessments that reflected conclusions and recommendations regarding social evaluation of presenting psychiatric problem/deficits, high-risk psychosocial issues, and the anticipated social work role in treatment of patients during their hospital stay.

Based on record review and interview, the facility failed to ensure that a neurological examination was completed for 3 of 9 active sample patients (A1, A2. A13.) For an additional 3 active sample patients (A6, A9, A15), the neurological documented failed to include any information to verify the specific testing performed. This failure to record a neurological examination with specific testing compromises the identification of pathology for geriatric patients, which may be pertinent to their current mental illness and compromises future comparative re-examination to assess the patient's response to treatment interventions.

Findings include:

A. Record Review:

1. Patient A1 (admitted 4/18/19) had no neurological completed on the History and Physical (H & P) dated 4/19/19. No progress notes were documented to show the staff's attempts to complete the neurological examination.

2. Patient A2 (admitted 3/28/19) had no neurological completed on the H & P dated 3/28/19. There were no progress notes documenting the staff's attempts to complete the neurological examination.

3. Patient A6 (admitted 4/16/19) had an H & P dated 4/17/19 that noted, "Neurologic: Nonfocal." There was no other information about the tests that were performed to substantiate this finding.

4. Patient A9 (admitted 4/10/19) had an H & P dated 4/11/19that noted, "Neurologic: Nonfocal." There was no explanatory information about the tests that were performed to substantiate this finding.

5. Patient A13 (admitted 3/8/19) had no neurological completed on H & P dated 4/17/19. There were no progress notes documenting the staff's attempts to complete the neurological examination.

6. Patient A15 (admitted 4/11/19) had an H & P dated 4/12/19 that noted, "Neurologic: Nonfocal." There was no explanatory information about the tests that were performed to substantiate this finding.

B. Interview

In the telephone interview with the Medical Director on 4/24/19 at noon, the history and physical examinations were discussed. He did not dispute the findings and agreed that the neurological examinations should include specifics tests and be completed for those patients missing an exam.

Based on record review and interview, the facility failed to ensure that the psychiatric evaluation for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) were completed by a physician and included all the necessary information to justify the patients diagnoses and planned treatment. Instead, psychiatric evaluations for these patients were completed by an Advanced Practice nurse without documented physician review. Several content areas in the psychiatric evaluation were cursory and did not include detailed information regarding past psychiatric history, substance abuse, and mental status. The failure to have the psychiatric evaluation completed with comprehensive information and provided under the direction of a physician potentially compromises the formulation of an accurate diagnostic view of the patient, thereby limiting the team's ability to develop a meaningful plan of care to meet the patient's individual psychiatric needs.

Findings include:

A. Record Review

The facility's "Collaborative Practice Agreement for Nurse Practitioner [NP]" signed 10/11/18 by the APRN and 12/11/18 by the Medical Director, stipulated that, " ...The NP is authorized to provide psychiatric and limited medical care under this collaborative practice agreement (CPA) in the inpatient geriatric psychiatric unit ... A collaborating physician, either primary, back-up or on-call, is continuously available to the NP, either in person or by telephone for consultation. The NP will document any consultation with a supervising physician for a specific case in the consumer's medical record." There was no documented evidence that the nurse practitioner received any consultation from the psychiatrist.

The Psychiatric Evaluations (PEs) of the following patients were reviewed (dates of evaluations in parentheses): A1 (4/19/19); A2 (3/28/19); A3 (4/13/19); A6 (4/18/19); A8 (4/12/19); A9 (4/11/19); A10 (4/13/19); A13 (3/9/19); and A15 (4/11/19). This review revealed that there was cursory or incomplete information included for the following sections of the PE:

1. Patient A1:

a. "Previous Psychiatric History" only stated, "Schizophrenia." This section failed to include past psychiatric hospitalization, medical health care, past suicidal attempts if any, past medications and response, past treatment and response.

b. "Substance Abuse History: "Unknown"

c. "Social and Developmental History:" This information was illegible.

d. "Mental Status Exam" Under the section titled "Thought Content" noted, "denies reported AV [Auditory/Visual hallucinations] by history." However, under the section titled, "Preliminary Treatment Plan" "Delusions, hallucinations, aggression" were listed, without any descriptive information or documented evidence to substantiate these problems.

e. Psychiatric Diagnosis: "Schizophrenia, Anxiety." This was not standard nomenclature that would document the admitting diagnoses.

2. Patient A2:

a. "Previous Psychiatric History" only stated, "Bipolar d/o [Disorder]." This section failed to include past psychiatric hospitalization, medical health care, past suicidal attempts if any, past medications and response, past treatment and response.

b. "Substance Abuse History: "Unknown"

c. "Social and Developmental History:" The only information provided was, "Lives at home [with] [spouse]."

d. "Mental Status Exam" Under the section titled "Thought Content" noted, "Auditory hallucinations" and "Somatic Delusion" with no descriptive information or documented evidence to support or substantiate these problems. Under the section titled, "Preliminary Treatment Plan" the psychiatric evaluation listed "Delusions" and "paranoia" again without any descriptive information or documented evidence to substantiate these problems.

e. Psychiatric Diagnosis: "Bipolar d/o [disorder], delusional d/o." There was insufficient information to substantiate a Bipolar Disorder or Delusional Disorder.

3. Patient A3:

a. "Previous Psychiatric History" only stated, "Bipolar d/o [Disorder]." This section failed to include past psychiatric hospitalization, medical health care, past suicidal attempts if any, past medications and response, past treatment and response. One of the chief complaints on the psychiatric evaluation was "SI [suicidal ideations] no plan."

b. "Substance Abuse History": "Unknown"

c. "Social and Developmental History": The only information provided was, "Lives at home [with] [spouse]."

d. "Mental Status Exam": Under the section titled "Mood" noted "Depressed," "Manic," and "Anxious," and under the section titled "Thought Content" noted, "Auditory hallucinations" and "Somatic Delusion" with no descriptive information or documented evidence to support or substantiate these problems. Under the section titled, "Preliminary Treatment Plan" the psychiatric evaluation listed "Delusions" and "paranoia" again without any descriptive information or documented evidence to substantiate these problems.

e. Psychiatric Diagnosis: "MDD [Major Depressive Disorder], Neurocognitive d/o and severe vascular dx [diagnosis] with behaviors." There was limited information to support these diagnoses. The diagnosis "Severe Vascular Diagnosis with behaviors" was not a recognized psychiatric diagnosis.

4. Patient A6:

a. "Previous Psychiatric History" stated "Anxiety, Dementia." This section failed to include past psychiatric hospitalization, medical health care, past suicidal attempts if any, past medications and response, past treatment and response.

b. "Social and Developmental History:" The only information provided was, "LTCF [Long-Term Care Facility] resident."

c. "Mental Status Exam": The section titled "Mood" noted "Irritable" and "Anxious" and the section titled "Thought Content" noted- "General somatic sensations" and the section titled, "Preliminary Treatment Plan" listed "aggression" and "delusions. There was no descriptive information or documented evidence to substantiate these problems.

d. Psychiatric Diagnosis: "Dementia." There was limited information to support this diagnosis.

5. Patient A8:

a. "Previous Psychiatric History" stated, "Amphetamine induced mood d/o, psychosis, substance abuse induced [sic]." There was no detailed information explaining these diagnoses. This section failed to include past psychiatric hospitalization, medical health care, past suicidal attempts if any, past medications and response, past treatment and response.

b. "Social and Developmental History:" The only information provided was, "Lives at home [with] [spouse]."

c. "Mental Status Exam": The section titled "Mood" noted "Appropriate," and the section titled "Thought Content" noted, "Delusions: paranoid" with no descriptive information or documented evidence to support or substantiate these problems. The section titled, "Preliminary Treatment Plan" listed "Delusions" and "anxiety" again without any descriptive information or documented evidence to substantiate these problems.

d. Psychiatric Diagnosis: "Mood d/o - substance induced [sic]." There was limited information to support this diagnosis.

6. Patient A9:

a. "Previous Psychiatric History" "MDD [Major Depressive Disorder], Anxiety, Dementia." This section failed to include past psychiatric hospitalization, medical health care, past suicidal attempts if any, past medications and response, past treatment and response.

b. "Social and Developmental History:" The only information provided was, "LTCF resident."

c. "Mental Status Exam" The section titled "Thought Content" noted "Hallucinations - Auditory, Command" and the section titled, "Preliminary Treatment Plan" listed "aggression" and "delusions" without any descriptive information or documented evidence to substantiate these problems.

d. Psychiatric Diagnosis: "MDD," Anxiety," and "Dementia." There was limited information to support these diagnoses.

7. Patient A10:

a. "Previous Psychiatric History" stated, "MDD" There was no detailed information explaining the diagnosis. This section failed to include past psychiatric hospitalization, medical health care, past suicidal attempts if any, past medications and response, past treatment and response.

b. "Social and Developmental History:" The only information provided was, "LTCF resident."

c. "Mental Status Exam" Under the section titled, "Preliminary Treatment Plan" the psychiatric evaluation listed "Delusions," "anxiety" and depression" again without any descriptive information or documented evidence to substantiate these problems.

d. Psychiatric Diagnosis: "MDD." There was limited information to support this diagnosis.

8. Patient A13:

a. "Previous Psychiatric History" stated, 'MDD." There was no detailed information explaining this diagnosis. This section failed to include past psychiatric hospitalization, medical health care, past suicidal attempts if any, past medications and response, past treatment and response.

b. "Social and Developmental History:" stated "LTCF resident."

c. "Mental Status Exam" The section titled "Thought Content" noted, "Delusions: Somatic, paranoid" with no descriptive information or documented evidence to support or substantiate these problems. Under the section titled, "Preliminary Treatment Plan" the psychiatric evaluation listed "Delusions, anxiety, depression," again without any descriptive information or documented evidence to substantiate these problems.

d. Psychiatric Diagnosis: "MDD." There was limited information to support this diagnosis.

9. Patient A15:

a. "Previous Psychiatric History" "MDD, Anxiety, Dementia, Mood d/o [disorder]." This section failed to include past psychiatric hospitalization, medical health care, past suicidal attempts if any, past medications and response, past treatment and response.

b. "Social and Developmental History:" The only information provided was, "LTCF resident."

c. "Mental Status Exam" The section titled "Thought Content" noted, "Hallucinations - Auditory, Command" and the section titled, "Preliminary Treatment Plan" listed "aggression" and "delusions," without any descriptive information or documented evidence to substantiate these problems.

d. Psychiatric Diagnosis: "Mood d/o" and "Dementia." There was limited information to support these diagnoses.

B. Interviews

1. In an interview on 4/23/19 at 3:05 p.m. with the APRN (Advanced Practice Registered Nurse), the psychiatric evaluations were reviewed. She did not dispute the findings and stated, "I need to include more information."

2. In a telephone interview with the Medical Director on 4/24/12 at noon, missing components of the psychiatric evaluation outlined above were reviewed. He did not dispute the findings and stated, "I agree with everything you are saying."

Based on record review and interview, the facility failed to ensure that the psychiatric evaluations for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) included comprehensive information regarding an estimate of intellectual functioning, memory functioning, and orientation. Lack of this necessary clinical information can negatively affect decision-making on the need of geriatric patients for further evaluation. Without more detailed information about a patient's orientation, level of intellectual functioning, and memory functioning, it is not possible to know the specific extent of the patient's capacity or impairment so that appropriate treatment modalities can be chosen, and so that changes in response to treatment can be measured.

Findings include:

A. Record Review:

The Psychiatric Evaluation (PE) of the following patients were reviewed (dates of evaluations in parentheses): A1 (4/19/19); A2 (3/28/19); A3 (4/13/19); A6 (4/18/19); A8 (4/12/19); A9 (4/11/19); A10 (4/13/19); A13 (3/9/19); and A15 (4/11/19). This review revealed that the PE contained deficient information regarding in the following sections of "Sensorium & Cognition Exam" and Attention and Concentration":

1. Patient A1:

Sensorium & Cognition Exam

a. "Orientation": "Person" was checked without any other information.

b. "Memory": "Impaired" was checked without any other documented evidence or tests to substantiate this finding.

Attention and Concentration - In this section "Impaired" was checked without any other documented evidence or tests to substantiate this finding. Under "Gross Estimate of Intelligence," "Avg. [average]" was checked without any additional information to substantiate this finding.

2. Patient A2:

Sensorium & Cognition Exam

a. "Orientation": "Person" was checked without any other information.

b. "Memory": "Intact" was checked without any other documented evidence or tests to substantiate this finding.

Attention and Concentration - This section was left blank with a notation that the patient refused to spell "World" forward and backward; do calculations or state the meaning of "A Stitch in time saves nine." There was no evidence in progress notes or any other attempts to obtain these assessments. In the section titled "Gross Estimate of Intelligence," "Avg. [average]" was checked without any additional information to substantiate this finding.

3. Patient A3:

Sensorium & Cognition Exam

a. "Orientation": "Person" was checked without any other information.

b. "Memory": "Impaired" was checked without any other documented evidence or tests to substantiate this finding.

Attention and Concentration - This section had "Impaired" checked without any information to substantiate this finding. The test information was left blank including the assessments regarding digital span, serial subtractions, spelling "World" forward and backward; doing calculations or stating the meaning of "A Stitch in time saves nine." There was no evidence in progress notes of any other attempts to obtain these assessments. In the section titled "Gross Estimate of Intelligence," "Avg. [average]" was checked without any additional information to substantiate this finding.

4. Patient A6:

Sensorium & Cognition Exam

a. "Orientation": "Person" was checked without any other information.

b. "Memory": "Impaired" was checked without any other documented evidence or tests to substantiate this finding.

Attention and Concentration - This section had "Impaired" checked without any information to substantiate this finding. The test information was left blank including the assessments regarding digital span, serial subtractions, spelling "World" forward and backward; doing calculations or stating the meaning of "A Stitch in time saves nine." There was no evidence in progress notes of any other attempts to obtain these assessments. In the section titled "Gross Estimate of Intelligence," "Avg. [average]" was checked without any additional information to substantiate this finding.

5. Patient A8:

Sensorium & Cognition Exam

a. "Orientation": "Person" was checked without any other information.

b. "Memory": "Impaired" was checked without any other documented evidence or tests to substantiate this finding.

Attention and Concentration - This section had "Impaired" without any information to substantiate this finding. The test information was left blank including the assessments regarding digital span, serial subtractions, spelling "World" forward and backward; doing calculations or stating the meaning of "A Stitch in time saves nine." There was no evidence in progress notes of any other attempts to obtain these assessments. In the section titled "Gross Estimate of Intelligence," "Avg. [average]" was checked without any additional information to substantiate this finding.

6. Patient A9:

Sensorium & Cognition Exam

a. "Orientation": "Person" was checked without any other information.

b. "Memory": "Impaired" was checked without any other documented evidence or tests to substantiate this finding.

Attention and Concentration - This section had "Impaired" checked without any other documented evidence or tests to substantiate this finding. Under "Gross Estimate of Intelligence," "Avg. [average]" was checked without any other information to substantiate this finding.

7. Patient A10:

Sensorium & Cognition Exam

a. "Orientation": "Time, Place, Person, Situation" were checked without any other information.

b. "Memory": "Intact" was checked without any other documented evidence or tests to substantiate this finding.

Attention and Concentration - This section was left blank with no designation that the patient's attention and concentration was either "intact" or "impaired.". In the section titled "Gross Estimate of Intelligence," "Avg. [average]" was checked without any additional information to substantiate this finding.

8. Patient A13:

Sensorium & Cognition Exam

a. "Orientation": "Person" was checked without any other information.

b. "Memory": "Impaired" was checked without any other documented evidence or tests to substantiate this finding.

Attention and Concentration - This section was left blank with a notation that the patient refused to spell "World" forward and backward; do calculations or state the meaning of "A Stitch in time saves nine." There was no evidence in progress notes of any other attempts to obtain these assessments. In the section titled "Gross Estimate of Intelligence," "Avg. [average]" was checked without any additional information to substantiate this finding.

9. Patient A15:

Sensorium & Cognition Exam

a. "Orientation": "Person" was checked without any other information.

b. "Memory": "Impaired" was checked without any other documented evidence or tests to substantiate this finding.

Attention and Concentration - In the area of "Gross Estimate of Intelligence," "Avg. [average]" was checked without any other information to substantiate this finding.

B. Interviews

1. In an interview on 4/23/19 at 3:05 p.m. with the APRN (Advanced Practice Registered Nurse), the psychiatric evaluations were reviewed. She did not dispute the findings and admitted that the facility did not use any formal assessment instruments for determining patients' cognitive functioning.

2. In a telephone interview with the Medical Director on 4/24/19 at noon, the deficient and insufficient information on the psychiatric evaluations were discussed. He did not dispute the deficient findings outlined above.

Based on record review and interview, the facility failed to include an inventory of each patient's personal assets in descriptive and non-interpretative fashion for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). Specifically, assets were selected from a preprinted list titled "Assets, Strengths, Resources for Treatment" with no additional information to individualize them or identify unique personal attributes, accomplishments, or interests. This deficiency results in a lack of necessary information to guide in developing a plan of treatment for the patient.

Findings include:

A. Record Review:

The Psychiatric Evaluation of the following patients were reviewed (dates of evaluations in parentheses): A1 (4/19/19); A2 (3/28/19); A3 (4/13/19); A6 (4/18/19); A8 (4/12/19); A9 (4/11/19); A10 (4/13/19); A13 (3/9/19); and A15 (4/11/19). This review revealed:

1. Patient A1's psychiatric evaluation had the following items checked, "Support of Family and Friends," "Stable Physical Health," and "Community Support" without any other information to explain which members of the family were supportive or how they supported the patient. Also, there was no information regarding the patient's stable physical health or community support.

2. Patient A2's psychiatric evaluation had the following items checked, "Support of Family and Friends," "Aware of Surrounding," Stable Physical Health," and "Community Support" without any other information to explain any of the items checked. There was no information about this patient's personal attributes including accomplishments, skills, or interests.

3. Patient A3's psychiatric evaluation had the following items checked, "Support of Family and Friends," "Able to Carry Out Simple Commands upon Request," and "Community Support" without any other information to explain any of the items checked. There was no information about this patient's personal attributes including accomplishments, skills, or interests.

4. Patient A6's psychiatric evaluation had the following items checked, "Support of Family and Friends" and "Community Support" without any other information to explain any of the items checked. There was no information about this patient's personal attributes including accomplishments, skills, or interests.

5. Patient A8's psychiatric evaluation had the following items checked, "Support of Family and Friends," "Aware of Surroundings," "Able to Carry Out Simple Commands upon Request," "Aware of Consequences to Behavior," "Adequate Finances," and "Community Support" without any other information to explain any of the items checked. There was no information about this patient's personal attributes including accomplishments, skills, or interests.

6. Patient A9's psychiatric evaluation had the following item checked, "Community Support" without any other information to explain who, what, or how the community was supportive to the patient.

7. Patient A10's psychiatric evaluation had the following items checked, "Support of Family and Friends," "Aware of Surroundings" "Stable Physical Health," and "Community Support" without any other information to explain with items checked.

8. Patient A13's psychiatric evaluation had the following items checked, "Support of Family and Friends," without any other information to explain which members of the family were supportive or how they supported the patient.

9. Patient A15's psychiatric evaluation had the following items checked, "Support of Family and Friends," "Stable Physical Health," and "Community Support" without any other information to explaining any of the items checked.

B. Interviews

1. In an interview on 4/23/19 at 3:05 p.m. with the APRN (Advanced Practice Registered Nurse), the psychiatric evaluations were reviewed. She did not dispute the findings that the preprinted items on the psychiatric evaluations were not individualized and did not include specific information about the patient's personal attributes, accomplishments, skills, or interests that could be used in treatment.

2. In a telephone interview with the Medical Director on 4/24/19 at noon, the insufficient information regarding the identification of assets that could be used in developing active treatment interventions was discussed. He did not dispute the finding.

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

I. Develop and document comprehensive Master Treatment Plans (MTPs) for nine (9) of nine (9) sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) under the leadership of a physician, and with all disciplines contributing individualized goals and interventions for patients. Neither a physician nor the APRN was involved in the development of the Master Treatment Plan; the preprinted MTP form did not include treatment goals for the physician but did include generic interventions which were selected by the admitting RN. Other sections of the MTPs were completed independently by other disciplines using preprinted documents with generic treatment goals and interventions associated by discipline. By observation, there was no evidence that the treatment team discussed these MTPs during the treatment team meetings. These deficient practices reflect a failure of collaborative input by all team members, resulting in the potential to compromise patients' opportunity to receive appropriate treatment measures.

Findings include:

A. Document Review

1. A review of the facility's policy titled "Plan of Care: Reference #1103" stipulated that "The patient's needs are identified from the information on the initial intake form and the initial nursing assessment. Care and treatment decisions are made on a collaborative basis, with input from all disciplines providing care and services to the patient, to allow for the development of a plan of care that is interdisciplinary in nature." The facility did not comply with this policy requirement.

2. A review of the facility's policy titled "Assessment DPU-2023: Progress recording and timeliness of Required Clinical Task Documentation" [no date] stipulated that "The following clinical task guidelines will be adhered to and documented in the medical record: ...Master treatment plan-multidisciplinary team/72 hours [completion timeframe] ..."

3. A review of the facility's policy titled "Plan for Clinical Services: Case Management Plan" stipulated under the section titled "Ongoing Evaluation and Treatment Planning" that "After initial evaluation and clarification of the proactive comprehensive discharge plan, it is then carried over in the Master Treatment Plan where it is evaluated through the weekly treatment meetings." The facility did not comply this with this policy requirement of evaluating the Master Treatment Plan.

4. The Master Treatment Plan (MTP) document was mostly a preprinted template that did not allow for individualization. The MTP contained a sheet titled "Master Problem List," which was handwritten by the RN, and preprinted templates associated with the master problem list. These sheets were initiated by the RN generally on the day of admission. The long-term goal was developed by the RN and was handwritten. The short-term goals were preprinted templates (called "Treatment Team Goals by this facility) with categories to be checked for "N" (Nursing), "T" (Therapy) and "TR" (Therapeutic Rehabilitation). The preprinted MTP Form did not include treatment goals for the physician. The "Date ID" entered by the RN was the date of admission, with later entry dates by the other disciplines as they completed their sections. Since no formal MTP was developed, for this survey report, the date used for the MTP was the date the problem list was generated.

5. There was on-going confusion throughout the survey process regarding the official date of the Master treatment plan (MTP). In an interview on 4/22/19 at approximately 9:10 a.m. the CEO stated that the MTPs were to be completed within 72 hours after admission. In an interview with the CEO and the Project Manager on 4/23/19 at 8:50 a.m., the surveyors were told that the MTP had multiple entry dates and was not completed until at discharge. When asked how they determine that the MTP was completed in 72 hours per facility policy, there was no answer provided to this question. Therefore, it was difficult to determine the completion date of the MTP.

B. Observation and Medical Record Review

1. During an observation on 4/23/19 at 1:00 p.m. the following findings were revealed:

a. The treatment team meeting was attended primarily by the Interim Director of Nursing, Director of Social Work, Case Manager, and Nurse Practitioner. The psychiatrist was not on-site at the hospital but attended via electronic telecommunication.

b. The Treatment team meeting included bringing in each patient for a five to ten minutes interview. The meeting was actually a rounding process where disciplines discussed the patient's progress and possible discharge planning. There was no collaboration on the development of the problems to be addressed, the treatment modalities to be implemented, the goals for the treatment to be provided, or the role of specific disciplines in carrying out the plan of care.

2. Review of the MTPs of the nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) revealed that the MTPs did not include consistent input and treatment recommendations from the physician, social work and therapeutic rehabilitation staff. Physician input was limited to the checklist of interventions made by the RN. The following patients did not have the full involvement of social work or therapeutic rehabilitation disciplines in the development of their MTP:

a. Patient A1 was admitted 4/18/19 and as of 4/23/19 had no goals or interventions for therapeutic rehabilitation staff.

b. Patient A2 was admitted 3/27/19 and as of 4/23/19 had no goals or interventions for therapeutic rehabilitation staff.

c. Patient A3 was admitted 4/13/19 and as of 4/23/19 had no goals or interventions for social work and therapeutic rehabilitation staff.

d. Patient A8 was admitted 4/12/19 and as of 4/23/19 had no goals or interventions for social work and therapeutic rehabilitation staff.

e. Patient A9 was admitted 4/9/19 and as of 4/23/19 had no goals or interventions for social work and therapeutic rehabilitation staff.

h. Patient A10 was admitted 4/13/19 and as of 4/23/19 had no goals or interventions for social work and therapeutic rehabilitation staff.

g. Patient A15 was admitted 4/11/19 and as of 4/23/19 had no goals or interventions for therapeutic rehabilitation staff.

C. Interviews:

1. During the interview on 4/23/19 at 3:05 p.m. with the APRN (Advanced Practice Registered Nurse), the treatment planning process was reviewed. When asked if she or the psychiatrist facilitated a discussion to reach consensus on targeted problems to be addressed and treatment modalities to be offered during the patient' hospital stay, she stated "No. I am a contract employee. I never see the treatment plan, don't sign them, and haven't been asked to sign off on them."

2. During the telephone interview on 4/24/19 at noon with the Medical Director, the treatment planning process was reviewed. When asked about his involvement in developing the treatment plan, he stated that the RN does the treatment plan and he reviews the plan and signs off. When informed that the MTPs did not have a sign off by him, he stated Medical Records staff was responsible for getting the plans to him to sign at home using an electronic signature process ("DocuSign.")

II. Provide comprehensive Master Treatment Plans (MTPs) that were cohesive, understandable, and individualized with all necessary components to provide active treatment for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). Specifically, the MTPs were missing the following components:

A. Behaviorally descriptive strength and disability statements (called problems by the facility) to be used as the basis for developing treatment plans. (Refer to B119.)

B. Observable and measurable goals based on each patient's presenting psychiatric symptoms and needs. (Refer to B121).

C. Individualized active treatment interventions with a method of delivery, frequency of contact and focus of treatment based on each patient's presenting psychiatric symptoms and needs. (Refer to B122).

D. Both the name and discipline of the staff member who was responsible and accountable for each of the interventions identified in the Master Treatment Plan. (Refer to B123).

Failure to develop a logical and understandable master treatment plan with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in the patient's active treatment needs not being met.

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) (called Master Treatment Plan of Care by the facility), were based on an inventory of patient's strengths that was behaviorally descriptive for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). The section in the MTP titled "Patient Strengths, Assets, resources" listed several preprinted items with boxes that were to be checked off by clinical staff. These items of strength were identical on all MTPs and were not individualized for each patient. In addition, there was a failure to include clearly defined and individualized problem statements written in behavioral and descriptive terms for eight (8) of nine (9) active sample patients (A1, A3, A6, A8, A9, A10, A13, and A15). The failure to identify patient strengths and behaviorally descriptive problems can adversely affect clinical decision-making in formulating MTPs and impairs the treatment team's ability to develop goals and results in treatment plans that are not individualized to patients' unique presenting psychiatric problems.

Findings include:

A. Record Review

1. Patient A1's MTP dated 4/18/19, included the following deficient patient strengths and psychiatric problem statements:

Strengths: The following boxes were checked in the section labeled, "Patient Strengths, Assets, Resources": "Support of family & [and] friends, Stable Physical Health, Cognitive, Adequate Finances to Obtain Meds [Medications], Education ..." None of the items checked, such as support of family, cognitive, education, were explained in descriptive terms to reflect this patient's personal skills, attributes, and accomplishments that the treatment team could use to assist the patient during the recovery period.

Problem: "Alteration of Perception Related to Cognitive Impairment Disease Process of Psychosis" and boxes checked included "Hallucinations, Delusions, Paranoia ..." This problem statement failed to include clear, descriptive information about the patient's hallucinations, delusions, and paranoia, such as the content of these symptoms and how they impacted the patient's behavior.

2. Patient A2's MTP dated 3/28/19, included the following deficient patient strengths and psychiatric problem statements:

Strengths: The following boxes were checked in the section labeled, "Patient Strengths, Assets, Resources": "Support of family & [and] friends, Stable Physical Health, Adequate Finances to Obtain Meds [Medications], Capable of Independent Living." None of the items checked were explained in descriptive terms to reflect this patient's personal skills, attributes, and accomplishments that the treatment team could use to assist the patient during the recovery period.

Problem: "Alteration of Mood RT [Related to]: Depressed presentation - As Evidenced By: Racing thoughts, Grandiose thinking." Although the MTP contained a brief description of some of the depressive symptoms, there was no descriptive information about the patient's "Psycho Motor Agitation/Retardation."

3. Patient A3's MTP dated 4/13/19, included the following deficient patient strengths and psychiatric problem statements:

Strengths: In the section labeled, "Patient Strengths, Assets, Resources," no boxes were checked. This section was left blank.

Problem: "Alteration of Mood RT: Depressed presentation - As Evidenced By: Pt tearful and sobbing nonstop." Although the MTP contained a brief description of some of the depressive symptoms, there was limited descriptive information about the patient's "depressed mood" and no information about the extent of the patient's "decreased interest/pleasure."

4. Patient A6's MTP dated 4/16/19, included the following deficient patient strengths and psychiatric problem statements:

Strength: The following box was checked in the section labeled, "Patient Strengths, Assets, Resources": "Support of family & friends." The item checked was not explained in descriptive terms to reflect what kind of support would be provided by the family and friends that the treatment team could use to assist the patient during the recovery period.

Problem: "Alteration of Perception Related to Cognitive Impairment Disease Process of Psychosis" showed the box checked was "Delusions." This problem statement failed to include clear, descriptive information about the patient's delusions, such as the content of the delusions and how they impacted the patient's behavior.

5. Patient A8's MTP dated 4/13/19, included the following deficient patient strengths and psychiatric problem statements:

Strengths: In the section labeled, "Patient Strengths, Assets, Resources," no boxes were checked. This section was left blank.

Problem: "Alteration of Perception Related to Cognitive Impairment Disease Process of Psychosis" showed the box checked was "Delusions." Although the MTP contained a brief description of the delusions, there was no descriptive information about the patient's cognitive impairment.

6. Patient A9's MTP dated 4/10/19, included the following deficient patient strengths and psychiatric problem statements:

Strengths: In the section labeled, "Patient Strengths, Assets, Resources," no boxes were checked. This section was left blank.

Problem: "Psychotic Disorder/External control or Possession delusions" showed the boxes checked were, "Decreased Reality Orientation" and "Acute Agitation/Rage/Impulse Control." The problem statement failed to include clear, descriptive information about the patient's cognitive impairment.

7. Patient A10's MTP dated 4/13/19, included the following deficient patient strengths and psychiatric problem statements:

Strengths: In the section labeled, "Patient Strengths, Assets, Resources," no boxes were checked. This section was left blank.

Problem: "Alteration of Mood RT": Neither of the boxes ("Manic presentation," "Depressed presentation") was checked. "As Evidenced by: Antisocial behavior et [and] not participating in program [skill]." The problem statement failed to include clear and descriptive information about the patient's mood.

8. Patient A13's MTP dated 3/9/19, included the following deficient patient strengths and psychiatric problem statements:

Strength: The following box was checked in the section labeled, "Patient Strengths, Assets, Resources": "Support of family & [and] friends." The item checked was not explained in descriptive terms to reflect what kind of support would be provided by the family and friends that the treatment team could use to assist the patient during the recovery period.

Problem: "Psychotic Disorder/External Control or Possession Delusions," had the box checked "Acute agitation/Rage/Impulse Control." The problem statement failed to include clear, descriptive information such as the content of these symptoms and their impact on the patient's behavior.

9. Patient A15's MTP dated 4/11/19, included the following deficient patient strengths and psychiatric problem statements:

Strength: In the section labeled, "Patient Strengths, Assets, Resources," no boxes were checked. This section was left blank.

Problem: "Alteration in Mood RT" had the box checked "Depressed Presentation As Evidence By: Patient is sad and wanting to go home." The problem statement failed to include clear, descriptive symptoms related to patient being sad.

B. Interviews

1. During the interview on 4/23/19 at 11:55 a.m., the missing patients' strengths in the MTPs were discussed with the Director of Social Work. She concurred with the findings.

2. During an interview on 4/23/19 at 3:05 p.m. with the APRN (Advanced Practice Registered Nurse), the missing patients' strengths on MTPs were discussed. She stated, "I never see the treatment plan, don't sign them, and haven't been asked to sign off on them."

3. During the telephone interview on 4/24/19 at 12:15 p.m. with the Medical Director, the missing patients' strengths/assets not showing up in the MTPs was discussed. He agreed with the findings.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that included substantiation of the psychiatric diagnoses that would form the basis for treatment for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). The absence of substantiated diagnoses on patients' MTPs compromises the ability of the treatment team to identify specific psychiatric and physical problems and plan effective treatment for which specific treatment modalities would be delineated and implemented during the current hospitalization.

Findings include:

A. Record Review

The MTPs for the following active sample patients were reviewed (dates of plans in parentheses): A1 (4/18/19), A2 (3/28/19), A3 (4/13/19), A6 (4/16/19), A8 (4/13/19), A9 (4/10/19), A10 (4/13/19), A13 (3/9/19), and A15 (4/11/19). This review revealed that none of the MTPs contained substantiated psychiatric diagnoses. The section labeled "Substantiated Non-Axial Diagnosis (From Psychiatric Evaluation)" was left blank.

B. Interviews

1. During the interview on 4/23/19 at 3:05 p.m. with the APRN (Advanced Practice Registered Nurse), the missing substantiated diagnoses on MTPs were discussed. She stated, "I never see the treatment plan, don't sign them, and haven't been asked to sign off on them."

2. During a telephone interview on 4/24/19 at 12:15 p.m. with the Medical Director, the missing substantiated diagnosis in the MTP's was discussed. He agreed with the findings.

Based on policy review, medical record review, and interview, the facility failed to developed Master Treatment Plans (MTPs) that include long and short term goals that were stated in observable, measurable, behavioral terms for nine (9) of nine (9) active sample patients ((A1, A2, A3, A6, A8, A9, A10, A13, and A15). The facility used preprinted templates for short terms goals (called "Treatment Team Goals" by this facility) with categories to be checked for "N" (Nursing), "T" (Therapy) and "TR" (Therapeutic Rehabilitation). The preprinted MTP Form did not include treatment goals for the physician. These preprinted goals were a list of the different clinical discipline expectations for the patients or treatment compliance issues. The goals were not individualized, observable, measurable, or written in behavioral terms. Most goals identified in the MTPs were identified by nursing, without goals from other disciplines. This failure results in a document that failed to identify patients expected treatment outcomes in a manner that staff could observe or measure to determine positive or negative patient's outcomes.

Findings include:

A. Policy Review

The facility's policy titled "Patient Care Procedures" effective 9/16 and revised 11/16, stated the following requirements: "The plan of care includes: Goals: Expressed in a manner that captures the patient's words or ideas, that build on the patient's strengths. Support the transition to community integration when identified as a need during assessment. Xxx Barriers that might need to be considered include co-occurring illnesses, cognitive and communicative disorders, development disabilities, vision or hearing disabilities, physical disabilities, and social environment factors." Also, the policy required that "Objectives: Include identified steps to achieve the goals, Are sufficiently specific to assess progress of the individual served; Are in terms that provide indices of progress." The facility did not comply with these policy requirements.

B. Medical Record Review

1. Patient A1 was admitted 4/18/19 with the chief complaints of verbal and physical aggression. The MTP, dated 4/18/19, included the following psychiatric problem: "Alteration of Perception Related to Cognitive Impairment Disease Process of psychosis..." There was no long-term goal identified for this problem.

Deficient treatment goals (identified by discipline) included the following:

Nursing: There were no treatment team goals identified by nursing for this problem.

Therapist: "Demonstrate Reality-Based Behavior Patterns, Free from Hallucinations/Delusions AEB [As Evidenced By]: Oriented Thought Process is Manifest with Minimal Bizarre Content, Responds to Verbal Cues Spontaneously, and Follows a Train of Conversation While Remaining Alert and Focus [sic] within [left blank] Days." This same goal statement was also checked in the MTP for Patient A6.

Therapeutic Rehabilitation: There were no treatment team goals identified by therapeutic rehabilitation staff for this problem.

The goal statement listed above included treatment compliance issues or what the staff was expecting for the patient. The statement was not observable or measurable or written in behavioral terms. The goal statement was written using words and psychiatric jargon that would not be easily understood by the patient. Therefore, the patient would have a difficult time understanding what to do to accomplish the treatment goal.

2. Patient A2 was admitted 3/28/19 with the chief complaint of paranoid behavior. The MTP, dated 3/28/19, included the following psychiatric problem: "Alterations of mood d/t [due to] manic presentation As Evidenced by: Racing Thoughts, Grandiose thinking ..."
The long-term goal was "Pt [Patient] to have stable and reduced pressured speech prior to discharge."

The deficient treatment team goals by discipline included the following:

Nursing: "Demonstrate Successive Approximation Engagement Through Direct Initiation of Conversation, Participation in Group, Being Out of Room and Engaging Community Program and Peers Within 5 Days." "Demonstrate Improved Mood AEB [as evidenced by] Responding with Stable Mood and Affect, Appropriate to the Situation ..."

Therapist: "Explore Behaviors and Recognize Triggers for the Start of a Mood Episode within 14 Days." "Will Explore identification/incorporation of daily coping Strategies For Mood Management Within 14 days."

Therapeutic Rehabilitation: There were no treatment team goals identified by therapeutic rehabilitation staff for this problem.

The goal statements listed above were not individualized and included treatment compliance issues or what the staff was expecting for the patient such as participating in groups. They were not observable or measurable or written in behavioral terms. The goal statements were written using words and psychiatric jargon that would not be easily understood by the patient. Therefore, the patient would have a difficult time understanding what to do to accomplish treatment goals.

3. Patient A3 was admitted 4/13/19 with the chief complaints of suicidal ideations with no plan and visual hallucinations. The MTP, dated 3/28/19, included the following psychiatric problem: "Alterations of mood d/t depressed presentation as evidenced by Pt tearful and sobbing nonstop." The long-term goal was "Decreased crying spells et [and] increased mood." The deficient treatment team goals by discipline included the following:

Nursing: "Demonstrate Medication/Treatment compliance Within 5 Days." "Verbalize Understanding A Prescribed Treatment/Medication and Desired Outcomes Within 5 Days."

Therapist: There were no treatment team goals identified by the therapist for this problem.

Therapeutic Rehabilitation: There were no treatment team goals identified by therapeutic rehabilitation staff for this problem.

The goal statements listed above included compliance issues or what the staff was expecting for the patient. They were not observable, measurable or written in behavioral terms. The goal statements were written using words and psychiatric jargon that would not be easily understood by the patient. Therefore, the patient would have a difficult time understanding what to do to accomplish treatment goals.

4. Patient A6 was admitted 4/16/19 with the chief complaint of physical aggression. The MTP, dated 4/16/19, included the following psychiatric problem: "Alterations of Perception Related to Cognition Impairment Disease Process of Psychosis." There was no long-term goal identified for this patient and deficient treatment team goals identified by discipline included the following:

Nursing: There were no treatment team goals identified by nursing for this problem.

Therapist: "Demonstrate Reality-Based Behavior Patterns, Free from Hallucinations/Delusions AED: Oriented Thoughts Process is Manifest with Minimal Bizarre Content, Responds to Verbal Cues Spontaneously, and Follow a Train of Conversation While Remaining Alert and Focused within [blank] Days." "Demonstrate improved anxiety, increased focus, attention. Regular [illegible] within 14 days."

Therapeutic Rehabilitation: There were no treatment team goals identified by therapeutic rehabilitation staff for this problem.

The goal statements listed above included treatment compliance issues or what the staff was expecting for the patient. The statements were not observable or measurable or written in behavioral terms. The goal statement was written using words and psychiatric jargon that would not be easily understood by the patient. Therefore, the patient would have a difficult time understanding what to do to accomplish the treatment goal.

5. Patient A8 was admitted 4/12/19 with the chief complaint of suicidal ideations with no plan. The MTP, dated 4/12/19, included the following psychiatric problem: "Alterations of Perception Related to Cognition Impairment Disease Process of Psychosis." The deficient long-term goal was "Pt to have decreased delusions & hallucinations [illegible] elevated mood." The deficient treatment goals identified by discipline included the following:

Nursing: "Engage staff at Least Minimally and 1 to 1 Communication in a Trustful, Non-defensive Open Manner with Gradual Expansion to Small Group Interaction Within [left blank] Days." "Verbalize Understanding of Disease Process and Identify Skills Needed to Enhance Resilience Within 5 Days."

Therapist: There were no treatment team goals identified by the therapist for this problem.

Therapeutic Rehabilitation: There were no treatment team goals identified by therapeutic rehabilitation staff for this problem.

The goal statements listed above included compliance issues or what the staff was expecting for the patient. They were not observable, measurable or written in behavioral terms. The goal statements were written using words and psychiatric jargon that would not be easily understood by the patient. Therefore, the patient would have a difficult time understanding what to do to accomplish treatment goals.

6. Patient A9 was admitted 4/9/19 with chief complaints of "physical aggression" and "paranoia." The MTP dated 4/10/19 included the following psychiatric problem: Problem 1 - "Alt [alteration] of Perception." The long-term goal was "Pt. to have [decreased] behaviors et [and] be less aggressive." This goal was unmeasurable. The deficient treatment team goals identified by discipline included the following:

Nursing: "[Patient] Demonstrate Medications/Treatment Compliance Within 5 Days, Verbalize Understanding of Prescribed Treatment/Medication With Desired Outcomes Within 5 days. Demonstrate Improved Impulse Control with No Overt Aggression Episodes for 5 days. Evaluate and Verbalize Operational Deterrents to Violence Within 5 days. Verbalize the Need to Remain Free from Intoxicating Chemicals Within 5 days."

Therapist: There were no treatment team goals identified by the therapist for this problem.

Therapeutic Rehabilitation: There were no treatment team goals identified by the therapeutic rehabilitation staff for this problem.

The goal statements listed above included compliance issues or what the staff was expecting for the patient. They were not observable, measurable, or written in behavioral terms. The goal statements were written using words and psychiatric jargon that would not be easily understood by the patient. Therefore, the patient would have a difficult time understanding what to do to accomplish treatment goals.

7. Patient A10 was admitted 4/13/19 with the chief complaint of "verbal aggression, SI [suicidal ideation] 0 [zero] plan. The MTP dated 4/13/19 included the following psychiatric problem: "Alteration of Mood RT [Related to] ..." The long-term goal was "Pt. will have elevated moods et [and] participate in programming." The deficient treatment team goals identified by discipline included the following:

Nursing: "Demonstrate Medication/Treatment compliance Within 5 Days. Engage Sleep Regularity Within Minimal Self-Reported Interruptions and Sleep Awakenings at Least 6 Hours Per Night, Within 5 days. Engage Appetite Regularity Eating 100 percent of meals Within 5 Days. Demonstrate Successive Approximation Engagement Through Direct Initiation of Conversation, Participation in group, Being Out of Room and Engaging Community Program and Peers Within 5 Days. Demonstrate Improved Mood and Affect AEB Responding With Stable Mood and Affect, Appropriate to the Situation, With Minimal Excessive Body Posturing/Energy, Display Slower, Focused, Speech Articulation With Normal Cadence and Rhythm With Direct Sustained Eye Contact Within 5 Days."

Therapist: There were no treatment team goals identified by the therapist for this problem.

Therapeutic Rehabilitation: There were no treatment team goals identified by therapeutic rehabilitation staff for this problem.

The goal statements listed above included treatment compliance issues or what the staff was expecting for the patient. They were not observable or measurable or written in behavioral terms. The goal statements were written using words and psychiatric jargon that would not be easily understood by the patient. Therefore, the patient would have a difficult time understanding what to do to accomplish treatment goals.

8. Patient A13 was admitted 3/8/19 with the chief complaint of paranoid delusions. The MTP dated 3/9/19, included the following psychiatric problem: "Risk For Violence/Other Directed." The long-term goal was to "decrease violent behavior with using learned coping skills [sic]."
The deficient treatment team goals identified by discipline included the following:

Nursing: "[Patient] Demonstrate Medications/Treatment Compliance Within 5 Days, Verbalize Understanding of Prescribed Treatment/Medication With Desired Outcomes Within 5 days. Demonstrate Improved Impulse Control With No Overt Aggression Episodes for 5 days."

Therapist: "Identified Basis/Triggers for Aggression and Self-Destructive Behavior Patterns Within 14 Days. Demonstrate Utilization of one coping skill to Increase Productive Expression of Negative feelings and Appropriate Manner within [left blank] days."

Therapeutic Rehabilitation: "Increase Anger Management, Self-Control and Functional Ability as Evidenced by Participating in Community Activities With Socially Appropriate Behavior Within 10 days. Pt will interact with peer's w/o [without] aggressive or violent bx [behavior] w/in [within] 5 days."

The goal statements listed above included treatment compliance issues or what the staff was expecting for the patient. They were not observable, measurable or written in behavioral terms. The goal statements were written using words and psychiatric jargon that would not be easily understood by the patient. Therefore, the patient would have a difficult time understanding what to do to accomplish treatment goals.

9. Patient A15 was admitted 4/11/19 with the chief complaint of anxiety and aggression. The MTP, dated 4/11/19, included the following psychiatric problem: "Problem 2 - Alteration of Mood RT: Depressed Presentation." The long-term goal was "Pt will have increased mood and decrease aggitative [sic] behaviors."

The deficient treatment team goals identified by discipline included the following:

Nursing: "Demonstrate Medication/Treatment compliance Within 5 Days. Engage Sleep Regularity Within Minimal Self-Reported Interruptions and Sleep Awakenings at Least 6 Hours Per Night, Within 5 days. Demonstrate Successive Approximation Engagement Through Direct Initiation of Conversation, Participation in group, Being Out of Room and Engaging Community Program and Peers Within 5 Days. Demonstrate improved mood and affect AEB Responding with Fuller Affect, Direct Eye contact, Increased Animation and Energy, Appropriate Body Posturing and Spontaneous Responses Within 5 Days. Demonstrate Improved Mood and Affect AEB Responding With Stable Mood and Affect, Appropriate to the Situation, With Minimal Excessive Body Posturing/Energy, Display Slower, Focused, Speech Articulation With Normal Cadence and Rhythm With Direct Sustained Eye Contact Within [blank] Days."

Therapist: "Explore Behaviors and Recognize Triggers for the Start of a Mood Episode Within 14 Days"

Therapeutic Rehabilitation: There were no treatment team goals identified by therapeutic rehabilitation staff for this problem.

The goal statements listed above included treatment compliance issues or what the staff was expecting for the patient. They were not observable, measurable or written in behavioral terms. The goal statements were written using words and psychiatric jargon that would not be easily understood by the patient. Therefore, the patient would have a difficult time understanding what to do to accomplish treatment goals.

B. Interviews

1. During the interview on 4/23/19 at 3:05 p.m. with the APRN (Advanced Practice Registered Nurse), the long term and treatment goals listed in the MTPs were discussed. She did not dispute the findings that the goals were not individualized nor measurable. She stated, "I never see the treatment plan, don't sign them, and haven't been asked to sign off on them."

2. During the interview on 4/24/19 at 8:15 a.m. with the Interim Director of Nursing, the nursing goals were discussed. She agreed with the findings that the goals checked on the MTPs were not individualized patient goals, written in behavioral terms, or measurable.

3. During an interview on 4/24/19 at 10:15 a.m. with RN 1, the nursing goals were discussed. RN1 acknowledged that the goals were not individualized or measurable.

4. During a telephone interview on 4/24/19 at 12:15 p.m. with the Medical Director, the long- term and short-term goals in the MTP were discussed. He did not dispute the findings that goals were staff expectation, not individualized nor measurable.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that identified physician, nursing and social work interventions that were individualized and specific to the treatment needs for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). The Master Treatment Plans contained preprinted interventions that were not individualized but instead were routine assessment and generic discipline routine job functions. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings Include

A. Record review

1. Patient A1's MTP, dated 4/10/19, included the following psychiatric problem: "Problem 1 - "Alteration of Perception Related to Cognitive Impairment Disease Process of psychosis." The following generic and routine discipline functions were checked as active treatment interventions in the treatment plan:

Physician/LIP [Licensed Independent Practitioner]: There were no physician/LIP interventions identified to address this problem.

Nursing: There were no nursing interventions identified to address this problem.

Therapy (Clinical Care Services): There were no therapist interventions identified to address this problem.

Therapeutic Rehabilitation: Therapy: There were no therapeutic rehabilitation interventions identified to address this patient.

2. Patient A2's MTP, dated 4/10/19, included the following psychiatric problem: "Problem 1 - "Alterations of mood d/t [due to] manic presentation As Evidenced by: Racing Thoughts, Grandiose thinking ..." The following interventions generic and routine discipline tasks were checked as active treatment interventions in the treatment plan.

Physician/LIP: "Physician/LIP to Assess / Reassess: Mood, Mental Status, /Compliance with Treatment. Therapeutic Treatment interventions of Multidisciplinary Treatment Team and Change in patient status and Needed Modification Plan of Care[sic]." These were routine and generic functions of the physician, not active treatment interventions based on the presenting psychiatric symptoms of this patient. The method of delivery listed under the section titled "Focus, Modality, Amount, Frequency, Duration" was "Treatment Review/Conference and PRN Individual Consultation." The frequency was "4x Week/PRN for TX [treatment] Duration." There was no duration identified, and the "PRN" contact did not represent an adequate frequency of contact for hospital treatment. The RN assigned these interventions and placed his/her [RN's] initials under the section titled "discipline Initials."

Nursing: "Nursing to Assess/Reassess: Sleep Regulation Patterns, Eating Patterns, Physical Status /Vital Signs, "Motivation/Participation Levels." These were routine and generic functions of the registered nurse. The method of delivery listed under the section titled "Focus, Modality, Amount, Frequency, Duration" was "Education Group - 50-60 min [minutes]." There was no focus of treatment for this group based on the patient's identified psychiatric needs.

Therapy (Clinical Care Services): There were no therapist interventions identified to address this problem.

Therapeutic Rehabilitation: There were no therapeutic rehabilitation interventions identified to address this problem.

3. Patient A3's MTP, dated 4/13/19, included the following psychiatric problem: "Problem 1 - "Alterations of mood d/t depressed presentation as evidenced by: Pt [Patient] tearful and sobbing nonstop." The following generic and routine discipline functions were checked as active treatment interventions in the treatment plan:

Physician/LIP: "Physician/LIP to Assess / Reassess: Mood, Mental Status, Energy Fluctuations, Presence of Level SI [suicidal ideation], Therapeutic Treatment interventions of Multidisciplinary Treatment Team." These were routine and generic functions of the physician, not active treatment interventions based on the presenting psychiatric symptoms of this patient. The method of delivery listed under the section titled "Focus, Modality, Amount, Frequency, Duration" was "Treatment Review/Conference and PRN Individual Consultation." The frequency was "4x Week/PRN for TX Duration." There was no duration identified, and the "PRN" contact did not represent an adequate frequency of contact for hospital treatment.

Nursing: "Nursing to Assess/Reassess: Presence of Level of SI, Mood, Affect, Hygiene Status, Sleep Regulation Patterns, Eating Patterns, Fluctuation of Energy, Motivation/Participation Levels, Implementation of Observation / Precautions Ordered." These were routine and generic functions of the registered nurse. The method of delivery listed under the section titled "Focus, Modality, Amount, Frequency, Duration" was "Education Group - 50-60 min [minutes]." There was no focus of treatment for this group based on the patient's identified psychiatric needs.

Therapy (Clinical Care Services): There were no therapist interventions identified to address this problem.

Therapeutic Rehabilitation: Therapy: There were no therapeutic rehabilitation interventions identified to address this problem.

4. Patient A6's MTP, dated 4/16/19, included the following psychiatric problem: "Problem 1 - "Alteration of Perception Related To Cognitive Impairment Disease Process of Psychosis." The following generic and routine discipline functions were checked as active treatment interventions in the treatment plan:

Physician/LIP: There were no physician/LIP interventions identified to address this problem.

Nursing: There were no nursing interventions identified to address this problem.

Therapy (Clinical Care Services): There were no therapist interventions identified to address this problem.

Therapeutic Rehabilitation: Therapy: There were no therapeutic rehabilitation interventions identified to address this problem.

5. Patient A8's MTP. dated 4/12/19, included the following psychiatric problem: "Problem 1 - "Alteration of Perception Related to Cognitive Impairment Disease Process of Psychosis." The following generic and routine discipline functions were checked as active treatment interventions in the treatment plan:

Physician/LIP: "Physician/LIP to Assess / Reassess: Presence and Intensity of Psychosis Mood Alteration and Behavioral Disturbance, Therapeutic Treatment interventions of the Multidisciplinary Treatment Team and Provide Direction, Need for Ordering of Additional Consultations." These interventions were routine and generic functions of the physician, not active treatment interventions based on the presenting psychiatric symptoms of this patient.
The method of delivery listed under the section titled "Focus, Modality, Amount, Frequency, Duration" was "Treatment Review/Conference and PRN Individual Consultation." The frequency was "4x Week/PRN for TX Duration." There was no duration identified, and the "PRN" contact did not represent an adequate frequency of contact for hospital treatment.

Nursing: "Nursing to Assess/Reassess: Presence/Intensity of Psychosis/Mood Alteration and Behavioral Disturbance, Sleep Regulation Patterns, Implementation of Observation / Precautions Ordered, Sleep Regulation Patterns to Reflect 100% within 5 Days, Eating Patterns to Reflect 100% Within 5 Days." These were routine and generic functions of the registered nurse and included staff-oriented goals for the patient instead of what the registered would be doing with the patient in individual or groups sessions to assist him/her in improving presenting psychiatric symptoms. The method of delivery listed under the section titled "Focus, Modality, Amount, Frequency, Duration" was "Education Group - 50-60 min [minutes]." There was no focus of treatment for this group based on the patient's identified psychiatric needs.

Therapy (Clinical Care Services): There were no therapist interventions identified to address this problem.

Therapeutic Rehabilitation: Therapy: There were no therapeutic rehabilitation interventions identified to address this problem.

6. Patient A9's MTP, dated 4/10/19, included the following psychiatric problem: "Problem 1 - "Risk For Violence/Other Directed Harm R/T [Related To]: Psychotic Disorder/External Control, Decreased Reality Orientation [and] Acute Agitation/Rage/Impulse Control." The following generic and routine discipline functions were checked as active treatment interventions in the treatment plan:

Physician/LIP: "Physician/LIP to Assess / Reassess: Mood, Mental Status, Presence of HI (homicidal ideation), and Compliance with Treatment. Therapeutic Treatment interventions of Multidisciplinary Treatment Team and Provider Direction. Change in patient status and Needed Modification Plan of Care. The Need of Transfer to judicial/More Secure Setting. Security, Observation Precautions Status. The Focus listed was "stabilization of Overt Aggressive Behavior." These were the routine generic functions of the physician.

Nursing: "Nursing to Assess/Reassess: Potential for Violence Completing the Overt Aggression scale daily. Presence of HI [homicidal Ideation], Mood, Early Signs of Agitation and Insight Mental Status. Level of Participation/Quality of Interaction with Peers/Staff. Presence of Internal Stimuli/Preoccupation and Implementation of Observations/Precautions and Implementation of Nonphysical De-Escalation Techniques to Reduce Agitation. These were the routine generic functions of the registered nurse.

Therapy (Clinical Care Services): There were no therapist interventions identified to address this problem.

Therapeutic Rehabilitation: Therapy: There were no therapeutic rehabilitation interventions identified to address this problem.

7. Patient A10's MTP, dated 4/13/19, included the following psychiatric problem: "Problem 1 - "Alteration of Mood R/T: "As Evidenced By: Antisocial behavior et [and] not participating in program [skill]." The following generic and routine discipline functions were checked as active treatment interventions in the treatment plan:

Physician/LIP: There were no physician/LIP interventions identified to be implemented for this patient.

Nursing: "Nursing to Assess/Reassess: Presence of Level of SI (Suicidal Ideation), Mood, Affect, and Hygiene Status. Sleep Regulation Patterns, Eating Patterns, Fluctuation of Energy, Motivation/Participation Levels, and Implementation of Observations/Precautions Ordered." These were the routine generic functions of the registered nurse.

Therapy (Clinical Care Services): There were no therapist interventions identified to address this problem.

Therapeutic Rehabilitation: Therapy: There were no therapeutic rehabilitation interventions identified to address this problem.

8. Patient A13's MTP, dated 3/9/19, included the following psychiatric problem: "Problem 1 - "Risk For Violence/Other Directed Harm R/T: Psychotic Disorder/External Control [and] Acute Agitation/Rage/Impulse Control." The following generic and routine discipline functions were checked as active treatment interventions in the treatment plan:

Physician/LIP: "Physician/LIP to Assess / Reassess: Compliance with Treatment. Therapeutic Treatment Interventions of Multidisciplinary Treatment Team and Provide Direction." These were routine and generic functions of the physician, not active treatment interventions based on the presenting psychiatric symptoms of this patient. The method of delivery listed under the section titled "Focus, Modality, Amount, Frequency, Duration" was "Treatment Review/Conference and PRN Individual Consultation." The frequency was "4x Week/PRN for TX Duration." There was no duration identified, and the "PRN" contact did not represent an adequate frequency of contact with this patient for hospital treatment.

Nursing: "Nursing to Assess/Reassess: Presence of HI (homicidal Ideations), Mood, Early Signs of Agitation. Level of Participation/Quality of Interaction with Peers/Staff. Presence of Internal Stimuli/Preoccupation. Implementation of Nonphysical De-Escalation Techniques to Reduce Agitation. Need for initiation of Restraint/Seclusion for Safety as a Last Resort Incorporating Any Special Conditions." These were routine and generic functions of the registered nurse.
The method of delivery listed under the section titled "Focus, Modality, Amount, Frequency, Duration" was "Education groups - 50 to 60 Minutes 2x daily for Duration of Treatment." There was no focus of treatment for this group based on the patient's identified psychiatric needs.

Therapy (Clinical Care Services): "Carry through Warning of Identified Victims to Policy and Procedure and Mandated Reporting as indicated." These were routine and generic functions of the therapist.

Therapeutic Rehabilitation: Therapy: There were no therapeutic rehabilitation interventions identified to address this problem.

9. Patient 15's MTP, dated 4/11/9, included the following psychiatric problem: "Alteration of Mood RT [Related to]: Depressed Presentation, As Evidenced by: Patient is sad and wants to go home." The following generic and routine discipline functions were checked as active treatment interventions in the treatment plan:

Physician/LIP: "Physician/LIP to Assess/Reassess: Mood. Mental Status, Energy Fluctuation, Presence of level of SI [suicide] Therapeutic Treatment Interventions of Multidisciplinary Team and Provide Direction. The need for ordering additional consultations: Observation/Precautions Levels [and] Change in Patient Status and needed Modifications for treatment Plan of Care." These were routine and generic functions of the physician, not active treatment interventions based on the presenting psychiatric symptoms of this patient.
The method of delivery listed under the section titled "Focus, Modality, Amount, Frequency, Duration" was "Medication Management, Treatment Review/Conference and PRN Individual Consultation." The frequency was "4x Week/PRN for TX Duration." There was no duration identified, and the "PRN" contact did not represent an adequate frequency of contact for hospital treatment.

Nursing: "Nursing to Assess/Reassess: Presence of Level of SI, Mood, Affect, Sleep Regulation Patterns, Motivation/Participation Levels [and] Implementation of Observation/Precautions Ordered." These were routine and generic functions of the registered nurse, not active treatment interventions based on the presenting psychiatric symptoms of this patient. The method of delivery listed under the section titled "Focus, Modality, Amount, Frequency, Duration" was Education Group 50 - 60 min [minutes], 2x Daily, for the Tx. [treatment] Duration, Q Shift/PRN [and] Administration of Medications As Ordered." There was no focus of treatment based on the patient's identified needs.

Therapy (Clinical Care Services): There were no therapist interventions identified to address this problem.

Therapeutic Rehabilitation: Therapy: There were no therapeutic rehabilitation interventions identified to address this problem.

B. Interviews

1. During the interview on 4/23/19 at 3:05 p.m. with the APRN (Advanced Practice Registered Nurse), the generic physician/LIP interventions listed in the MTPs were discussed. She stated, "I never see the treatment plan, don't sign them, and haven't been asked to sign off on them. I better read these if they have me responsible [for interventions]."

2. During the Interview on 4/24/19 at 8:15 a.m. with the Interim Director of Nursing, the nursing interventions were discussed. She agreed with the findings that the interventions checked in the MTP were routine nursing care tasks. She stated, "That's how we were trained."

3. During an interview on 4/24/19 at 10:15 a.m. with RN 1, the generic nursing interventions were discussed. RN1 acknowledged the findings and said, "We could do with more training."

4. During the telephone interview on 4/24/19 at 12:15 p.m. with the Medical Director, the intervention being generic discipline tasks were discussed. He stated; I agree."

Based on policy review, medical record review, and interview, the facility failed to ensure that the primary responsible staff person was identified by name for each of the treatment interventions listed in the Master Treatment Plans for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). Instead, each intervention had the staff person initials and discipline. The master treatment plan form had a column for staff to place their initials. This deficient practice results in difficulty identifying the primary responsible person for treatment which may cause a lack of staff accountability for the intervention.
Findings include

A. Policy and Medical Record Review

1. The facility's policy titled, "Plan of Care" effective 9/16 and revised 11/16, did not provide instruction to guide staff on the requirement for the primary responsible staff person to be identified by name in the MTPs.

2. The MTPs for the following active sample patients were reviewed (dates of plans in parentheses): A1 (4/18/19), A2 (3/28/19), A3 (4/13/19), A6 (4/16/19), A8 (4/13/19), A9 (4/10/19), A10 (4/13/19), A13 (3/9/19), and A15 (4/11/19). This review revealed that the column marked "Discipline initial" was left blank or had the initials for nursing, clinical care services, and therapeutic rehabilitation staff listed beside each checked intervention but not the responsible person's name and classification. For the physician, the RN placed his/her initials.

B. Interviews

1. During the interview on 4/23/19 at 3:05 p.m. with the APRN (Advanced Practice Registered Nurse), the missing primary responsible names in the MTPs were discussed. She did not dispute the findings.

2. During the interview on 4/24/19 at 8:15 a.m. with the Interim Director of Nursing, the missing name of the primary nurse responsible for nursing interventions was discussed. She agreed and stated, "We were trained to put initials."

3. During an interview on 4/24/19 at 10:15 a.m., RN1 acknowledged that the name of nurse responsible for nursing interventions was not on the MTPs.

4. During a telephone interview on 4/24/19 at 12:15 p.m. with the Medical Director, the missing name of the clinician responsible for each intervention in the MTPs was discussed. He did not dispute the findings.

Based on document review, medical record review, and interview, the facility failed to ensure that the physician responsible for psychiatric treatment wrote progress notes as stipulated by facility policy for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) and five (5) non-sample active patients selected to review progress notes (A4, A7, A11, A12, and A16). Specifically, since there was no on-site physician, patients were seen for psychiatric treatment for approximately five to ten minutes once per week via electronic telecommunication (a telemedicine process). The physician did not document these contacts in progress notes. The APRN who was onsite at the facility two days per week recorded progress notes without documented physician review. These notes were documented on the form titled "Psychiatric Physician Progress Note." The APRN signed these notes under the section titled "Physician Signature" without identifying her credentials. This practice gave the impression that a physician signed the progress notes. The progress notes written by the APRN were not written daily as required by hospital policy and failed to consistently document progress or lack of progress related to the presenting psychiatric symptoms that resulted in hospitalization. Entries reflected brief observations and failed to indicate how well patients were responding to treatment related to their presenting psychiatric symptoms or problems. Also, the rationale for medication orders or changes was not included in these notes. The absence of comprehensive documentation of each patient's progress prevented an up to date picture of pertinent changes in the patient's psychiatric condition or response to changes in the medication.

Findings include:

A. Document Review

1. The facility's policy titled "Medical Record Content Policy" stipulated that "All entries in the medical record shall be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided ... Physician progress notes shall be documented daily, and as the patient's condition dictates." The facility failed to comply with its policy of daily progress notes documented daily by the physician responsible for psychiatric treatment. Neither the physician responsible for psychiatric issues nor the APRN documented daily progress notes. (See below for findings).

2. A review of the facility's policy titled "Assessment DPU-2023: Progress recording and timeliness of Required Clinical Task Documentation" [no date] stipulated that "Rounding physicians will provide documentation in the physician's notes as well as orders within the physician's orders section ..." The facility did not comply with this policy requirement. The physician saw patients regarding psychiatric issues for approximately five to ten minutes once per week via electronic telecommunication (a telemedicine process). The physician did not document these contacts in progress notes. (Refer to B126 for details).

3. The facility's "Collaborative Practice Agreement for Nurse Practitioner [NP]" signed 10/11/18 by the APRN and 12/11/18 by the Medical Director, stipulated that, " ...The NP is authorized to provide psychiatric and limited medical care under this collaborative practice agreement (CPA) in the inpatient geriatric psychiatric unit ... A collaborating physician, either primary, back-up or on-call, is continuously available to the NP, either in person or by telephone for consultation. The NP will document any consultation with a supervising physician for a specific case in the consumer's medical record." There was no documented evidence that the nurse practitioner received any consultation from the physician regarding psychiatric treatment and medications for any of the nine active sample patients.

4. The facility's "Medical Staff By-Laws" [no date] stipulated, "The word 'physician' shall be defined in accordance with the Centers for Medicare and Medicaid Services in §1861. [42 U.S.C. 1395x] of the Social Security Act as: A doctor of medicine or osteopathy ..." There was nothing in the medical by-laws that addressed the practice of the APRN who was "authorized to provide psychiatric and limited medical care."

B. Medical Record Review - Active sample patients

1. Patient A1, admitted 4/18/19, with diagnoses of "Schizophrenia" and "Anxiety" listed on the psychiatric evaluation dated 4/19/19. There were no progress notes documented as of the morning of 4/23/19.

2. Patient A2, admitted 3/28/19, with diagnoses of "Bipolar d/o [disorder] and delusional d/o" listed in the psychiatric evaluation dated 3/28/19. There were six progress notes completed by the APRN. The information on these forms was brief and cursory such as the progress note dated 4/19/19, under the section titled "Progress" which reported: "Slept 8 hours, eating 75-100%. Cooperative [with] meds [medications], meals ... mood behavior stable. Keeps to self ... Makes contact, verbalizes needs." There was no information regarding the patient's progress or lack of progress related to presenting symptoms of "delusions" and "paranoia" identified in the psychiatric evaluation. These forms showed that the APRN ordered or made medication changes on 4/9/19, 4/16/19, and 4/21/19. There was no evidence in these progress notes to explain the rationale for medications orders or changes. The APRN signed all of these progress notes with no credentials identified in the section titled "Physician Signature." This practice gave the appearance that a physician signed the progress notes. None of the progress notes had documented evidence of being reviewed by the psychiatrist.

3. Patient A3, admitted 4/13/19, with diagnoses of "MDD [Major Depressive Disorder], Neurocognitive d/o and severe vascular dx [diagnosis] with behaviors" listed in the psychiatric evaluation dated 4/13/19. There were two progress notes completed by the psychiatric APRN. The information on these forms was brief and cursory such as the progress note dated 4/19/19, under the section titled "Progress" which noted: "Slept 3 hours, eating 25%. Tearful at noc [night]. 'I wanna be where [s/he] is.' Attending et[and] minimal participation in groups/activities. Distressed affect." There was no information regarding the patient's progress or lack of progress related to presenting symptoms of "hallucinations," "delusions," and "anxiety" identified in the psychiatric evaluation. These forms showed that the APRN changed or increased medications on 4/16/19 and 4/19/19. There was no evidence in the progress notes to explain the rationale for these medications' changes. The APRN signed these progress notes with no credentials identified in the section titled "Physician Signature." This practice gave the appearance that a physician signed the progress notes. None of the progress notes had documented evidence of being reviewed by the psychiatrist.

4. Patient A6, admitted 4/16/19, with a diagnosis of "Dementia" listed in the psychiatric evaluation dated 4/18/19. There was one progress note completed by the psychiatric APRN. The information in the progress note dated 4/19/19, was brief and cursory and reported: "Slept 6 hours, eating 50%. Verbally aggressive [with] staff. Cooperative [with] meds], meals et cares [Comprehensive Assessment and Review for Long Term Care Services]. Verbalize needs with some difficulty." There was no information regarding the patient's progress or lack of progress related to presenting symptoms of "delusions" identified in the psychiatric evaluation. The APRN signed this progress note with no credentials identified in the section titled "Physician Signature." This practice gave the appearance that a physician signed the progress note. There was no documented evidence that the psychiatrist had reviewed this progress note.

5. Patient A8, admitted 4/12/19, with a diagnosis of "Mood d/o - substance induced [sic]" listed in the psychiatric evaluation dated 4/13/19. There were two progress notes completed by the APRN. The information on these forms was brief and cursory such as the progress note dated 4/19/19, under the section titled "Progress" which noted: "Slept 8 hours, eating 100%. Self isolates in room. Cooperative [with] meds. Attending / participating in groups et activities." These forms noted that the APRN changed a medication on 4/16/19. There was no evidence in the progress notes to explain the rationale for this medication. The APRN signed this progress note with no credentials identified in the section titled "Physician Signature." This practice gave the appearance that a physician signed the progress notes. None of the progress notes had documented evidence of being reviewed by the psychiatrist.

6. Patient A9, admitted 4/10/19, with diagnoses of "MDD [Major Depressive Disorder]," Anxiety," and "Dementia" listed in the psychiatric evaluation dated 4/11/19. There were three progress notes completed by the psychiatric APRN. The information on these forms was brief and cursory such as the progress note dated 4/19/19, under the section titled "Progress" which reported: "Slept 4 hours [positive] daytime naps. Eating 75-100%. Aggressive [with] cares. PRN IM given 4/16/19 et 4/17/19 as pt [patient] was danger to self/others." Though the statements regarding aggression reflected symptoms present on admission, there was no synthesis of this information that included a description of the patient's aggressive behavior. Also, there was no information regarding the patient's progress or lack of progress related to presenting symptoms of "aggression" and "delusions" identified in the psychiatric evaluation. These forms noted that the APRN changed medications on 4/9/19, 4/16/19, and 4/21/19. There was no evidence in the progress notes to explain the rationale for these medication changes. The APRN signed all of these progress notes with no credentials identified in the section titled "Physician Signature." This practice gave the appearance that a physician signed these progress notes. None of the progress notes had documented evidence of being reviewed by the psychiatrist.

7. Patient A10, admitted 4/13/19, with a diagnosis of "MDD" listed in the psychiatric evaluation dated 4/13/19. There was one progress note completed by the psychiatric APRN. The information in this note dated 4/16/17 was brief and cursory and under the section titled "Progress" reported: "Slept 6 hours, eating 100%. Refuses meds. Word Salad speech. 'that's not correct [sic].' Cooperative at times. Refuses meals at times. Pt at LTCF [Long Term Care Facility] < 72 hours prior to admission to [name of facility]." There was no information regarding the patient's progress or lack of progress related to presenting symptoms of "Delusions," "anxiety," and depression" identified in the psychiatric evaluation. The APRN signed this progress note with no credentials identified in the section titled "Physician Signature." This practice gave the appearance that a physician signed this progress note. There was no documented evidence that the psychiatrist had reviewed this progress note.

8. Patient A13, admitted 3/8/19, with a diagnosis of "MDD" listed in the psychiatric evaluation dated 3/9/18. There were nine progress notes completed by the psychiatric APRN. The information on these forms was brief and cursory such as the progress note dated 4/16/19, under the section titled "Progress" which noted: "Slept 3 hours, eating 75-100%. Stable self-esteem, compliant [with] meds, meals et cares. Verbalizes needs. Making eye contact. Attending et participating in groups/activities. Difficult to redirect. Passive participation in groups." There was no information regarding the patient's progress or lack of progress related to presenting symptoms of "Delusions," "anxiety" and depression" identified in the psychiatric evaluation. These forms noted that the APRN ordered or made medication changes on 3/9/19, 3/14/19, 3/15/19, 3/21/19, 3/26/19, 4/1/19, and 4/9/19. There was no evidence in the progress notes to explain the rationale for these medications' changes. The APRN signed all of these progress notes with no credentials identified in the section titled "Physician Signature." This practice gave the appearance that a physician signed these progress notes. None of the progress notes had documented evidence of being reviewed by the psychiatrist.

9. Patient A15, admitted 4/11/19, with diagnoses of "Mood d/o" and "Dementia" listed in the psychiatric evaluation dated 4/11/19. There were two progress notes completed by the psychiatric APRN. The information on these forms was brief and cursory such as the progress note dated 4/16/19, under the section titled "Progress" which noted: "Slept 6-8 hours, eating 25-50%. Significant memory impairment. Attending et minimal participation in groups/activities. [illegible word]. Verbalizes needs. Makes eye contact. Cooperative [with] meds, meals et cares." There was no descriptive content regarding the patient's "significant memory impairment." Also, no information regarding the patient's progress or lack of progress related to presenting symptoms of "aggression" and "delusions" identified in the psychiatric evaluation. The APRN signed these progress notes with no credentials identified in the section titled "Physician Signature." Thereby, gave the appearance that a physician signed the progress notes. None of the progress notes had documented evidence of being reviewed by the psychiatrist.

C. Medical Record Review - Non-sample active patients

A review of progress notes for the following non-sample active patients revealed the following findings:

1. Patient A4, admitted 3/26/19, had four progress notes completed by the APRN. The information on these forms was brief and cursory such as the progress note dated 4/12/19, under the sections titled "Progress" which reported: "Slept 8 hours, eating 100%...PRN Haldol/Ativan/Benadryl recently. 4/11/19 [sic]. Manipulative. Difficult to redirect. Tearful at times. Emotionally labile." There was no explanatory or descriptive information regarding the patient's behavior. Also, there was no information regarding the patient's progress or lack of progress related to symptoms of "auditory hallucinations, visual hallucinations, and delusions - somatic, paranoid" checked in the section of the progress note titled "Thought Content." These forms noted that the APRN ordered or made medication changes on 4/1/19, 4/2/19, 4/9/19, and 4/12/19. There was no evidence in the progress notes to explain the rationale for these medications' changes. The APRN signed all of these progress notes with no credentials identified in the section titled "Physician Signature." This practice gave the appearance that a physician signed these progress notes. None of the progress notes had been reviewed and signed by the psychiatrist.

2. Patient A7, admitted 4/17/19, had one progress note completed by the APRN. The information in this note dated 4/23/19 was brief and cursory under the sections titled "Progress" which reported: "Slept 8 hours, eating 100%. Difficult to redirect. Yells out for more smoke breaks. Poor participation in groups/activities. Flat affect. [Illegible word] Makes some eye contact." There was no information regarding the patient's progress or lack of progress related to symptoms of "auditory hallucinations, visual hallucinations, and delusions - somatic, paranoid" checked in the section of the progress note titled "Thought Content."

3. Patient A11, admitted 4/18/19, had one progress note completed by the APRN. The information on this progress dated 4/23/19 was brief and cursory sunder the sections titled "Progress" which noted: "Slept 4 hours, eating 100%. Up all noc, pacing halls, difficult to redirect. Attends et participates in groups/activities. Hyperverbal. Augmentative at noc. Makes eye contact." There was no information regarding the patient's progress or lack of progress related to symptoms of "Delusions - paranoid / somatic" checked in the section of the progress note titled "Thought Content." The APRN signed this progress note with no credentials identified in the section titled "Physician Signature." This practice gave the appearance that a physician signed the progress note.

4. Patient A12, admitted 4/17/19, had one progress note completed by the APRN. The information on this progress note dated 4/23/19 was brief and cursory under the sections titled "Progress" which reported: "Slept 8 hours, eating 100%. Hateful at times, can be difficult to redirect. Cooperative [with] meds, meals et cares. Most of the time attends groups, struggles to participate in groups/activities. Verbal/physical aggression." There was no descriptive information regarding the patient's symptoms and behaviors. Also, there was no information regarding the patient's progress or lack of progress related to symptoms of "Delusion - paranoid, precursory" checked in the section of the progress note titled "Thought Content."

5. Patient A16, admitted 4/18/19, had one progress note completed by the psychiatric APRN.
The information on this progress note dated 4/23/19 was brief and cursory under the sections titled "Progress" which reported: "Slept 8 hours, eating 100%. Cooperative [with] meds, meals, et cares. Withdrawn. Poor attendance at evening groups. Requires coaxing to take meals. CARE assessment pending, Activities reports [s/he] participates in group." There was no descriptive information regarding the patient's withdrawn behaviors. Also, there was no information regarding the patient's progress or lack of progress related to symptoms of "Delusion - somatic" checked in the section of the progress note titled "Thought Content." The progress note showed that the APRN ordered or made a medication change. There was no evidence in this progress note to explain the rationale for the medication change.

D. Interviews

1. In an interview on 4/23/19 at 3:05 p.m. with the APRN (Advanced Practice Registered Nurse), the progress notes were reviewed. She did not dispute the findings and stated, "I need to include more information." When asked about her signature on the progress notes, she admitted she had been signing these forms without her credentials.

2. During the telephone interview on 4/24/19 at noon with the Medical Director, the progress notes were discussed. He agreed that these notes needed more information. When informed that the APRN signed these notes without identifying her credentials, he acknowledged these progress notes should have documented evidence showing a review by him.

Based on policy review, medical record review, and interview, the facility failed to follow its policy in providing timely discharge summaries for three (3) of five (5) sampled discharged patients (D1, D3, and D4). This deficiency results in a failure to communicate in a timely manner psychiatric assessments and discharge plan to providers providing follow-up care.

Findings include:

A. Policy and Medical Record review

1. The facility's policy titled, "Medical Record Content Policy" effective 9/16 and revised 12/16, page 4 sub-heading "The discharge summary or final summary" stated, "A copy of the discharge instruction given to the patient is filed in the medical record. The medical record must be completed within 30 days post patient discharge." The facility did not comply with its policy.

1. Discharged Patient D1, was discharged on 3/12/19; the discharge summary was reviewed and signed on 4/17/19, five days late.

2. Discharged patient D3 was discharged on 3/11/9; the discharge summary was reviewed and signed on 4/17/19, six days late.

3. Discharged patient D4 was discharged on 3/12/19; discharge summary was not in the medical record and could not be located by hospital medical record staff.

B Interviews

1. On 4/23/19 at 2.30 p.m. the missing discharge summary was discussed with the Medical Records Director. She stated, "If I can't find it, I will ask the doctor to do one."

2. During the telephone interview on 4/24/19 at noon with the Medical Director, the past due and missing discharge summaries were discussed. He did not dispute the findings.

Based on interview and document review, the facility failed to provide a physician to supply on-site coverage to treat acutely ill geriatric patients adequately and on a regular basis. Instead, a psychiatrist saw patients for approximately five to ten minutes once per week for psychiatric treatment via electronic telecommunication (a telemedicine process). Specifically, the facility failed to provide an on-site physician to provide, direct, and supervise psychiatric treatment including completing the psychiatric assessment, determining appropriate psychotropic medications, observing and monitoring of patient's condition, and documenting patients' progress during psychiatric treatment. This failure potentially delays the treatment of acutely mentally ill geriatric patients with appropriate psychiatric treatment and psychotropic medications.

Findings include:

A. Interviews

1. In an interview on 4/22/19 at 12:30 p.m., the Chief Executive Officer (CEO) stated that the psychiatrist, who was also the Medical Director, was available via telemedicine on Tuesdays at 2:00 p.m. for the weekly treatment team meeting. He reported that there was no on-site psychiatrist at the facility.

2. In an interview on 4/24/19 at 8:25 a.m., the Interim Director of Nursing (IDON), the availability of the Medical Director and the APRN was discussed. She acknowledged that not having an on-site psychiatrist and APRN to deal with patient care issues on a regular basis placed significant responsibility on the registered nurse.

2. In a telephone interview with the Medical Director on 4/24/12 at noon, the following information was obtained regarding physician coverage at the facility.

a. The Medical Director confirmed that he did not provide on-site contact with patients because of family commitments.

b. He stated he acts as a backup to the Nurse Practitioner [NP] and facility staff was expected to contact him only if they were unable to reach the nurse practitioner. He reported, "They call her first, and I am called if they can't reach her [NP]." Facility staff was expected to call the medical physician for physical care issues.

c. He was asked to explain the comment in the "Medical Staff Meeting minutes" dated 3/22/19 that reported, " ... He [Medical Director] talked about how [name of APRN] is limited on the medications she prescribes ..." The Medical Director explained that he made this comment "because she never uses the full dimension of medications." He noted that the APRN usually orders the same medications "Risperdal" (an anti-psychotic) and "Remeron" (an antidepressant.)

d. When asked about the signatures on the psychiatric evaluation, progress notes, and other forms requiring a physician signature, he reported he was to countersign these forms. When informed that they were not consistently countersigned, he said that the Medical Record Director was supposed to get them to him so they could be signed via DocuSign.

e. When discussing the history and physical examinations, psychiatric evaluation, MTPs, and progress notes, the Medical Director did not dispute the findings regarding the missing components and deficiencies in these documents. He stated, "I agree with everything you are saying."

B. Document Review

1. The CMS Medical Staffing form prepared by hospital staff and signed by the Medical Director on 4/24/19 via DocuSign noted a total of ".1 [one tenth full-time equivalent] physicians" on staff, which represented telemedicine contact once per week starting at 1:00 each Tuesday and on-call coverage when the APRN was not available. The form also showed a total of .4 [four-tenths full-time equivalent] Advanced Practice Registered Nurse, which represented on-site coverage two days per week and on-call coverage when assigned. This staffing pattern resulted in three days during the weekdays that there was no on-site psychiatric coverage at the facility.

2. The facility's "Collaborative Practice Agreement for Nurse Practitioner [NP]" signed 10/11/18 by the APRN and 12/11/18 by the Medical Director, stipulated that, " ...The NP is authorized to provide psychiatric and limited medical care under this collaborative practice agreement (CPA) in the inpatient geriatric psychiatric unit ... A collaborating physician, either primary, back-up or on-call, is continuously available to the NP, either in person or by telephone for consultation. The NP will document any consultation with a supervising physician for a specific case in the consumer's medical record." There was no documented evidence that the nurse practitioner received any consultation from the psychiatrist regarding treatment and medications for any of the nine active sample patients.

3. The facility's "Medical Staff By-Laws" [no date] stipulated, "The word 'physician' shall be defined in accordance with the Centers for Medicare and Medicaid Services in §1861. [42 U.S.C. 1395x] of the Social Security Act as: A doctor of medicine or osteopathy ..." There was nothing in the medical by-laws that addressed the practice of the APRN who was "authorized to provide psychiatric and limited medical care."

Based on record review and interview, the Medical Director failed to monitor, provide sufficient oversight, and take corrective actions to ensure appropriate assessments, diagnosis, and quality psychiatric treatment for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) and five active non-sample patients selected to review physician progress notes. Specifically, the Medical Director failed to:

I. Ensure that a neurological examination was completed for three (3) of nine (9) active sample patients (A1, A2, and A13.) For an additional three (3) active sample patients (A6, A9, and A15), the neurological exam failed to include any information to verify the specific testing performed. This failure to document a neurological examination with specific testing compromises the identification of pathology for geriatric patients, which may be pertinent to their current mental illness and compromises future comparative re-examination to assess the patient's response to treatment interventions. (Refer to B109).

II. Ensure that the psychiatric evaluations for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) were provided by a physician and included all the necessary information to justify the patients' diagnoses and planned treatment. Instead, psychiatric evaluations for these patients were completed by an Advanced Practice nurse without documented physician review. Several content areas in the psychiatric evaluation were cursory and did not include detailed information regarding past psychiatric history, substance abuse, and mental status. The failure to have the psychiatric evaluation completed with comprehensive details and provided under the direction of a physician potentially compromises the formulation of an accurate diagnostic view of the patient, thereby limiting the team's ability to develop a meaningful plan of care to meet the patient's individual psychiatric needs. (Refer to B110).

III. Ensure that the psychiatric evaluations for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) included comprehensive information regarding an estimate of intellectual functioning, memory functioning, and orientation. Lack of this necessary clinical information can negatively affect decision-making on the need of geriatric patients for further evaluation. (Refer to B116).

IV. Ensure that the psychiatric evaluations included an inventory of each patient's personal assets such as accomplishments, skills, or interests written in descriptive and non-interpretative fashion for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). This deficiency results in the lack of necessary information to guide in developing a plan of treatment for the patient. (Refer to B117).

V. Ensure that comprehensive Master Treatment Plans (MTP) for nine (9) of nine (9) sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) were developed and documented. Instead, MTPs were completed separately by each discipline using a preprinted document with treatment goals and interventions assigned by discipline. There was no evidence that the treatment team discussed MTPs during the once-weekly treatment team meetings. Also, the psychiatrist/medical director and APRN were not involved in the development of the Master Treatment Plan. These deficient practices fail to reflect collaborative input by all team members resulting in the potential to compromise patients' opportunity to receive appropriate treatment measures. (Refer to B118-I).

VI. Ensure that Master Treatment Plans (MTPs) were individualized and included all the requirements for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). Failure to develop individualized Master Treatment Plans by the team and with all the required components hampers the staff's ability to provide coordinated interdisciplinary care, potentially resulting in the treatment needs of patients not being met. (Refer to B118-II)

VII. Ensure that the physician responsible for psychiatric treatment wrote progress notes as stipulated by facility policy for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) and five (5) non-sample active patient selected to review progress notes (A4, A7, A11, A12, and A16). Instead, progress notes were written by the APRN without physician review. These notes failed to document progress or lack of progress related to the presenting psychiatric symptoms and rationale for medication orders and changes. The absence of comprehensive documentation of each patient's progress prevented an up to date picture of pertinent changes in the patient's psychiatric condition or response to changes in the medication. (Refer to B126)

VIII. Ensure that discharge summaries were completed according to the facility's policy in providing timely discharge summaries for three (3) of five (5) sampled discharged patients (D1, D3, and D4). This deficiency results in a failure to communicate in a timely manner psychiatric assessments and discharge plan with providers providing follow-up care. (Refer to B133).

IX. Ensure the presence of a physician to provide on-site coverage to treat acutely ill geriatric patients adequately and provide consistent oversight and supervision of psychiatric treatment on a regular basis. Instead, a psychiatrist saw patients for approximately five to ten minutes once per week via electronic telecommunication (a telemedicine process). Other care of the patients was relegated to an APRN, who was only at the facility two weekdays per week. This failure potentially delays the treatment of acutely mentally ill geriatric patients with appropriate psychiatric treatment and psychotropic medications. (Refer to B142).

Based on record review and interview, the facility failed to employ a Director of Nursing (DON) with a Master's Degree in Psychiatric Nursing, or alternatively provide sufficient consultation or continuing training to the DON. The DON did not have documented evidence of supervisory consultation from a nurse with a Master's degree in Psychiatric/Mental Health Nursing or ongoing training in psychiatric/mental health nursing. This failure results in the facility not having a qualified nursing director to manage psychiatric/mental health nursing care of the patients.

Findings include:

A Record Review

On 4/23/19 at 4:00 p.m. the Nurse Surveyor reviewed the personnel file for the Interim Director of Nursing (IDON) and found that she graduated from an Associated Degree in Nursing (ADN) program in 1999. The resume of the Registered Nurse listed as the IDON consultant was provided by the hospital and was reviewed. The Nurse consultant graduated with a Master's Degree in Nursing Administration in 2018, and there was no evidence on record supporting ongoing training in psychiatric/mental health nursing for this individual. Neither the IDON nor the Nurse consultant met the educational requirement for either position.

B. Interview

During an interview on 4/24/19 at 8.25 a.m. with the IDON, her credentials were reviewed. She confirmed that she has an ADN and is currently taking classes toward her Bachelor of Nursing Degree.

Based on record review and interview, the Director of Nursing failed to monitor and take corrective action to:

I. Ensure that nurses taking verbal orders documented them accurately on the form titled "Admit Orders / Preliminary Plan of Care." Specifically, telephone orders were recorded as being ordered by the psychiatrist when they were orders received from the APRN for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). This deficient practice results in the lack of appropriate monitoring of medication orders resulting in falsified medical documentation.

Findings include:

A. Medical Record Review

The forms titled "Admit Orders / Preliminary Plan of Care" were reviewed, dates of forms in parentheses: A1 (4/18/19), A2 (3/27/19), A3 (4/13/19, A6 (4/16/19), A8 (4/12/19), A9 (4/10/19), A10 (4/13/19), A13 (3/9/19, and A15 (4/11/19). This review revealed that the section of the form titled "Admit to the Care of"' contained the name of the Medical Director. The following section contained the RN's signature and identified the Medical Director as the physician receiving the read back verbal orders. This section read: "Physician Certification: My signature below indicates that I certify that the level of care prescribed is medically necessary ... and the patient is in need of diagnostic studies to formulate a plan of treatment." "RBVO [Read Back Verbal Order] Nurses Sig [registered nurse signature] via Dr/LIP [Medical Director's name] - Date/Time _____. [varied]"

B. Interviews

1. During a confidential interview, the Read Back Verbal Order section of the "Admit Orders / Preliminary Plan of Care" Form was discussed with Staff A. Staff A stated that the orders were from the APRN and stated, "[Staff] was told to do this because [psychiatrist's name] is the physician."

2. During the interview on 4/24/19 at 8:25 a.m. with the Interim Director of Nursing, the above practice was discussed. She did not dispute the findings and stated, "You make me want to cry."

3. In the telephone interview on 4/24/19, the Medical Director stated he acts as a backup to the Nurse Practitioner and facility staff was expected to contact him only if they were unable to reach the Nurse Practitioner (APRN). He stated, "They call her first, and I am called if they can't reach her [APRN]." He reported he handled psychiatrist issues only.

II. Ensure that short-term nursing goals in Master Treatment Plans (MTPs) for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) were written in observable, measurable and behavioral terms to address the individual patient presenting problems and needs (Refer to B121).

III. Ensure the development of individualized treatment plans which clearly delineated nursing interventions to address specific patient problems and assist patients in accomplishing treatment goals. Specifically, Master Treatment Plans (MTPs) included routine and generic nursing functions such as assessing, reassessing, and motivating, written as active treatment interventions for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). This deficiency potentially results in nursing staff not being able to provide consistent and focused active treatment. (Refer to B122).

IV. Ensure that the name and of the nursing staff person(s) responsible for specific nursing interventions were identified in the Master Treatment Plans (MTPs). This practice resulted in the facility's inability to monitor the nursing staff's accountability for modalities. (Refer to B123).

Based on observation, document review and interview the facility failed to provide an adequate number of Registered Nurses (RNs) to provide active treatment interventions, supervise paraprofessional staff, and monitor patients. The facility's staffing of RNs results in the lack of active treatment provided by registered nurses and limited direction and supervision of paraprofessional staff in the provision of psychiatric nursing care and may potentially comprise patient safety.

Findings include

A. Observations

1. Observations occurred on 4/22/19 from 2:30 - 3:30 p.m. and 4/23/19 from 11:00 - 11:50 a.m. The census on the unit was 17 and 16 patients on 4/22/19 and 4/23/19 respectively. During these times, the registered nurse (RN) rarely left the nursing station. The RN duties included admitting patients, completing the paperwork associated with admission and discharge, obtaining telephone orders, and answering the office phone. These work assignments represented a heavy workload for one RN. While the RN stayed busy in the nursing station, there were limited active treatment interventions implemented and limited supervision of the Mental Health Technicians (MHTs).

2. The Licensed Practical Nurse (LPN) duties were administering medications to 17 patients, giving treatments, transcribing orders, and teaching the health education group, and completing group notes for up to 10 patients.

B. Document Review

1. The "Direct Nursing Staffing Form" completed by the IDON for the period of 4/15/19 through 4/22/19 revealed the following daily staffing. This staffing pattern showed that no nurse supervisor was available to provide RN coverage for meal and bathroom breaks. [Note: The IDON, during the interview on 4/23/19 at 8:32 a.m., stated that nursing staff did not take meal breaks but were paid for the required 30 minutes breaks].

4/15/19, 7:00 a.m. 7:00 p.m. shift: One RN, Zero LPN, and 4 MHTs. 7:00 p.m. to 7:00 a.m. shift: One RN, One LPN, and 3 MHTs. The census was 17.

4/16/19, 7:00 a.m. 7:00 p.m. shift: One RN, One LPN, and 4 MHTs. 7:00 p.m. to 7:00 a.m. shift: One RN, Zero LPN, and 3 MHTs. The census was 17.

4/17/19, 7:00 a.m. 7:00 p.m. shift: One RN, One LPN, and 4 MHTs. 7:00 p.m. to 7:00 a.m. shift: One RN, One LPN, and 3 MHTs. The census was 17.

4/18/19, 7:00 a.m. 7:00 p.m. shift: One RN, One LPN, and 3MHTs. 7:00 p.m. to 7:00 a.m. shift: One RN, One LPN, and 3 MHTs. The census on this day was 14.

4/19/19, 7:00 a.m. 7:00 p.m. shift: One RN, One LPN, and 4 MHTs. 7:00 p.m. to 7:00 a.m. shift: One RN, One LPN, and 3 MHTs. The census was 15.

4/20/19, 7:00 a.m. 7:00 p.m. shift: One RN, One LPN, and 3 MHTs. 7:00 p.m. to 7:00 a.m. shift: One RN, Zero LPN, and 3 MHTs. The census was 16.

4/21/19, 7:00 a.m. 7:00 p.m. shift: One RN, Zero LPN, and 4 MHTs. 7:00 p.m. to 7:00 a.m. shift: One RN, One LPN, and 3 MHTs. The census was 16.

4/22/19, 7:00 a.m. 7:00 p.m. shift: One RN, One LPN, and 3 MHTs. 7:00 p.m. to 7:00 a.m. shift: One RN, One LPN, and 3 MHTs. The census was 17.

2. Review of the "Nursing Needs Assessment" Form completed on 4/23/19, for the unit revealed a high acuity level and the following care needs:

a. Fifteen patients were classified as being potentially assaultive. Two patients were classified as having low suicidal risk and required some protection against impulses. Two patients were classified as in an intermediate risk with a high potential for self-injury; required close observation. Two patients classified as an acute risk for suicide and in immediate danger of suicide. Eight patients were experiencing active hallucinations/delusion and were in potential jeopardy due to these disturbances in thought processes.

b. Special Status patients included: Fifteen (15) on assault precautions. Twelve (12) patients were on elopement precautions. Two patients were on fall precautions and three (3) patients were classified as being constantly demanding of staff times (e.g., requests and interruptions).

3. The Nursing Needs Assessment data also showed the unit had an average of six (6) discharges per week on the day shift and one (1) on the evening shift.

4. The "Nursing complement Data" Form revealed nursing staff showed two FTEs for RNs assigned to the day shift and no FTEs for RNs for the night shift. This number of FTEs was not sufficient to provide 24/7 RN coverage for the facility. The IDON was staffing the night shift with agency or per diem RNs, and she worked the night shift if these RNs were unavailable. The vacancies and leave of absences section of the form revealed two RN vacancies on the night shift.

5. The Interim Director of Nursing, in addition to her administrative responsibilities, frequently had to provide RN coverage due to insufficient RN staff. The IDON confirmed she had to cover the unit on the 7p - 7a shift on 4/21/19.

C. Interview

1. During an interview on 4/24/19 at 8:25 a.m., the staffing was discussed with the Interim Director of Nursing (IDON) after reviewing the "Direct Nursing Staffing Form" for the first day of the survey 4/22/19 and the week of 4/15/19 to 4/21/19. She did not dispute the findings of insufficient RN staff to provide active treatment. She stated, "I already know the night shift is two RNs short."

2. During an interview on 4/24/19 at 10:15 a.m. with RN1, the findings of the overly busy work schedule of the RN was discussed. RN1 concurred with the findings and stated, "Someone stationed at the desk to answer the phone would help."

Based on staff interviews, the facility has not ensured the availability of services by a licensed psychologist for the geriatric patients in its care. This deficiency potentially results in patients not receiving the full array of diagnostic and intervention services when needed, and patients' needs not being met in a timely manner.

Findings include:

Interview

1. During the telephone interview on 4/24/19 at 12:15 p.m., the Medical Director stated that he was not aware of a contract for psychological services.

2. During an interview on 4/24/19 at 1:00 p.m., the Chief Executive Officer (CEO) stated he did not have a contract for psychological services for the facility.

Based on medical record review and staff interview, the Director of Social services failed to:

I. Ensure that the Psychosocial Assessments included a comprehensive statement of conclusion and recommendations for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A9, A10, A13, and A15). These assessments did not document detailed summarized information or conclusions and recommendations regarding the social evaluation of deficits or presenting psychiatric problems, high-risk psychosocial issues, anticipated necessary steps for discharge to occur, or and the anticipated social work role in treatment during hospitalization. This failure to comprehensively assess the patient's psychosocial needs potentially resulted in suboptimal inpatient progress and inadequate discharge care plans. (Refer to B108).

II. Ensure that short-term goals in MTPs for five (5) of nine (9) active sample patients (A1, A2, A3, A6, A13, and A15) were identified by social work staff and written in observable, measurable and behavioral terms to address the individual patient presenting problems and needs. Social worker staff did not identify treatment team goals for four (4) of nine (9) active sample patients (A3, A8, A9, and A10). (Refer to B121).

II. Ensure the development of individualized treatment plans which clearly delineated social work interventions to address specific patient problems and assist patients in accomplishing treatment goals. Specifically, Master Treatment Plans (MTPs) included routine and generic social work functions written as active treatment interventions for one (1) of nine (9) active sample patients (A13). Social work staff did not identify interventions for eight (8) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, and A15). This deficiency potentially results in social work staff not being able to provide consistent and focused active treatment. (Refer to B122).

III. Ensure that the name and discipline of the social work staff responsible for specific social work interventions that were identified in the Master Treatment Plans (MTPs). This practice results in the facility's inability to monitor the social worker's accountability for modalities. (Refer to B123).

Based on document review, observation, and interview, the facility failed to have a sufficient number of qualified therapeutic rehabilitation (TR) staff to plan and implement a structured therapeutic rehabilitation program for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). Specifically, there were no structured therapeutic activities and active treatment interventions offered by TR staff during evenings and weekends. Also, none of the active sample patients had active treatment interventions by TR included in the Master Treatment Plan (MTP). This failure results in patients not receiving active treatment at the intensity and frequency necessary for psychiatric hospital treatment, potentially delaying recovery.

Findings include:

A. Document Review

1. The MTPs for the following active sample patients were reviewed (dates of plans in parentheses): A1 (4/18/19), A2 (3/28/19), A3 (4/13/19), A6 (4/16/19), A8 (4/13/19), A9 (4/10/19), A10 (4/13/19), A13 (3/9/19), and A15 (4/11/19). This review revealed that none of the active sample patients' MTPs included therapeutic rehabilitation staff interventions in the Master Treatment plan.

2. A review of the unit schedule showed that two groups from 10:00 to 10:45 a.m. and 11:00 a.m. to 12:00 p.m. titled "Group B Psychotherapy/Group A - Activity Group" were scheduled four days per week on Mondays, Tuesdays, Thursdays, and Fridays. Two groups with the same title were scheduled on Wednesdays from 1:00 p.m. to 2:00 p.m. and 2:00 p.m. to 3:00 p.m. These groups were generally held for 45 minutes. Patients assigned to Group A were classified as the higher functioning patients or Group B, the lower functioning patients. There were no active treatment groups provided by TR staff after hours or on weekends.

B. Observations

1. During an observation on 4/22/19 at 10:15 a.m., the group on the unit schedule was conducted by the Activity Coordinator, with seven patients who were identified as lower functioning (Group B). The group was a discussion regarding, "What are the stages of Behavior." The group leader used a whiteboard to record patients' responses. Two patients were sleeping, and one patient had his/her head on the table. During an interview after the group at 10:45 a.m., the Activity Coordinator stated she tries to find time to do a one on one with patients regarding the group topic for about five minutes. She reported that the patients identified as higher functioning were discussing the same topic with the Director of Social Work.

2. During an additional observation of groups provided by the Activity Coordinator on 4/22/19 at 11:10 a.m. and on 4/23/19 at 11:25 a.m., Group A, the higher functioning patients, discussed the same group topic that was presented during the 10:15 a.m. observation. The group leader did not use any different group techniques or strategies for the patients in the lower functioning groups. Most of these patients had cognitive impairments or memory issues and struggled with the discussion type group.

C. Interviews

1. In the interview on 4/22/19 at 10:45 a.m. with the Activity Coordinator, the facility's TR program was discussed. She stated she was not involved in determining the group topics or the patients' level of functioning and said, "I go by directions from [the Director of Social Work]." She stated that she had completed a Bachelor degree in Recreational Therapy and Psychology and was studying to obtain her Certification in RT. The surveyor was unable to verify the Activity's Coordinator's degree in her personnel folder.

2. In an interview on 4/23/19 at 4:15 p.m. with the Director of Social Work, who provided oversight of Therapeutic Rehabilitation (TR) staff, the following information was obtained:

a. When asked about the facility's Therapeutic Rehabilitation program, the SW Director stated that she was not aware of a written description of the therapeutic and rehabilitative activities provided for the geriatric patients served by the facility. She acknowledged that the schedule did not identify an array of TR activities and that there was "no curriculum for psychoeducational groups" on the unit schedule. She stated, "We hope to get there." When discussing assigning patients according to their level of functioning, she admitted that they did not use a formal assessment instrument to determine patients' level of functioning. She stated, "I ask the charge nurse to give some ideas about which group patients should be assigned."

b. When asked about TR staffing and the lack of evening and weekend therapeutic activities, she reported there was one full-time TR staff (the Activity Coordinator) employed two weeks ago. She stated that until that time, the facility had no TR staff.