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

I. Ensure that comprehensive treatment plans were formulated for 2 of 8 active sample patients (N3 and W8) that addressed all acute or new-onset medical problems. The absence of an integrated, comprehensive treatment plan that includes medical issues needing treatment during the hospitalization results in delay in the recognition and provision of timely treatment of co-occurring medical conditions in patients already compromised by psychiatric illness. (Refer to B118)

II. Ensure that active treatment was provided for 2 of 8 active sample patients (N3 and W8). On admission (6/17/12), Patient N3 had a raised, erythematous, pruritic rash of unclear causation on both forearms in addition to psychiatric problems. There was no documentation of further medical assessment or active treatment for the rash by the psychiatric or medical staff, or of the patient's response to treatment until the first day of the survey (6/20/12). Patient W8, admitted on 6/8/12, refused to eat or drink fluids for several days. This problem was identified and documented by the nursing staff, but it was not adequately evaluated by the attending psychiatrist or a general medical practitioner, nor was it included on the Master Treatment Plan as a problem. Thus, specific guidelines for adequate fluid and nutritional intake were not provided to the nursing staff. Failure to ensure active treatment from medical professionals results in the potential for delay in the recognition and timely treatment of co-occurring medical problems detrimental to patient well-being, safety, and recovery. (Refer to B125)

Based on record review and interviews, the facility failed to ensure that comprehensive treatment plans were formulated for 2 of 8 active sample patients (N3 and W8) that addressed all acute or new-onset medical problems. The absence of an integrated, comprehensive treatment plan that includes medical issues needing treatment during the hospitalization results in delay in the recognition and provision of timely treatment of co-occurring medical conditions in patients already compromised by psychiatric illness.

Findings include:

A. Active sample patient N3

1. N3 was admitted to the facility on 6/17/12. On admission, in addition to psychiatric problems, the patient presented with a raised, erythematous, and pruritic rash on both forearms, leading the doctor performing the Admission Physical Exam (dated 6/17/12) to question whether the rash was the manifestation of sun poisoning or toxic dermal necrolysis. In the assessment/plan section of the Physical Exam, the examining physician wrote: "? sun 'allergy' or toxic dermal necrolysis...will rx [treat with] prednisone x 2 more days."

2. When the team convened to develop the Master Treatment Plan on 6/18/12, the attending psychiatrist did not ensure that the rash on the patient's forearms would be included on Axis III as a substantiated diagnosis or identified as a problem to be addressed with specific nursing and medical interventions.

3. The problem, "Rash both arms as evidenced by red raised rash, itching" was added to the Master Treatment Plan on 6/19/12, with only the following nursing interventions developed: "monitor for S/S [signs and symptoms] infection" and "monitor effects of medication." No interventions by the team psychiatrist or non-psychiatric medical personnel were documented for ongoing evaluation or treatment of the rash.

4. A referral for a "medicine consult re pain + rash" was mentioned for the first time in a Psychiatry Daily Clinical Note of 6/20/12. However, identified goals and medical interventions were still not added to the Master Treatment Plan when reviewed by the surveyor later in the day on 6/20/12 and again on 6/21/12.

5. In an interview on 6/20/12 at 10:30a.m., patient N3 stated that the rash was still causing distress and "bothering me." The patient also said, "I feel like I've been forgotten...they told me I would see the medical doctor yesterday and then promised me I would see the doctor today."

B. Active sample patient W8

1. W8 was admitted to the facility on 6/8/12. The problem, "new-onset repeated refusal to take fluids and food by mouth" was identified by nursing on 6/09/12. The problem was documented in the following Interdisciplinary Progress Notes:

(6/9/12; 1330 (1:30 p.m.): "without fluid and without food intake. Refused O.J [orange juice] ...Lunch without intake food or fluids"
(6/9/12; 2240 (10:40p.m.): "Refused meal...."
(6/10/12; 1330 (1:30p.m.): "Pt declined offered meals...despite encouragement from staff"
(6/10/12; 2245 (10:45p.m.): "Pt was non compliant with meals and fluids prior to 2225 (10:25 p.m.) trip to dining room"
(6/11/12; 1437 (2:37p.m.): "Pt has refused all offered groups, meds and meals..."
(6/12/12; 1306 (1:06p.m.): "Pt refused all meds and meals."
(6/13/12; 1530 (3:30p.m.): "...in bed most of the day did take fluids po but no food..:
(6/14/12; 2200 (10p.m.): "During dinner time pt walked down to dining room stared at her plate of food but did not eat one bite."
(6/20 [no year noted]; 1350 (1:50p.m.): "pt has refused all meals today. Pt also refused all offered liquids."

2. The Master Treatment Plan developed on 6/11/12 did not identify the patient's problem with food and fluid intake, and did not delineate specific interventions to be taken by designated nursing and medical personnel.

3. The Master Treatment Plan was reviewed by the treatment team on 6/18/12 at 1:30p.m. The review did not result in any plan revisions/updates to include the patient's fluid and food intake problem.

4. In an interview on 6/20/12 at 2:20p.m., when asked what the main concerns and interventions were for active sample patient W8, RN1 responded, "Hydration and meds." When asked whether the patient's refusal to take fluids and eat were on the Master Treatment Plan, RN1 responded, "No, they're not...they should be there for both nursing and medical (staff)."

5. In an interview on 6/21/12 at 9:40a.m., MD2 was asked if documentation regarding patient W8's refusal to drink and eat had been added to the Master Treatment Plan once it was noted as a persisting problem by nursing staff, and whether the Master Treatment Plan included patient goal(s) and intervention(s) to be provided by designated team members, MD2 stated "No...I didn't feel it was a problem."

Based on record review and interview, the facility failed to consistently provide Master Treatment plans (MTPs) that identified patient centered behavioral short term goals for 8 of 8 active sample patients (N3, N8, N13, S2, S9, S11, W3 and W8). Many of the listed goals were not stated as specific or measurable patient outcome behaviors. The goals also were incorrectly listed as staff goals (expectations) for patient participation in treatment (or treatment compliance) rather than patient outcome behaviors. These deficiencies hamper the ability of the treatment team to provide goal directed treatment and determine effectiveness of interventions based on changes in patient behaviors.

Findings include:

A. Record Review (MTP dates in parentheses)

1. Active sample patient N3 (MTP 6/18/12). The identified problems were: "Psychosocial stressors - non-compliance [with] meds [medication]" and "Relapse on ETOH [alcohol] & [and] crack [cocaine], [no] daily structure." Two staff goals/expectations for patient participation in treatment, (incorrectly listed as patient goals), were: "Meet [with] SW [social worker] daily & discuss d/c [discharge] at least 3 times weekly" and "patient groups daily."

2. Active sample patient N8 (MTP review 6/1/12). For the identified problem, "Depression," a non-measurable goal was "Decrease feelings of frustration when discussing mother."

3. Active sample patient N13 (MTP 6/8/12). An identified problem was "Psychosocial stressors - Etoh [alcohol] abuse, lack of supports/daily structure." Two staff goals for patient participation in treatment (incorrectly listed as patient goals) were: "Meet [with] SW daily & discuss d/c [discharge] at least 3 times weekly" and "Attend groups."

4. Active sample patient S2 (MTP 6/11/12). An identified problem was "Alteration in cognition R/T [related to] Dementia." A staff goal for patient participation in treatment (incorrectly listed as a patient goal) was "pt [patient] will participate in 2 activities daily." For the problem, "Depression," a listed staff goal for the patient was "take meds as prescribed." Another (non-measurable) goal was "pt will be free from suicidal ideas."

5. Active sample patient S9 (MTP 6/4/12). An identified problem was "Alteration in thought process." A non-measurable goal was "use behaviors to decrease stress." For the problem "Alteration in patient's mood and perception," a non-measurable goal was "pt will have significant decline in her symptoms of depression and will not have any hallucinations or anxiety for 3 days in a row." For the problem "Disposition problems," a staff goal for patient participation in treatment (incorrectly listed as a patient goal) was "Pt will participate in d/c planning meetings, voice & allow appropriate referrals."

6. Active sample patient S11 (MTP undated). For the problem "Risk for violence directed towards others." a non-measurable goal was "will learn new coping skills one [sic] week." For the problem "Psychosocial problem," a staff goal for patient participation in treatment (incorrectly identified as a patient goal) was "pt will cooperate with Psychosocial Assessment within 24 hrs [hours] of initial tx [treatment] plan." For the problem "Alt [alteration] in behavior in context of dementia," the staff goal for the patient was "pt will partic (participate) in 2-3 purposeful activities daily within 2 wks [weeks]."

7. Active sample patient W3 (MTP 6/18/12). For the problem "short term memory loss," a non-measurable goal was "pt will be made knowledgeable of treatment process daily." For the problem "psycho/social concerns," staff goals for patient participation in treatment were "Complete psycho/soc ass. [psychosocial assessment]", and "ID [identify] sobriety plan to promote safety."

8. Active sample patient W8 (MTP review 6/18/12). For the problem "psychosis," the non-measurable goal was "client will be free of thought blocking [sic] x [times] 4 days." For the problem "alteration in thought process," the non-measurable goal was "pt will consistently demonstrate an organized approach towards talk within two weeks."

B. Interviews

1. In an interview on 6/20/12 at 12:40p.m., the staff goals for patients (incorrectly written as patient goals), and the non-measurable goals for sample patient N13 were discussed with RN1. RN1 was asked to critique the goals shown to her/him. RN1 stated" they [goals] are not relevant or measurable."

2. In an interview on 6/20/12 at 2:15p.m., the non-measurable goals on the active sample patients' treatment plans were discussed with RN2, who helped train facility staff in treatment plan development. RN2 acknowledged that many of the short term goals were not "measurable, observable, or achievable."

3. In an interview on 6/21/12 at 4:10p.m., the inadequate goals on the patients' MTPs were discussed with the Medical Director. He did not dispute the findings.

Based on record review and interview, the facility failed to provide Master Treatment plans [MTP] that consistently included staff interventions with a specific focus, based on the identified individual treatment needs of 8 of 8 active sample patients (N3, N8, N13, S2, S9, S11, W3 and W8). Many of the listed interventions were generic monitoring and discipline functions to be performed by physician, nursing, social work and/or therapeutic activity staff. In addition, the plans failed to consistently state how these generic modalities would be delivered and how often they would be delivered. These deficiencies result in lack of guidance to staff regarding the specific modalities needed and the purpose for each modality, potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Facility policy #TR-01, titled "Interdisciplinary Treatment Team Planning Meeting," dated 11/18/10, did not include any mention of treatment interventions. The facility revised the Master Treatment plan policy during the Follow-Up survey on 6/20/12, but the plan had not yet been reviewed and approved by the Policy and Procedure committee).

2. Active sample patient N3. The MTP dated 6/18/12, listed the following generic and routine discipline functions for the problem "Bipolar I MRE [most recent episode] dep [depression]": psychiatry - "Assess mental status & [and] safety", "Assess efficacy of meds [medications]." The interventions also lacked a specific focus and frequency.

3. Active sample patient N8. The MTP dated 6/1/12, listed the following generic and routine discipline functions for the problem "chronic pain": Nursing - "Medicate as per MD [doctor] orders."
For the problem "psychosocial," the generic and routine discipline functions were: Social work - "Meet [with] pt [patient] to identify types of stressors to formulate tx [treatment] plans", "sign releases for support, contact support & coordinate care." The interventions also lacked frequency.

For the problem "depression," the generic intervention was: Physician - "Provide [positive] reassurance and [positive] reflective listening."

4. Active sample patient N13. The MTP dated 6/8/12 listed the following generic intervention for the identifying problem of "depression": Psychiatry - "Assess mood, safety & mental status."

For the problem "confusion/hallucinations/delusions," the generic physician interventions were "Assess mental status & safety" and "Monitor labs." The interventions lacked information on delivery and frequency.

For the problem "depression with suicidal ideations," the generic nursing interventions were "monitor safety checks as ordered, encourage use of prn [as needed] medications." These interventions did not describe any specific focus, mode or frequency of delivery.

5. Active sample patient S2. The MTP dated 6/11/12 listed the following generic nursing interventions for the problem of "alteration in cognition r/t [related to] dementia": "provide structure, encourage individual purposeful activities, encourage group activities as able." The interventions lacked focus, mode of delivery or frequency.

For the problem "alteration in thought process r/t psychosis," a generic nursing intervention was "medicate per MD orders."

For the problem "Alt in thought in context of dementia," a generic therapeutic programs intervention was "Provide milieu programs and encourage socialization." This intervention also lacked a specific focus.

For the problem "depression," the generic interventions were: Nursing - "Administer meds as prescribed." MD - "Assess mood & tol [toleration] of meds by daily clinical interview & direct obs [observations] & adjust as needed."

For the problem "psychosocial stressors," the generic social work intervention was "SW complete psychosocial to identify pts needs & preferences."

6. Active sample patient S9. The MTP dated 6/4/12 listed the following generic social work intervention for the problem "disposition problems": "initiate referral to appropriate agencies pursuant to pt needs/wishes."

For the problem "alt in thought/mood," the generic therapeutic activities intervention was "provide group program [with] expressive arts, purposeful activity, exercise...Encourage involvement in daily activities." The interventions also lacked focus and frequency of delivery.

7. Active sample patient S11. The MTP (undated) listed the following generic social work intervention for the problem "psychosocial problem": "Complete psychosocial assessment."

For the problem "risk for falls," the generic nursing intervention was "v/s [vital signs] baseline on admit." This intervention was not specific as to what "baseline" meant for this patient.

For the problem "alt in behavior in context of dementia," the generic therapeutic activities intervention was "provide milieu program including exercise, music, crafts, and individualized activities as tolerated." No focus was mentioned.

8. Active sample patient W3. The MTP update of 6/11/12, listed the following generic therapeutic activities intervention for the problem "alteration in thought process": "Encourage pt to attend daily goals group and set simple and attainable goals."

9. Active sample patient W8. The MTP dated 6/18/12 listed the following generic physician intervention for the problem "psychosis": "MD will order appropriate titrated meds and assess daily."

B. Interviews

1. In an interview on 6/20/12 at 2:15p.m., the generic interventions were discussed with the Nursing Director. She agreed with the findings.

2. In an interview on 6/21/12 at 4:10p.m., the generic interventions were discussed with the Medical Director who said, "I understand what you are saying. We've had education on the treatment plans, but there's still more to be done."

Based on patient record review and interviews, the facility failed to ensure that active treatment measures were provided for 2 of 8 active sample patients (N3 and W8). On admission (6/17/12), Patient N3 had a raised, erythematous, pruritic rash of unclear causation on both forearms in addition to psychiatric problems. There was no documentation that the psychiatric or medical staff provided ongoing medical assessment or active treatment for the rash, or documented the patient ' s response to treatment until 6/20/12. Patient W8, admitted on 6/08/12, refused to drink fluids or eat food. This problem was noted by nursing staff, but it was not adequately evaluated by the attending psychiatrist or a general medical practitioner, nor was it added to the Master Treatment Plan as a problem. Thus, specific guidelines for adequate fluid and nutritional intake were not provided to nursing staff. Failure to ensure needed treatment for co-occurring medical problems can result in detriment to patient well-being, safety, and recovery.

Findings include:

A. Active sample patient N3

1. Patient N3 was admitted to the facility on 6/17/12. In addition to psychiatric problems, the patient presented with a raised, erythematous (reddened), pruritic (itchy) rash on forearms, leading the doctor performing the Admission Physical Exam (dated 6/17/12) to question whether the rash was the manifestation of sun poisoning or toxic dermal necrolysis. In the assessment/plan section of the Physical Exam, the examining physician wrote: "? Sun 'allergy' or toxic dermal necrolysis....will rx [treat with] prednisone x 2 more days."

2. When the treatment team convened on 6/18/12 to develop the Master Treatment Plan, the rash was not identified as needing to be included on the plan, neither as a medical diagnosis on Axis III, nor as a problem to be addressed with specific nursing or medical interventions.

3. The problem "Rash both arms as evidenced by red raised rash, itching" was added to the MTP on 6/19/12, with only the following nursing interventions developed: "monitor for S/S [signs and symptoms] infection" and "monitor effects of medication." No interventions by the team psychiatrist or non-psychiatric medical staff for ongoing evaluation or treatment of the rash were included on the plan.

4. Referral for a "medicine consult re pain + rash" was mentioned for the first time in a Psychiatry Daily Clinical Note of 6/20/12.

5. In an interview on 6/20/12 at 10:30a.m., patient N3 stated that the rash was still causing distress and "bothering me." The patient also said, "I feel like I've been forgotten...they told me I would see the medical doctor yesterday and then promised me I would see the doctor today."

6. A medical nurse practitioner saw the patient to assess the rash for the first time on 6/20/12. A Physician's Progress Note (dated 6/20/12) stated that the visit was for the following reason: "pt still c/o pruritis to B/L [bilateral] arms and neck." A Physician Order, dated 6/20/12 at 11:30a.m. was written for "prednisone 30mg po x 2 days; prednisone 20mg po 6/22 & 6/23; then d/c [discontinue]; D/C Benedryl on 6/22/12."

B. Active sample patient W8

1. W8 was admitted to the facility on 6/8/12. A new-onset repeated refusal to take fluids and food by mouth was identified by nursing staff on 6/09/12. The problem was documented in the following Interdisciplinary Progress Notes:

6/9/12; 1330 (1:30p.m.): "without fluid and without food intake. Refused O.J [orange juice] ...Lunch without intake food or fluids"
6/9/12; 2240 (10:40p.m.): "Refused meal..."
6/10/12; 1330 (1:30p.m.): "Pt declined offered meals...despite encouragement from staff"
6/10/12; 2245 (10:45p.m.): "Pt was non compliant with meals and fluids prior to 2225 (10:25p.m.) trip to dining room"
6/11/12; 1437 (2:37p.m.): "Pt has refused all offered groups, meds and meals..."
6/12/12; 1306 (1:06p.m.): "Pt refused all meds and meals.
6/13/12; 1530 (3:30p.m.): "...in bed most of the day did take fluids po but no food...
6/14/12; 2200 (10p.m.): "During dinner time pt walked down to dining room stared at her plate of food but did not eat one bite."
6/20 [no year noted]; 1350 (1:50p.m.): "pt has refused all meals today. Pt also refused all offered liquids."

2. The Master Treatment Plan developed on 6/11/12 did not identify the patient's refusal to take fluids or eat as a problem or delineate specific interventions to be taken by designated nursing and medical personnel.

3. The Master Treatment Plan was reviewed by the treatment team on 6/18/12 at 1:30p.m. The review did not result in any revisions/updates of the plan to address the patient's refusal to drink fluids or eat meals.

4. The Psychiatry Daily Clinical Notes for the dates 6/13/12 through 6/20/12 did not document any ongoing assessment of patient W8's hydration or nutritional status.

5. In an interview on 6/20/12 at 2:20p.m., when asked what the main concerns and interventions were for active sample patient W8, RN1 responded "Hydration and meds." When asked whether the patient's refusal to take fluids and eat were on the Master Treatment Plan with identified goals and interventions, RN1 responded "No, they're not...They should be there for both nursing and medical (staff)."

6. A medical Nurse Practitioner (NP) saw the patient on 6/20/12. The Physician's Progress Note on 6/20/12 at 1600 (4p.m.) addressed patient W8's decreased po [oral] intake and hydration status for the first time since the 6/8/12 admission to the facility. A physical exam was conducted. (According to documentations on the Admission Physical Exam form for the dates of 6/6/12, 6/10/12, and 6/11/12, previous attempts to perform the admission physical exam were refused by the patient). The NP note documented the patient's blood pressure as "101/50", pulse rate "60", and respiration rate "18"...skin: good turgor, without tenting" but with findings of "+ (positive) edema/swelling R [symbol for 'greater than'] forearm" and an assessment and plan consisting of "no s/sx [signs/symptoms] of dehydration...monitor."

7. Review of Physician Orders did not reveal any orders to the nursing staff for the monitoring of signs or symptoms of dehydration such as the periodic documentation of vital signs, evaluation of skin turgor, or condition of W8's mucous membranes, or presence or absence of tenting.

8. In an interview on 6/21/12 at 9:40a.m., MD2 was asked if he or a medical colleague had been following the nutrition and hydration status of patient W8 since admission. MD2 stated that he had been observing the patient for "skin turgor and dry mucus membranes" and that "there was not a problem with hydration." When asked if these observations and conclusions were documented in the daily clinical notes, MD2 stated "No." When asked if he had ensured that the patient's refusal to drink and eat had been added to the Master Treatment Plan, with patient goal(s) and staff intervention(s) designated team members, MD2 stated "No...I didn't feel it was a problem."

Based on record review and interview, the Medical Director failed to monitor the quality and appropriateness of clinical care provided. Specifically, the Medical Director failed to ensure that:

1. Comprehensive treatment plans were formulated for 2 of 8 active sample patients (N3 and W8) that addressed all acute or new-onset medical problems. The absence of an integrated, comprehensive treatment plan that includes medical issues needing treatment during the hospitalization results in delay in the recognition and provision of timely treatment of co-occurring medical conditions in patients already compromised by psychiatric illness. (Refer to B118)

2. The facility provided Master Treatment plans (MTP) that consistently identified patient centered behavioral short term goals for 8 of 8 active sample patients (N3, N8, N13, S2, S9, S11, W3 and W8). Many of the listed goals were not stated as specific or measurable patient outcome behaviors. Other goals were incorrectly listed as staff interventions or staff expectations for patient participation in treatment. These deficiencies hamper the ability of the treatment team to provide goal directed treatment and determine the effectiveness of interventions based on changes in patient behaviors. (Refer to B121)

3. The facility provided Master Treatment Plans that consistently included interventions with a specific focus, based on the individual treatment needs of 8 of 8 active sample patients (N3, N8, N13, S2, S9, S11, W3 and W8). Many of the interventions on the MTPs were generic monitoring and discipline functions to be performed by physician, nursing, social work and therapeutic activity staff. In addition, the plans failed to consistently state how these generic modalities would be delivered and how often they would be delivered. These deficiencies result lack of guidance to staff, potentially resulting in inconsistent and/or ineffective treatment. (Refer to B122)

4. Active treatment measures were provided to 2 of 8 active sample patients (N3 and W8). On admission (6/17/12), Patient N3 had a raised, erythematous, pruritic rash of unclear causation on both forearms in addition to psychiatric problems. There was no documentation of ongoing medical assessment or treatment for the rash by the psychiatric or medical staff, or the patient ' s response to treatment until 6/20/12. Patient W8, admitted to the facility on 6/8/12, refused to drink fluids and eat food. This problem was noted by nursing personnel, but it was not adequately evaluated by the attending psychiatrist or a general medical practitioner, nor was it added to the Master Treatment Plan as a problem. Thus, specific guidelines for adequate fluid and nutritional intake were not provided to the nursing staff. Failure to ensure active treatment for co-occurring medical problems is detrimental to patient well-being, safety, and recovery. (Refer to B125)

Based on record review and interview, the Director of Nursing failed to monitor the quality and appropriateness of nursing care. Specifically, the Nursing Director failed to:

I. Ensure that the Master Treatment plans of 4 of 8 active sample patients (N8, N13, S2 and S11) included nursing interventions that were specific and related to patients' individual goals and treatment needs. The listed nursing interventions on the patient's MTPs were routine generic nursing functions, inappropriately written as treatment interventions. This failure results in a lack of guidance for nursing staff in providing individualized approaches to patient care that is purposeful and goal directed.

II Ensure that the nursing staff provided adequate fluid and nutritional intake for active sample patient W8 under the guidance and directions of the attending or general practitioner. Failure to ensure active treatment by nursing staff under the directions of medical staff for a co-occurring medical problem is detrimental to patient ' s well-being, safety, and recovery.

Findings include:

I. Failure to ensure individualized nursing interventions on the Master Treatment Plan

A. Record Review

1. Facility policy #TR-01, titled "Interdisciplinary Treatment Team Planning Meeting," dated 11/18/10, does not include any mention of treatment interventions in the policy. [Note: The facility revised the Master Treatment plan policy during the Follow-Up survey on 6/20/12, but the plan had not been reviewed and approved by the Policy and Procedure committee by the end of the survey.]

2. Active sample patient N8. The MTP dated 6/1/12 listed the following generic and routine nursing functions for the identified problem "chronic pain": "Medicate as per MD [doctor] orders."

3. Active sample patient N13. The MTP dated 6/8/12 listed the following generic nursing interventions for the identified problem "depression with suicidal ideations": "monitor safety checks as ordered, encourage use of prn medications."

4. Active sample patient S2. The MTP dated 6/11/12 listed the following generic nursing interventions for the problem "alteration in cognition r/t [related to] dementia": "provide structure, encourage individual purposeful activities, encourage group activities as able." For the problem "depression," the generic nursing intervention was "Administer meds as prescribed."

5. Active sample patient S11. The MTP (undated) listed the following generic nursing intervention for the identified problem "risk for falls": " v/s [vital signs] baseline on admit." This intervention also was not specific as to what "baseline" means.

B. Interview

In an interview on 6/20/12 at 2:15p.m., the generic interventions were discussed with the Nursing Director. She agreed with the findings.

II. Failure to provide treatment for a patient's medical condition under the directions of medical staff

A. Record Review

1. Active sample patient W8 was admitted to the facility on 6/8/12. The problem, "new-onset repeated refusal to take fluids and food by mouth" was identified by nursing staff on 6/9/12. The problem was documented in the following Interdisciplinary Progress Notes:

6/9/12; 1330 (1:30p.m.): "without fluid and without food intake. Refused O.J [orange juice]...Lunch without intake food or fluids"
6/9/12; 2240 (10:40p.m.): "Refused meal..."
6/10/12; 1330 (1:30p.m.): "Pt declined offered meals...despite encouragement from staff"
6/10/12; 2245 (10:45p.m.): "Pt was non compliant with meals and fluids prior to 2225 (10:25 p.m.) trip to dining room"
6/11/12; 1437 (2:37p.m.): "Pt has refused all offered groups, meds and meals..."
6/12/12; 1306 (1:06p.m.): "Pt refused all meds and meals. "
6/13/12; 1530 (3:30p.m.): "...in bed most of the day did take fluids po but no food ...
6/14/12; 2200 (10p.m.): "During dinner time pt walked down to dining room stared at her plate of food but did not eat one bite."
6/20 [no year noted]; 1350 (1:50p.m.): "pt has refused all meals today. Pt also refused all offered liquids."

2. The Master Treatment Plan developed on 6/11/12 did not include the patient's fluid and food intake issue as a problem or delineate specific nursing interventions for this problem, despite the nursing notes (see #1 above) that documented the patient's refusal to drink fluids or eat meals.

3. The Master Treatment Plan was reviewed by the treatment team on 6/18/12 at 1:30p.m. The review did not result in revision/updates to the plan to include the patient's fluid and food intake problem, despite the nursing documentations in the progress notes about the patient's continuing refusal to take fluids or eat.

B Interview

In an interview on 6/20/12 at 2:20 p.m., when asked what the main concerns and interventions were for active sample patient W8, RN1 responded "Hydration and meds." When asked whether the patient's refusal to take fluids and eat were on the Master Treatment Plan with identified goals and interventions, RN1 responded "No, they're not...They should be there for both nursing and medical (staff)."