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Based on interview and document review, the Governing Body failed to ensure systems were effectively established and implemented to ensure care was provided in a safe manner by staff and contracted services. This failure had the potential to affect all current 108 patients in the hospital and any future patients that would be admitted to the hospital.

Findings include:

The hospital was found not to be in compliance with the Condition of Governing Body 42 CFR 482.12. The hospital failed to ensure all services furnished whether performed by direct staff or contract, were provided in a safe and effective manner. Refer to A-0083.

The hospital was found not to be in compliance with the Condition of Patient Rights at 42 CFR 482.13 related to the use of medications for a patient which were excluded from court ordered treatment. Refer to A-0115.

The hospital was found not to be in compliance with the Condition of Quality Assessment and Performance Improvement 42 CFR 482.21 due to the hospital's failure to ensure quality assurance processes were in place to minimize and/or prevent medical errors. Refer to A-0263.

The hospital was found not to be in compliance with the Condition of Nursing 42 CFR 482.23 due to the failure to ensure comprehensive plans of care were developed for nursing services. Refer to A-0385.

Based on interview, document, and document review, the Governing Body failed to have on going effective Quality Assessment Performance Improvement (QAPI) programs for each of the hospital designated areas which include contract services and for the areas that had programs were not always reporting their findings and programs to the overall QAPI program. This had the potential to affect 108 of 108 current inpatients and all future patients.

Findings include:

On 10/21/15, at 9:00 a.m. a meeting was held with the director of quality assurance for the facility. During the meeting an overview of the facility's QAPI program was discussed. The information taken out of the meeting was that the facility did have a QAPI program which included Centers for Medicare and Medicaid (CMS) directed core measures. The CMS directed core measures were the following: initial assessments done within three days, the use of multiple antipsychotic medications and justification, care plans created, care plans to providers within five days, restraint hours, and seclusion hours. The facility's quality programs included: cardiometabolic syndrome screening which included body mass index (BMI), blood pressure (BP), and smoking; inpatient consumer surveys (ICS), reducing admissions, psych evaluations, discharge orders, discharge summaries, medication errors and adverse drug reactions.

The minutes for the QAPI program were reviewed for the following dates: 10/23/14, 1/22/15, 3/26/15, 5/28/15, 7/23/15, and 10/6/15. Areas that were not included in the overall facility quality programs were contracted services which included laboratory and radiology, kitchen, maintenance, rehabilitation services, safety, and medical records.

On 10/23/15, at 9:30 a.m. the senior process improvement and the director of regional affairs at the cooperate level were interviewed by phone. Both of these individuals confirmed the Anoka facility did have a QA program using the CMS core measures. In addition, it was confirmed the facility did not have QAPI program for each area in the facility. They revealed "a few months ago they did not have tools" to collect the data and had been working on the tools since they have been having many surveys. They were going to e-mail the tools, lab, they were proposing for quality after the phone interview. They had a lab process completed which had not been put into effect at the time of the phone interview. The next phase would be to identity each area for quality improvement which had not been done. In addition, they were not aware that some departments (rehab, kitchen, maintenance) had not been reporting data to the facility's QAPI program . They acknowledged the QA policy dated 1/1/15, was the most current policy. These employees further confirmed the facility did not have an effective ongoing QA program at the time of survey. The facility provided the QA outline for lab services after phone interview. Lab QA had not been put into place at time of survey.

Performance Evaluations were done for the contracted radiology and laboratory services on 5/26/15. The documentation indicated there were no concerns with these vendors for either. The facility's QA director was interviewed on 10/23/15, at 2:00 p.m. and confirmed there were no QAPI program with goals for either of these contracted services. The contract for the laboratory services was due to end on 10/31/15, and was being renegotiated with the current vendor. The contract for radiology had been extended from 6/30/15 to 6/30/18.

The Governing Body did not ascertain that all services provided to the patients had QAPI program which identified quality and performance concerns, which implemented appropriate corrective action to improve patient care and to ensure monitoring of the QAPI program was being done. Refer to 0273.

Based on interview and document, it was determined that the hospital failed to promote and protect the rights of 2 of 5 patients (P30, P28) reviewed who had physical/chemical restraints used to manage their behaviors.

Findings include:

The hospital did not meet the Condition of Participation of Patient Rights at 42 CFR 482.13. The cumulative effect of this system failure resulted in the hospital's inability to ensure patient rights were protected and promoted.

Based on documentation and interview, the hospital failed to ensure that 1 of 5 patients (P30) received medications to manage her behaviors in accordance with Court Orders. Refer to A-0131.

Based on documentation and interview, the hospital failed to ensure residents were free from restraints not required to treat medical symptoms for 1 of 1 patient (P28) reviewed. Refer to A-0154.

Based on interview and document review, the hospital failed to ensure a patient, or representative, had the right to participate in the provision of treatment for 1 of 30 patients reviewed (P30) who required psychiatric medication use.

The findings include:

P30 was admitted to the hospital on 9/23/15, with diagnoses including chronic schizoaffective disorder and bipolar disorder.

A psychiatric progress note from 9/30/15, indicated P30 had exhibited increasing agitated behaviors that morning: "...She had come out of her room entirely naked and was screaming and yelling. She was then partially covered with a sheet. She did argue and rant at this writer. She refused redirection...She did accept guidance to the seclusion room and took 20 mg [milligrams] of Zyprexa [an antipsychotic medication] orally....I met with her about 12:15 [p.m.] in the common area. She was sitting by the phone and was yelling and again making religious statements and wanted alcohol. She threatened this writer with physical harm. Despite multiple staff interventions to verbally calm her, she just got more agitated. I indicated she would be getting Haldol IM [intramuscular]." The notes further indicated the patient received Haldol 10 mg, Benadryl 50 mg, and Ativan 2 mg intramuscularly at 12:25 p.m.

The Physician Order indicated Haldol 5 mg orally (po) twice a day (BID) had been prescribed for P30 on 10/2/15, at 1:59 p.m., due to the patient's refusal to accept treatment for "significant hypothermia." Review of the medication administration records revealed P30 received oral Haldol 5 mg on 10/2/15 at 8:21 p.m., on 10/3/15 at 8:58 a.m. and 8:49 p.m., 10/4/15 at 8:29 a.m. and 7:09 p.m., and on 10/5/15 at 8:59 a.m.

Additional review of P30's record revealed a notice from the District Court Judge, to the hospital, dated 10/5/15 which indicated: "HALDOL AND RISPERDAL REMAIN EXCLUDED AND SHALL NOT BE ADMINISTERED. Continued administration of those medications is in violation of this Court's Order. Failure to comply will result in an Order to Show Cause and a hearing as to whether this Court should find the prescribing/administering physician in contempt or violation of this Court's Order..." Subsequently, P30's record revealed a discontinuation order dated 10/5/15, at 12:20 p.m. for the use of the oral Haldol 5 mg.

During interview with the psychiatrist responsible for P30's care, on 10/22/15, at 11:15 a.m., the psychiatrist stated he had been unaware of the Haldol exclusion on the patient's Court Order for use of neuroleptic medication treatment. The psychiatrist provided a copy of a 3/19/15, Court Order which did not indicate any exclusions. However, in Court documents related to the civil commitment of P30, and the use of electroconvulsive therapy, dated 9/9/15, the District Court Judge had added, "Respondent's current neuroleptic treatment order dated March 19, 2015 is amended to exclude Haldol and Risperdal..." The psychiatrist stated he did not think the exclusion for the use of these neuroleptic medications should have been documented on this form. He stated he had not looked in the record to check for any other documentation related to exclusions since he'd reviewed the 3/19/15, Court Order. Additional documentation in P30's record included a hand documented form which had been completed 7/14/15 for "New ECT" Order. The exclusions at the end stated, "current neuroleptic treatment order amended to exclude Haldol and Risperdal."

During interview with the medical records (MR) staff-B on 10/22/15, at 1:00 p.m. she confirmed the Court Order filed 7/14/15, had been received with P30 at the time of admission and had been filed in P30's chart on 9/23/15.

Based on interview and document review, the facility failed to treat an intermittently used Posey device as a restraint, failed to obtain orders for each use, failed to monitor P28 for circulation or adverse outcomes, failed to document start and finish times, and failed to consider alternatives to restraint prior to use of the Posey device restraint for 1 of 1 patient (P28) reviewed who used a Posey restraint.
Findings include:
P28 was admitted to the facility on 10/9/15, with diagnoses which included major neurocognitive disorder, (likely due to alcoholism), dementia, diabetes, hypertension, problems with aggression, and history of falls per the Patient Treatment Plan Report.

The Physician Order dated 10/9/15, noted nursing was to use an adjustable Posey on P28 to "eliminate pt. [patient] falling from wheelchair."

The Patient Treatment Plan Report which included the Comprehensive Plan Update dated 10/15/15, indicated P28 would be free from injury from any potential falls. P28 was impulsive and could be resistive to cues. The intervention was to have nursing utilize a bed alarm and Posey positioning device for use in wheelchair to reduce the risk of P28 getting up impulsively and falling.

A Progress Note dated 10/20/15, read "Staff continue to utilize bed alarm and Posey positioning device for use in wheelchair to reduce risk of getting up impulsively and falling." P28 "continues to be cooperative in using his bed alarm and Posey positioning device in the wheelchair. He maintained it on throughout the shift."

On 10/22/15, at 12:50 p.m. registered nurse (RN)-E was interviewed and stated, according to the record P28 was at risk for falls due to confusion, unsteadiness with ambulation, and forgetfulness. RN-E verified there was no documentation in the record of an assessment for use of the Posey device, monitoring of use, or indications of when it was to be utilized or released. RN-E further stated she was not certain when the Posey was last utilized, but the care plan and explanation in the record indicated it was being used as a restraint. RN-E also confirmed an assessment should have been completed as to the least restrictive measure to be utilized and parameters set up in the treatment plan.

RN-F was interviewed on 10/22/15, at 1:25 p.m. and indicted P28 was very confused and disoriented as to time, place and situation. RN-F indicated P28 was able to follow simple directions and could possibly open the Posey device, but not on a consistent basis. RN-F further replied P28 had an unsteady gait and would impulsively stand and attempt to walk/run away from wheelchair. RN-F confirmed a Posey device was utilized in resident's wheelchair.

The Adult Mental Health Seclusion or Restraint policy dated 9/25/15, identified a restraint as "Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely." The policy also indicated the facility was "to evaluate the patient's immediate situation, the patient reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion."

Based on interview and document review, the hospital failed to ensure a process for Quality Assessment and Performance Improvement (QAPI) activities that reflected the need for patient safety and enhanced health outcomes when providing treatment for behavioral symptoms. This had the potential to affect all 108 patients who received services from the hospital.

Findings include:

The failure to ensure the Quality Assessment and Performance Improvement committee had a process to identify quantitative and qualitative measures in accordance with the hospital's complexity to provide a safe environment when treating individuals with behavioral symptoms resulted in the hospital's inability to determine qualitative assessment measures and implement improvement activities. Therefore, the hospital was unable to meet the Condition of Participation: Quality Assessment and Performance Improvement Program at 42 CFR 482.21. The cumulative effect of this system failure resulted in the hospital's inability to ensure an effective QAPI program.

The deficient practice had the potential to impact all patients receiving services at the hospital.

Based on interview and document review the hospital failed to ensure a Quality Assessment and Performance Improvement program that measured, analyzed and tracked aspects of performance that assess processes of care, hospital service and operations and therefore, failed to use that data to monitor the effectiveness and safety of services and quality of care for all patients including 2 of 30 patients reviewed who had medication/ restraint used to manage behavior with out appropriate orders and/or assessment:

P30, who received an antipsychotic medication identified as an exclusion to her Court Orders. Refer to A-0131

P28 was restrained without appropriate assessment and review. Refer to A-0154

Nursing care plans failed to identify all necessary interventions to meet the needs of patients. Refer to A-0396.

Based on interview and document review, the facility failed to have on going effective Quality Assessment Performance Improvement (QAPI) programs for each of the hospital designated areas and for the areas that had programs were not always reporting their findings and programs to the overall QAPI program. This had the potential to affect 108 of 108 current inpatients and all future patients. In addition, the facility failed to bring forth a medication error for QAPI for 1 of 1 patient (P30) who inadvertently received Haldol and for 1 of 1 patient (P28) who was restrained.

Findings include:

On 10/21/15, at 9:00 a.m. a meeting was held with the director of quality assurance for the facility. During the meeting an overview of the facility's QAPI program was discussed. The information taken out of the meeting was that the facility did have a QAPI program which included Centers for Medicare and Medicaid (CMS) directed core measures. The CMS directed core measures were the following: initial assessments done within three days, the use of multiple antipsychotic medications and justification, care plans created, care plans to providers within five days, restraint hours, and seclusion hours. The facility's quality programs included: cardiometabolic syndrome screening which included body mass index (BMI), blood pressure (BP), and smoking; inpatient consumer surveys (ICS), reducing admissions, psych evaluations, discharge orders, discharge summaries, medication errors and adverse drug reactions.

The minutes for the QAPI meetings were reviewed for the following dates: 10/23/14, 1/22/15, 3/26/15, 5/28/15, 7/23/15, and 10/6/15. Areas that were not included in the overall facility quality programs were contracted services which included laboratory and radiology, kitchen, maintenance, rehabilitation services, safety, and medical records.

The QA director was interviewed on 10/21/15, at 2:00 p.m. and confirmed she called the director of dietary once a year to discuss any issues in dietary. The QA director then confirmed dietary did not have any QAPI programs with established goals. In addition, the QA director confirmed maintenance did not have any QAPI programs and there was no reports of maintenance issues brought forward to the QAPI hospital wide program.

The computer programmer for the facility was interviewed on 10/21/15, at 2:55 p.m. and revealed the facility's computer had many reports that could be pulled up with data. For instance, a safety report can be run with a multitude of items such as small parts or screws loose/shower hooks. The small parts and/or screws had been known to be swallowed by current patients. Self-injurious behavior (SIB) reports can also be run and reviewed for frequency by a patient. The computer program confirmed staff can run reports on just about anything and used for quality improvement.

The facility's QA director was again interviewed on 10/22/15, at 10:30 a.m. and indicated the facility had two projects that they had been working on which were reducing restraints and seclusion and second provisional discharge and risk assessment timeliness.

On 10/22/15, at 3:00 p.m. a meeting was held with the director of psychology (DOP). The DOP confirmed rehabilitation services had been tracking attendance at activities on the weekends since 8/11. The rehabilitation department tracked patient attendance at four activities which included: community resource room, computer usage, library usage, and the fitness center. The data collected was used within the rehabilitation department and had not been shared with the hospital wide QAPI program. The DOP indicated the information had not been requested by the hospital QAPI program and there was not representation from the rehabilitation department on the QAPI committee.

During interview on 10/22/15, at 3:30 p.m. the director of the pharmacy was asked to provide documentation of a QAPI program for the pharmacy department of the facility. The director of pharmacy replied that there was no QAPI program for the pharmacy department.

On 10/23/15, at 9:30 a.m. the senior process improvement and the director of regional affairs at the cooperate level were interviewed by phone. Both of these individuals confirmed the Anoka facility did have a QA program using the CMS core measures. In addition, it was confirmed the facility did not have QAPI programs for each area in the facility. They revealed "a few months ago they did not have tools" to collect the data and had been working on the tools since they have been having many surveys. They were going to e-mail the tools, lab, they were proposing for quality after the phone interview. They had a lab process completed which had not been put into effect at the time of the phone interview. The next phase would be to identity each area for quality improvement which had not been done. In addition, they were not aware that some departments (rehab, kitchen, maintenance) had not been reporting data to the facility's QAPI program. They acknowledged the QA policy dated 1/1/15, was the most current policy. These employees further confirmed the facility did not have an effective ongoing QA program at the time of survey. The facility provided the QA outline for lab services after phone interview. Lab QA had not been put into place at time of survey.

Performance Evaluations were done for the contracted radiology and laboratory services both done on 5/26/15. The documentation indicated there were no concerns with these vendors for either. The facility's QA director was interviewed on 10/23/15, at 2:00 p.m. and confirmed there were no QAPI programs with goals for either of these contracted services. The contract for the laboratory services was due to end on 10/31/15, and was being renegotiated with the current vendor. The contract for radiology had been extended from 6/30/15 to 6/30/18.

The facility's policy, Direct Care and Treatment State Operated Services Quality Improvement Plan dated, 1/1/15, indicated that the Quality Improvement Plan highlighted the quality improvement framework for Direct Care and Treatment/State Operated Services. This document indicated that quality improvement was important and that "we strive to maintain and promote a culture of continuous quality improvement and to partner with the people we serve so they can acquire the tools they need to live independently in their own home that they have chosen in the community." "A culture of continuous improvement takes a methodical team based approach to measuring, evaluating, and improving services throughout the system on a priority basis. With this, quality improvement work occurs at all levels and areas of Direct Care and Treatment/State Operated Services. This includes all systems of care and management." "Successful Quality Improvement processes create feedback loops, by using data to inform practice, measure results, and proactively prevent and reduce risk. Fact-based decisions are likely to be correct decisions." "For continuous improvement of care, statistical tools and methods are needed that foster knowledge and understanding. We use a defined set of analytic tools such as run charts, cause and effect diagrams, flowcharts, Pareto charts, histograms, control charts, Failure Mode and Effect Analysis, Root Cause Analysis, Results Based Accountability, and process mapping to turn data into information." Under continuous improvement, the policy indicated processes must be continually reviewed and improved. Small incremental changes do make an impact and we can almost always find an opportunity to make things better.

The QA policy further outlined there were six sigma which were: (only five were in the policy).
"DEFINE the problem and set the goal: focused not simply on the outcomes, but on the process
MEASURE the defects or process operation. Develop a tool to collect the necessary data. Looking at existing sources that you may already be collecting to help measure the problem.
ANALYZE the data and discover the causes of the problem. Use brainstorming techniques, bar graphs, etc., to help analyze. Identify the process that needs improving (identify the root causes, both direct and indirect)
IMPROVE the process to remove causes of defects. Test solutions a small scale to see if they work. If it doesn't work, try another process.
CONTROL the process to make sure defects don't recur. Establish standard measures to maintain performance."



08769

P30 was admitted to the hospital on 9/23/15, with diagnoses including chronic schizoaffective disorder and bipolar disorder. P30 received Haldol in which there was no order for the Haldol. The medication error was not brought to the attention of the facility's QA director for QAPI.

A psychiatric progress note from 9/30/15, indicated P30 had exhibited increasing agitated behaviors that morning: "...She had come out of her room entirely naked and was screaming and yelling. She was then partially covered with a sheet. She did argue and rant at this writer. She refused redirection...She did accept guidance to the seclusion room and took 20 mg [milligrams] of Zyprexa [an antipsychotic medication] orally....I met with her about 12:15 [p.m.] in the common area. She was sitting by the phone and was yelling and again making religious statements and wanted alcohol. She threatened this writer with physical harm. Despite multiple staff interventions to verbally calm her, she just got more agitated. I indicated she would be getting Haldol IM [intramuscular]." The notes further indicated the patient received Haldol 10 mg, Benadryl 50 mg, and Ativan 2 mg intramuscularly at 12:25 p.m.

The Physician Order indicated Haldol 5 mg po (orally) Bid (twice a day) had been prescribed for P30 on 10/2/15, at 1:59 p.m., due to the patient's refusal to accept treatment for "significant hypothermia." Review of the medication administration records revealed P30 received oral Haldol 5 mg on 10/2/15 at 8:21 p.m., on 10/3/15 at 8:58 a.m. and 8:49 p.m., 10/4/15 at 8:29 a.m. and 7:09 p.m., and on 10/5/15 at 8:59 a.m.

Additional review of P30's record revealed a notice from the District Court Judge, to the hospital, dated 10/5/15 which indicated: "HALDOL AND RISPERDAL REMAIN EXCLUDED AND SHALL NOT BE ADMINISTERED. Continued administration of those medications is in violation of this Court's Order. Failure to comply will result in an Order to Show Cause and a hearing as to whether this Court should find the prescribing/administering physician in contempt or violation of this Court's Order..." Subsequently, P30's record revealed a discontinuation order dated 10/5/15, at 12:20 p.m. for the use of the oral Haldol 5 mg.

During interview with the psychiatrist responsible for P30's care, on 10/22/15, at 11:15 a.m., the psychiatrist stated he had been unaware of the Haldol exclusion on the patient's Court Order for use of neuroleptic medication treatment. The psychiatrist provided a copy of a 3/19/15, Court Order which did not indicate any exclusions. However, in Court documents related to the civil commitment of P30, and the use of electroconvulsive therapy, dated 9/9/15, the District Court Judge had added, "Respondent's current neuroleptic treatment order dated March 19, 2015 is amended to exclude Haldol and Risperdal..." The psychiatrist stated he did not think the exclusion for the use of these neuroleptic medications should have been documented on this form. He stated he had not looked in the record to check for any other documentation related to exclusions since he'd reviewed the 3/19/15, Court Order. Additional documentation in P30's record included a hand documented form which had been completed 7/14/15, for "New ECT" Order. The exclusions at the end stated, "current neuroleptic treatment order amended to exclude Haldol and Risperdal."

During interview on 10/22/15, at 10:47 a.m. the assistant director of nursing was asked to provide documentation of a QAPI program for the nursing department of the facility. She stated that she was not aware of any QAPI program project in the nursing department. She verified being unaware of any QAPI related to the use of Haldol for P30.



30951

P28 was admitted to the facility on 10/9/15, with diagnoses which included major neurocognitive disorder, (likely due to alcoholism), dementia, diabetes, hypertension, problems with aggression, and history of falls per the Patient Treatment Plan Report.

The Physician Order dated 10/9/15, noted nursing was to use an adjustable Posey on P28 to "eliminate pt. [patient] falling from wheelchair."

The Patient Treatment Plan Report which included the Comprehensive Plan Update dated 10/15/15, indicated P28 would be free from injury from any potential falls. P28 was impulsive and could be resistive to cues. The intervention was to have nursing utilize a bed alarm and Posey positioning device for use in wheelchair to reduce the risk of P28 getting up impulsively and falling.

A Progress Note dated 10/20/15, read "Staff continue to utilize bed alarm and Posey positioning device for use in wheelchair to reduce risk of getting up impulsively and falling." P28 "continues to be cooperative in using his bed alarm and Posey positioning device in the wheelchair. He maintained it on throughout the shift."

During interview on 10/22/15, at 10:47 a.m. the assistant director of nursing was asked to provide documentation of a QAPI program for the nursing department of the facility. She stated that she was not aware of any QAPI program project in the nursing department. She verified being unaware of any QAPI for P28 related to restraint.

On 10/22/15, at 12:50 p.m. registered nurse (RN)-E was interviewed and stated, according to the record P28 was at risk for falls due to confusion, unsteadiness with ambulation, and forgetfulness. RN-E verified there was no documentation in the record of an assessment for use of the Posey device, monitoring of use, or indications of when it was to be utilized or released. RN-E further stated she was not certain when the Posey was last utilized, but the care plan and explanation in the record indicated it was being used as a restraint. RN-E also confirmed an assessment should have been completed as to the least restrictive measure to be utilized and parameters set up in the treatment plan.



20810

Based on interview and document review, the hospital failed to ensure plans to meet patient care needs were based on ongoing assessment of individual patient needs for 8 of 8 patients (P8, P9, P30, P1, P2, P5, P13, P14) whose records were reviewed.
Findings include:

The hospital did not meet the Condition of Participation of Nursing Services at 42 CFR 482.23. The cumulative effect of this system failure resulted in the hospital's inability to ensure patient care was implemented based on individual patient needs, physician orders, and nursing assessments. Refer to A-0396.

Based on interview and document review, the hospital did not ensure a comprehensive treatment plan, which included nursing care, was maintained for 8 of 8 patients (P8, P9, P30, P1, P2, P5, P13, P14) whose care plans were reviewed.

Findings include:

Patient P8 was admitted to the psychiatric hospital on 4/14/15, according to the Minnesota State Operated Services Face Sheet. The Psychiatric Assessment data sheet, dated 4/15/15, indicated the patient had diagnoses which included schizo-affective disorder, bipolar type and poly-substance abuse. The assessment indicated the patient had attempted suicide in the past and had a history of violence toward self and others. The treatment and management plan identified on the psychiatric assessment included frequent observations given the history of suicide attempts and self-injury. The assessment also indicated the patient estimated he had attempted suicide 40 to 50 times since age eleven with methods ranging from hanging, running into traffic, cutting, stabbing, and "suicide by cop."

The Nursing Assessment, dated 4/15/15, identified the patient as an emergency admit to the hospital due to psychosis and non-compliance with medications. The patient stated he was admitted to the hospital to get chemical dependency treatment.

The Vulnerability Risk Reduction Plan/Initial Treatment Plan (VRRP), dated 4/15/15, and completed by a registered nurse (RN), identified a risk of self-harm due to self-injurious behaviors and attempts at suicide by hanging. The VRRP was updated to include patient incidents which included: punched/shattered window in dayroom (4/20/15), attempted self-harm by choking himself with a blanket (5/11/15), cutting at wrist (5/20/15), attempted to hang self while in jail (5/21/15), assaulted peer and cut forearm with broken glass (9/15/15), and suicide attempt by tying a shoelace around his neck (9/19/15). The VRRP also identified a risk of aggressive or predatory behavior toward peers which included both physical aggression as well as verbal aggression. The VRRP indicated the patient had made threatening remarks to staff, pulled a phone off the wall and cut his wrist on 5/20/15, and was taken to jail. Although the VRRP/Initial Treatment Plan included many nursing interventions, none of these were on the current Patient Treatment Plan, dated 10/20/15.

The Support Plan, dated 9/4/15, identified patient behaviors which included self-injurious behaviors and property destruction. The plan included coping skills the patient could use as well as precursors the patient exhibited prior to target behaviors. The support plan included interventions staff could use if the patient was showing the beginning of self-injurious behavior or property destruction. An emergency intervention procedure identified in the support plan included allowing the patient to sit in the restraint chair without the application of restraints with a weighted blanket on him and to inform the patient he could leave the restraint room at any time. Staff were directed to remain with the patient the entire time. Staff were directed to apply a restraint as a last resort if all other interventions had failed. None of these interventions or plans were included in the most recent Patient Treatment Plan and Report, dated 10/20/15.

Although the patient had cut his forearm with broken glass on 9/15/15, and had tied a shoe lace around his neck on 9/19/15, the most recent Patient Treatment Plan Report, last updated 10/20/15, no longer addressed a problem related to suicide ideation. Although interventions were used during attempts at self-harm such as close observation and 1:1 observation, these were not identified on the Patient Treatment Plan. Although nursing staff had identified coping mechanism and triggers which provoked aggressive behaviors and suicide ideation in the Vulnerability Risk Reduction Plan (VRRP) and the Support Plan, none of these were included in the Patient Treatment Plan.

Progress notes dated 9/15/15, 9/16/15, 9/17/15 and 10/20/15 indicated the patient was restrained in either the restraint chair or four point restraints. The Patient Treatment Plan, dated 10/20/15, did not address the use of restraints.

A review of the Patient Treatment Plan Report, last updated 9/22/15, identified a problem related to a history of suicide ideation and violence toward other staff and himself. The goal included the patient working with the treatment team to lessen/eliminate impulsive behaviors, including harming himself and aggression toward peers and staff. Although the patient continued to have evidence of suicide attempts and violence to self and others, the status of the goal was identified as "not met but ended" and the date the goal was met, according to the treatment plan, was 9/18/15.


P9 was admitted to the psychiatric hospital on 8/7/15, according to the Minnesota State Operated Services Face Sheet.

The Nursing Assessment, completed 8/7/15, indicated the patient had a history of self-injurious behavior and suicidal thoughts. The patient also had reported a past history of swallowing a razor blade five months earlier. The initial care plan, dated 8/7/15, revealed medical records had indicated the patient reported she would injure herself if left alone and she had followed that with a suicide attempt two weeks earlier. The patient identified triggers to psychiatric symptoms as yelling and screaming, patients fighting and the recent death of her aunt and cousin. The patient identified signs which could indicate she may be stressed as beginning to isolate herself and unwillingness to talk to anyone. The initial care plan indicated the patient would be on frequent observations until further assessment could be completed.

The Psychiatric Assessment, dated 8/7/15, indicated the patient had diagnoses which included a recent suicide attempt by ingesting multiple medications, impulse control disorder, depression and post-traumatic stress disorder.

Although the Vulnerability Risk Reduction Plan (VRRP)/Initial Treatment Plan, completed by nursing and dated 8/7/15, had been updated by nursing to include a suicide attempt since admission and incidents of aggression toward staff and peers, none of this information was included in the Patient Treatment Plan. Although the patient had identified coping skills and staff interventions which could be used to prevent harming herself as well as triggers which provoked aggression, none of these were included in the Patient Treatment Plan. Interventions on the Patient Treatment Plan were generic and were normal functions of the professional disciplines involved in the patient's care and were not individualized to the patient.

P30 was admitted to the psychiatric hospital on 10/1/15, according to the Minnesota State Operated Services Face Sheet.

The admission Psychiatric Assessment, dated 10/2/15, indicated the patient had diagnoses which included bipolar disorder (severe with psychotic features), schizo-affective disorder and alcohol use disorder. The patient also experienced auditory hallucinations. The patient was admitted due to medication non-compliance and making terroristic threats.

The Patient Treatment Plan Report, dated 10/21/15, contained generic interventions for all disciplines, including nursing, which were normal functions of the professional disciplines and not individualized to the patient. One objective on the plan was to identify behaviors that interfered with the patient's daily living. Nursing interventions were to monitor the effectiveness of medications and manage side effects and to meet with the patient daily to identify behaviors which interfered with his daily living as evidenced by documentation.



20810

P1 was admitted to the psychiatric hospital on dated 9/23/15, according to the Minnesota State Operated Services Face Sheet.

The Minnesota State Operated Services Face Sheet dated 9/23/15, described P1 as being admitted to a state facility due to aggression and severe property damage, with medical diagnoses that included diabetes, hypertension, asthma, and chronic low back pain.

The current Minnesota Department of Human Services State Operated Services Patient Treatment Plan Report for P1, dated 10/20/15, contained generic interventions that were normal functions of a professional discipline and not individualized to the patient. The interventions included a nursing intervention that read, "Primary nurse will meet with (patient name) two times per week to educate him on how adherence to medications can help improve mental health symptoms and discuss benefit of taking his medications upon discharge." The treatment plan contained a goal for managing P1's back pain, but there was no goal for P1's diabetes or any of the patient's other medical problems.


P2 ' s Minnesota Department of Human Services State Operated Services History and Physical Assessment Report form, dated 9/10/15, indicated P2 was admitted the same date. The form described P2 as being admitted to a state facility related to mental illness, chemical dependency, suicidal ideation and homicidal ideation. The current Minnesota Department of Human Services State Operated Services Patient Treatment Plan Report for P2, last updated 10/20/15, contained generic interventions that were normal functions of a professional discipline and not individualized to the patient. The interventions included a nursing intervention that read, "Primary nurse will meet with (patient name) three times per week to discuss the benefits identified while taken [sic] medication and answer any questions he might have regarding the subject." The current treatment plan did not include a problem or goal related to P2's suicidal or homicidal ideation.


P5 ' s revealed a Minnesota Department of Human Services State Operated Services History and Physical Assessment Report form, dated 5/16/15, showing this patient was admitted 5/15/15. This form described P5 as being admitted to a state facility due to mental illness and terroristic threats. The current Minnesota Department of Human Services State Operated Services Patient Treatment Plan Report for P5, last update 10/20/15, contained generic interventions that were normal functions of a professional discipline and not individualized to the patient. The interventions included a nursing intervention that read, " Nursing staff will meet with (patient name) daily to assess the progress of her treatment goal and provide documentation."


P13 ' s revealed a Minnesota Department of Human Services State Operated Services History and Physical Assessment Report form, dated 7/31/15, showing this patient was admitted the same date. This form described P13 as being admitted to a state facility due to delusional behavior and arson. The current Minnesota Department of Human Services State Operated Services Patient Treatment Plan Report for P13, last updated 10/6/15, contained generic interventions that were normal functions of a professional discipline and not individualized to the patient. The interventions included a nursing intervention that read, "Nursing will meet with (patient name), daily, to prompt and encourage to attend groups and participate in engagement sessions."


P14 ' s revealed a Minnesota Department of Human Services State Operated Services History and Physical Assessment Report form, dated 6/22/15, showing this patient was admitted the same date. This form listed chronic pain, history of asthma, and repetitive self-induced hand trauma as issues under physical exam review. A Minnesota Department of Human Services State Operated Services Nursing Assessment form, dated 6/22/15, described P14 as being admitted to this facility due to bipolar illness and terroristic threats. The current Minnesota Department of Human Services State Operated Services Patient Treatment Plan Report for P14, last updated 10/16/15, contained generic interventions that were normal functions of a professional discipline and not individualized to the patient. The interventions included a nursing intervention that read, "Nursing will encourage and remind of group times daily." The treatment plan did not contain a problem or goal related to P14's history of asthma, chronic pain, or repetitive self-induced hand trauma.

During interview on 10/21/15, at 9:40 a.m. the facility's clinical review coordinator was asked if there was any other documentation of a nursing care plan in a different location of the record and she replied that the nursing care plan was included in the treatment plan. She went on to explain that treatment plans should be updated every fourteen days, and drive all the care at this facility, including nursing care.


RN-B was interviewed on 10/22/15, at 2:40 p.m. and stated the Treatment Plans could be more specific and measurable. RN-B stated nursing staff used a Nursing Report form to communicate shift to shift any individual patient incidents which had occurred, which interventions had been effective and coping skills the patient may have demonstrated. The information did not become a part of the Patient Treatment Plan but was occasionally entered on the VRRP or the Support Plan.

The Adult Mental Health Nursing Assessment/Reassessment policy, dated 4/17/15, indicated newly assessed needs identified during reassessment would be added to the Initial Nursing Plan of Care or Comprehensive Treatment Plan, once it had been developed.

The Adult Mental Health Comprehensive Treatment Plan Development and Review policy, last updated 7/29/14, indicated the Psychiatric and Nursing assessments and the Vulnerability Risk Reduction Plan (VRRP) identified initial needs of the patient upon admission and prior to the establishment of a team generated comprehensive treatment plan. A review of the treatment plan was conducted minimally one time every two weeks. Any changes which occurred within the VRRP should be mentioned in the Treatment Plan Review. Although the VRRP had been updated frequently, none of the information had been carried forward to the current Patient Treatment Plan.

Based on observation, interview and document review, the hospital was found to be out of compliance with Life Safety Code Requirements at CFR §485.623(d). These findings had the potential to affect all 108 patients in the Acute Care Hospital.

Findings include:

Please refer to Life Safety Code inspection tags K18, K25, K29, K38, K52, K56, K62, and K147.

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

1) Address problems identified in the clinical Assessments and develop Treatment Plans based on the individualized needs of six (6) of nine (9) active sample patients. Specifically the facility failed to ensure that the treatment goals and interventions documented on the Master Treatment Plans (MTP) addressed the identified needs of patients (A1, A2, A3, A4, A6 and A9). Failure to individualize treatment plans can prevent patients from progressing in treatment and fail to give staff guidance for addressing specific treatment problems which can result in unmet needs and potentially longer lengths of hospitalization. (See B118)

2) Develop Master Treatment Plans that identified patient centered Short Term Goals (STG) stated in observable, measurable, behavioral terms for nine (9) of nine (9) (A1, A2, A3, A4, A5, A6, A7, A8 and A9) active sample patients. This lack of patient specific goals hampers the treatment team's ability to assess patient's response to interventions and may contribute to failure to modify plans in response to patient's needs. (See B121)

3) Identify in the MTP specific treatment interventions/modalities to address the identified patient problems for nine (9) of nine (9) (A1, A2, A3, A4, A5, A6, A7, A8 and A9) active sample patients. The treatment interventions were stated in vague terms and were non-individualized generic discipline functions rather than directed at specific interventions. This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients. (See B122)

4) Provide active treatment including alternative interventions for three (3) of nine (9) active sample patients (A6, A8 and A9). All of the patients were unwilling to attend many of their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement. (See B125)

Based on Record review, Policy review and Staff interview, the facility failed to develop and document comprehensive multidisciplinary treatment plans (MTP) based on the individualized needs of patients for six (6) of nine (9) active sample patients (A1, A2, A3, A4, A6 and A9). Specifically the facility failed to ensure that the treatment goals and interventions documented on the MTP addressed the identified needs of the patients. Failure to individualize treatment plans can prevent patients from progressing in treatment and fail to give staff guidance for addressing specific patient problems which can result in unmet needs and potentially longer lengths of hospitalization.

Findings include:

Medical Record Review:

1) Patient A1 was hospitalized on 9/23/15. The Psychiatric Assessment dated 9/24/15 documented principal diagnosis, "Schizoaffective disorder, bipolar type". The physician progress notes of 9/30/15 states "did not sleep much last night", "came out of her room entirely naked and was screaming and yelling", "making religious statements and wanting alcohol" "threatened this writer with physical harm". Progress note of 10/2/15 states "remains pressured in speech, with racing thoughts, flight of ideas, impulsivity, loose associations and psychotic suspiciousness about caregivers' intentions". The MTP updates of 10/1/15 and 10/14/15 listed only two (2) short term goals (STG): "(Patient) will increase positive engagement in treatment by interacting in calm, respectful ways in the milieu daily accepting cues to modify behavior" and "(Patient) will improve safety with ambulation and transfers by allowing staff assistance with daily activities". The treatment plans had not been modified and the problems identified in the physician Progress Notes were not addressed on the treatment plan as of 10/21/15.

2) Patient A2 was hospitalized on 10/09/15. The Psychiatric Assessment dated 10/09/15 documented principal diagnosis, "Major neurocognitive disorder NOS, likely 2/2 alcoholism. R/O other medical etiology ". The MTP dated 10/15/15 listed 2 STGs: "(Patient) will be free from injury from any potential falls", "(Patient) will have safe behavior with no physical aggression so (he/she) can move to a supportive setting back in the Wadena area". The treatment plan does not address problems related to Dementia or Alcoholism.

3) Patient A3 was hospitalized on 08/18/15. The Psychiatric Assessment dated 08/18/15 documented principal diagnosis, "Bipolar disorder type I: Patient fluctuates between elevated mood and suicidality". "Other Diagnoses: TBI, Substance use disorder, PTSD". The same physicians' Psychiatric Assessment "treatment and management plan" indicates need to "create behavior plan for patient with team". Initial MTP of 08/25/15 and 4 Treatment plan updates (09/01/15, 09/28/15, 10/07/15 and 10/20/15) listed STGs were: "(Patient) will meet with staff daily to express her frustrations without threats and aggression as evidenced by her ability to share her feelings with staff in a non-threatening manner", "Within the next 2 weeks,(patient) will identify 3 reasons taking meds are important and exhibit prosocial behavior when getting her needs met", "(Patient) will work on ways to remain safe by "being myself, going to my room, or going to the sensory room", "(Patient) will identify three effective coping skills to use during times of dysregulation". The 10/20/15 treatment plan updated case formulation states "(he/she) appeared to be looking for items to hurt (him/herself) with but denies urges for self harm. (He/she) brought off a couple of pieces of Formica wood from the nursing station". Treatment plans do not address problems and/or interventions related to suicidality, TBI, Substance abuse and PTSD. No behavior plan has been identified in the treatment plan per physician treatment and management plan.

4) Patient A4 was hospitalized on 09/10/15. The Psychiatric Assessment dated 09/10/15 documented principal diagnosis, "Antisocial personality" other diagnosis: "Schizoaffective Disorder, bipolar type by history, Polysubstance dependence, Schizotypal Personality Disorder". The initial MTP dated 09/15/15 and the 2 subsequent Treatment Plan updates (09/22/15 and 10/06/15) listed 2 STGs: "Over next 2 weeks (Patient name) will cooperate with treatment plan as evidenced by taking (his/her) medications as ordered", "In the next two weeks (patient name) will be able to identify three benefits of taking medications as prescribed and how adhering to medication can enhance (his/her) mental health stabilization in the community after discharge". The treatment plans do not address problems and /or interventions related to Schizoaffective Disorder or Substance abuse.

5) Patient A6 was admitted on 10/7/15. The Psychiatric Assessment dated 10/7/15 documented principal diagnosis, " Psychosis, NOS (Not Otherwise Specified) " The patient was psychotic on admission, had stopped taking (his/her) medications and was aggressive/assaultive. The Rule Out diagnosis were Bipolar Disorder vs (versus) Schizoaffective Disorder, bipolar type. The initial Master Treatment Plan dated 10/12/15 listed one Short-Term Goal: "In the next two weeks [Patient] will build rapport with staff to increase pro-social behaviors as evidenced by agreeing to meet with staff daily to engage in a conversation about a topic of [his/her] choice." There was nothing in the treatment plan to address the aggressive behavior, the patient's delusions, non-compliance with medication or the fact that [he/she] refused to attend groups or meet with clinicians.

6) Patient A9 was admitted on 10/2/15. The Psychiatric Assessment dated 10/2/15 documented principal diagnosis of "Psychosis, NOS". The assessment acknowledged substance abuse, psychotic behavior and medication non-compliance. The Initial Master Treatment Plan dated 10/6/15 listed the Short-Term Goal: "In the next two weeks [Patient] will meet daily with staff to discuss [his/her] mental health and participate in two groups daily to increase [his/her] understanding of [his/her] illness." The treatment plan did not address medication non-compliance, substance abuse or [his/her] psychotic symptoms. There was nothing in the treatment plan to address Patient A9 ' s refusal to attend groups or [his/her] isolation.

Policy Review:

Adult Mental Health Procedure Number: 16682, Effective Date: August 15, 2014 titled "Comprehensive Treatment Plan Development and Reviews" under "Problem and Description" states "The challenge and barriers as a result of mental illness, addictive disorder, or medical problems that stand in the way of the individual meeting their goals and/or achieving the criteria for discharge".

Staff Interview:

1) In a meeting with the program supervisor RN4 on 10/19/15 at 2 p.m., regarding the treatment plans, the supervisor agreed and stated "the treatment plans are not patient specific and it's broad and general".

2) In a meeting with the Medical Director on 10/20/15 at 3 p.m., regarding the treatment plans agreed and stated "looks like boiler plate treatment plans, do not reflect patients' clinical needs".

Based on Record review and Staff interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered short-term goals stated in observable, measurable, behavioral terms for nine (9) of nine (9) active patients (A1, A2, A3, A4, A5, A6, A7, A8 and A9). Same nine (9) of nine (9) (A1, A2, A3, A4, A5, A6, A7, A8 and A9) active patient's MTP's had no long-term treatment goals identified. This lack of patient specific goals hampers the treatment team's ability to assess changes in patient's condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient's needs.

Findings include:

Medical Record Review:

1) Patient A1 admitted on 9/23/15 with a diagnosis of Schizoaffective Disorder, bipolar type, alcohol dependence and dementia had listed on MTP (master Treatment Plan) dated 9/30/2015 for the problem, "(Patient) has been hospitalized at Regions several months during 2015. (He/she) committed in July and was provisionally discharged to Hayes Residence on 9/1. On 9/9, (he/she) called from a bar in a disoriented state and could not figure out how to get back to Hayes. (He/she) became verbally abusive toward others and readmitted to Regions", the following Short Term Goal [STG]: (Patient) will increase positive engagement in treatment by interacting in calm, respectful way in the milieu daily accepting cues to modify behavior".

2) Patient A2 admitted on 10/09/15 with a diagnosis of "Major Neurocognitive Disorder NOS, likely due to alcoholism", updated MTP of 10/13/15 for the problem, "(Patient name) was residing at his home a few months ago and reportedly drinking heavily. (He/she) was moved to facilities due to safety concerns. While at golden Living, (he/she) was aggressive and sexually inappropriate which led to assault of a peer. (He/she) has poor impulse control with cognitive impairments. (He/she) was hospitalized and placed on a MI/CD commitment", the following STG: "(Patient name) will show improved impulse control by engaging in social/purposeful activities accepting cues to increase prosocial (reduce aggression/sexually inappropriate) behavior.

3) Patient A3 was admitted on 08/18/15 with a diagnosis of "Bipolar disorder type I, MTP of 08/25/15 for the problem, "(patient name) was admitted here after (his/her) provisional discharge was revoked as evidenced by the fact that (he/she) was not taking (his/her) medications and threatened suicide", the following STG: "(patient name) will meet with staff daily to express [his/her] frustrations without threats and aggression as evidenced by her ability to share (his/her) feelings with staff in a non-threatening manner".

4) Patient A4 was admitted on 09/10/15 with a diagnosis of "Schizoaffective disorder bipolar type, Polysubstance dependence" MTP dated 09/15/15 "Discharge as (he/she) no longer meets hospital level of care", the following STG: "Over the next two weeks (patient name) will cooperate with treatment plan as evidenced by taking (his/her) medications as ordered".

5) Patient A5 admitted on 8/26/15 with a diagnosis of Schizoaffective Disorder, Bipolar Subtype had listed on the Master Treatment Plan Update on 10/2/15 for the problem, "[Patient] has been expressing paranoid delusional ideation, to the effect that [he/she] is being persecuted ...[Patient] also believes that [she/he] has been poisoned by 'angel dust'...", the following Short-Term Goal: "Within 2 weeks [Patient] will be able to identify three (3) symptoms of [his/her] illness and cooperate with treatment and nursing care."

6) Patient A6 admitted on 10/7/15 with a diagnosis of Psychosis, NOS (Not Otherwise Specified), R/O (Rule Out) Bipolar Disorder vs (versus) Schizoaffective Disorder, bipolar type had listed on the Master Treatment Plan dated 10/12/15 for the problem, "[Patient] has been charged with Felony Domestic assault against [his/her] mother and interference of an emergency call from an incident that occurred on 8/19/15", the following Short-Term Goal: "In the next two weeks [Patient] will build rapport with staff to increase pro-social behaviors as evidenced by agreeing to meet with staff daily to engage in a conversation about a topic of [his/her] choice."

7) Patient A7 admitted on 10/2/15 with a diagnosis of Schizoaffective Disorder vs Delusional Disorder vs Psychosis NOS vs Schizophrenia had listed on the Master Treatment Plan dated 10/10/15 for the problem, "Schizoaffective disorder as evidenced by visual and auditory hallucinations including seeing ghosts, hearing commands, and that [he/she] was being stalked while recently incarcerated", the following Short-Term Goal: "[Patient] will check in with staff to monitor moods and maintain safe behaviors incase [sic] of any changes that might occur with [him/her]during the day."

8) Patient A8 admitted on 5/15/15 with a diagnosis of Schizoaffective disorder, bipolar type; Gender Identity Disorder; Substance Abuse Disorder had listed on the Master Treatment Plan dated 10/14/15 for the problem, "Patient needs a structured environment to assist with [his/her] underlying psychotic disorder", the following Short-Term Goal: "In the next two weeks, [Patient] will gain more knowledge about [his/her] mental illness AEB [As Evidenced By] attending 3 treatment groups per week."

9) Patient A9 admitted on 10/2/15 with a diagnosis of Psychosis, NOS had listed on the Master Treatment Plan dated 10/6/15 for the problem, "Psychosis as evidenced by starting a grass fire at an apartment complex and exhibiting bizarre behaviors while in jail...that led to [his/her] current legal charges", the following Short-Term Goal: "In the next two weeks [Patient] will meet daily with staff to discuss [his/her] mental health and participate in two groups daily to increase [his/her] understanding of [his/her] illness."

Staff Interview:

In a meeting with the program supervisor RN4 on 10/19/15 at 2 p.m., the supervisor agreed the goals were not patient problem specific.

Based on Record review, Policy review and Staff interview the facility failed to identify in the MTP specific treatment interventions/modalities to address the identified patient problems for nine (9) of nine (9) (A1, A2, A3, A4, A5, A6, A7, A8 and A9) active sample patients. The treatment interventions were stated in vague terms and were non-individualized generic discipline functions rather than directed at specific interventions. This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients.

Findings include:

A. Record review:

Medical Record Review:

1) Patient A1 was admitted on 9/23/15 with a diagnosis of "Schizoaffective Disorder, Alcohol Dependence and Dementia" had listed in the updated MTP on 10/24/15 the following STG: " [Patient] will increase positive engagement in treatment by interacting in calm, respectful ways in the milieu daily accepting cues to modify behavior". The treatment interventions listed were: "Rehab will offer groups weekly to encourage prosocial behavior and interactions". "Social worker will meet at least weekly to address social services requests and coordinate meetings with ACT team workers".

2) Patient A2 was admitted on 10/09/15 with a diagnosis of "Major Neurocognitive Disorder NOS, likely due to alcoholism" had listed on MTP dated 10/13/15 the following STG: "(patient name) will show improved impulse control by engaging in social/purposeful activities accepting cues to increase prosocial (reduce aggression and sexually inappropriate) behavior". The treatment interventions listed were: "Rehab will offer 1:1s weekly for purposeful engagement and to assess for group participation", "Social worked will meet at least weekly to engage in prosocial interaction and facilitate phone conference with case manager to begin planning for discharge".

3) Patient A3 was admitted on 08/18/15 with a diagnosis of "Bipolar disorder type I" had listed on MTP of 08/25/15 the following STG: "(patient name) will meet with staff daily to express (his/her) frustrations without threats and aggression a evidenced by (his/her) ability to share (his/her) feelings with staff in a non-threatening manner". The treatment interventions listed were: "Clinician will continue to adjust and monitor medications as needed".

4) Patient A4 was admitted on 09/10/15 with a principal diagnosis of "Antisocial Personality Disorder" and Axis I: Polysubstance Dependence, Schizoaffective Disorder" had listed on MTP of 09/15/15 the following STG: "Over the next two weeks (patient name) will cooperate with treatment plan as evidenced by taking (his/her) medications as ordered". The treatment interventions listed were: "Daily nurse will meet with (patient name) and encourage (him/her) to take (his/her) medications as ordered and also giving [him/her] praise for doing so", "Social worker will meet with (patient name) daily to engage and build rapport and offer (him/her) encouragement to continue taking (his/her) medications as ordered, so that (he/she) can work toward improvement of (his/her) mental health stability in the next two weeks".

5) Patient A5 admitted on 8/26/15 with a diagnosis of Schizoaffective Disorder, Bipolar Subtype had listed on the Master Treatment Plan Update on 10/2/15 the following STG: "Within 2 weeks [Patient] will be able to identify 3 symptoms of [his/her] illness and cooperate with treatment and nursing care." The treatment interventions listed included: "Nursing will meet with [patient] to discuss any concerns and educate [him/her] on what possible symptoms [he/she] may be experiencing" and "SW [Social Worker] will meet with [patient] weekly to discuss d/c [discharge] planning and encourage [him/her] to learn more about [his/her] symptoms."

6) Patient A6 admitted on 10/7/15 with a diagnosis of Psychosis, NOS (Not Otherwise Specified), R/O (Rule Out) Bipolar disorder vs (versus) schizoaffective disorder, bipolar type had listed on the Master Treatment Plan dated 10/12/15 the following Short-Term Goal: "In the next two weeks [Patient] will build rapport with staff to increase pro-social behaviors as evidenced by agreeing to meet with staff daily to engage in a conversation about a topic of 10/12/15 [his/her] choice." The treatment interventions listed included: "Social Worker will meet with [patient] weekly to provide support and build rapport" and "Occupational Therapy will offer groups that foster engagement and rapport with staff and peers."

7) Patient A7 admitted on 10/2/15 with a diagnosis of Schizoaffective Disorder vs Delusional Disorder vs Psychosis NOS vs Schizophrenia had listed on the Master Treatment Plan dated 10/10/15, the following Short-Term Goal: "[Patient] will check in with staff to monitor moods and maintain safe behaviors incase [sic] of any changes that might occur with [him/her] during the day." The treatment interventions listed included: "OT [Occupational Therapy] will provide activities to keep [him/her] busy and engaged" and "Nursing will check in with [patient] daily to discuss any psychiatric symptoms or changes in mood/behavior [he/she] may be having and offer feedback."

8) Patient A8 admitted on 5/15/15 with a diagnosis of Schizoaffective disorder, bipolar type; Gender Identity Disorder; Substance Abuse Disorder had listed on the Master Treatment Plan dated 10/14/15, the following Short-Term Goal: "In the next two weeks, [Patient] will gain more knowledge about [his/her] mental illness AEB [As Evidenced By] attending 3 treatment groups per week." The treatment interventions listed included: "Nursing staff will engage [patient] in 1:1 conversation daily and as needed to assess for [his/her] needs and to build rapport" and "Nursing staff will administer medication to [patient] as ordered and provide medication education as needed, to answer any questions [patient] may have about [his/her] medications."

9) Patient A9 admitted on 10/2/15 with a diagnosis of Psychosis, NOS had listed on the Master Treatment Plan dated 10/6/15, the following Short-Term Goal: "In the next two weeks [Patient] will meet daily with staff to discuss [his/her] mental health and participate in two groups daily to increase [his/her] understanding of [his/her] illness." The treatment interventions listed included: "Nursing staff will meet with [patient] daily to build rapport and to assess the progress of [his/her] treatment goal" and "BAPA [Behavior Analyst Program Assistant] will assist with keeping [patient] engaged in groups."

Policy Review:

Adult Mental Health Procedure Number: 16682, Effective Date: August 15, 2014 titled "Comprehensive Treatment Plan Development and Reviews" under "Interventions (Modalities)" states "Interventions are actions that staff will take and need to state the specific treatment modality used and the purpose, intent, or the impact the intervention is expected to have for the patient on accomplishing their treatment plan objective".

Staff Interview:

In interview on 10/20/15 at 11:40 a.m., the administrator acknowledged that the interventions were generic and routine discipline practice.

In interview on 10/20/15 at 2:30 p.m., the Assistant Director of Nursing agreed that the nursing interventions were not individualized to patient needs but rather were generic nursing interventions that were routine nursing duties for all patients.

In a meeting with the Medical Director on 10/20/15 at 3 p.m., regarding the treatment plans agreed and stated "looks like boiler plate treatment plans, do not reflect patients' clinical needs".

Based on record review, interview and observation, the facility failed to provide active treatment including alternative interventions for three (3) of nine (9) active sample patients (A6, A8 and A9). All of the patients were unwilling to attend many of their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement.

Findings include:

A. Specific Patient Findings

1. Patient A6 was admitted on 10/7/15. The Psychiatric Evaluation dated 10/7/15 listed the diagnoses as "Psychosis, NOS (Not Otherwise Specified), R/O (Rule Out) Bipolar disorder vs schizoaffective disorder, bipolar type." The documented reason for hospitalization was aggression after stopping his/her medication. The patient was described as psychotic and aggressive during interview, stating, "I don't want to talk to you." On admission, the patient was experiencing delusions and hallucinations.

The Master Treatment Plan (MTP) dated 10/12/15 listed one problem, "[Patient] has been charged with Felony Domestic assault against [his/her] mother and interference of an emergency call from an incident that occurred on 8/19/15." The short-term goal for this problem was "In the next two weeks [patient] will build rapport with staff to increase pro-social behaviors as evidenced by agreeing to meet with staff daily to engage in a conversation about a topic of [his/her] choice." The interventions included "Primary nurse will meet with [him/her] three times weekly and provide education on the importance of hygiene for [his/her] mental and physical health, offer hygiene supplies and clothing from donation closet to promote wellness"; "Occupational Therapy will offer groups that foster engagement and rapport with staff and peers" and "BAPA [Behavior Analyst Program Assistant] will meet with [him/her] daily and offer group engagement and rapport with staff and peers." The goals and interventions on the MTP were not amended to address the patient's non-participation in groups and non-interaction with staff nor was there evidence that alternative treatment interventions were available for Patient A6.

Review of the Therapeutic Observation Record (15 minute checks) from 10/13/15-10/19/15 revealed that Patient A6 was in an Engagement Activity (group) only once, at 8:45 a.m. on 10/16/15. The majority of the entries placed the patient in his/her room. The Attendance Record posted from 10/7/15 to 10/19/15 revealed that Patient A6 had failed to attend any of his/her assigned groups.

Review of Progress Notes revealed the following:

10/14/15 - "[He/She] stayed in [his/her] room most of the shift, came out for meals" and "Patient decline [sic] afternoon group. Games was [sic] offered."

10/15/15 - "[Patient] refused to remain out on the unit and declined offer for groups or 1:1 with staff " and "Staff invited and encouraged client to attend and participate in group. Client stated, 'absolutely not'.

10/18/15 - "Patient declines all group activities. We will continue to encourage group attendance and participation" and "[Patient] has been fairly isolative today and has only been noted coming out for meals."

10/19/15 - "Client declined group invite and stayed resting in (his/her) room" and "Client was asked x2 to come to group. Client stated 'Absolutely not', I will not be participating in any groups here."

Observation on the E Unit on 10/19/15 at 2:15 p.m. revealed that Patient A6 was in bed during his/her assigned Engagement Group. Observation on the E Unit on 10/20/15 at 10:15 a.m. revealed that Patient A6 was in bed during his/her assigned Engagement Group.
Observation on the E Unit on 10/20/15 at 2:20 p.m. revealed that Patient A6 was in bed during his/her assigned Engagement Group.

During interview on 10/19/15 at 11:35 a.m., RN1 when asked why Patient A6 was not in group, stated that the patient was "new and getting used to us" (Patient A6 had been on the unit for 12 days). During interview on 10/19/15 at 11:40 a.m., RN2 stated that Patient A6 didn't attend groups. "He/She pretty much stays in [his/her] room and comes out for meals."

During attempted interview on 10/19/15 at 1:40 p.m., Patient A6 refused to speak with the surveyor and stated, "It was really nice to meet you though."


2. Patient A8 was admitted on 5/15/15. The Psychiatric Evaluation dated 5/15/15 listed the diagnoses as "Schizoaffective disorder, bipolar type; gender identity disorder; substance abuse disorder." The documented reason for hospitalization was attributed to making threats to harm doctors at a local hospital and threats to a judge.

The Master Treatment Plan Update (MTP) dated 10/14/15 listed one problem, "Patient needs a structured environment to assist with his underlying psychotic disorder." The short-term goal for this problem was, "In the next two weeks [patient] will gain more knowledge about [his/her] mental illness AEB (as evidenced by) attending 3 treatment groups per week."

The interventions included "Rehab staff will offer treatment groups to learn symptoms of mental illness, manage anxiety, stress, and utilize healthy coping skills." The goals and interventions on the MTP were not amended to address Patient A8's non-participation in groups.
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The Attendance Record posted from 9/15/15 to 10/15/15 revealed that Patient A8 had attended 50% of his/her assigned groups. 50% of the groups attended by Patient A8 were "Fitness Walks" (20 to 30 minute walks).

Review of Progress Notes revealed the following:

10/8/15 - "[His/Her] participation this week was somewhat limited."

10/9/15 - "[Patient] stated 'I can't stand this' when asked to engage in a team based game about anger." "[He/She] declined to participate in Task Group stating, 'I'm on vacation.' "

10/10/15 - "[Patient] laughed and stated 'I'm not going to group on Saturday, it's rest day."

10/12/15 - "[Patient] was in his room sleeping for most of the morning. [He/She] did get up to eat breakfast and lunch."

10/17/15 - "[He/She] stayed in bed then [sic] for most of the morning and came out for lunch."

10/18/15 - "[He/She] is not engaged in his treatment plan at this time."

Observation on the G Unit on 10/20/15 at 9:15 a.m. revealed that Patient A8 was in his/her room during his/her assigned Body Group. Observation on the G Unit on 10/20/15 at 2:15 p.m. revealed that Patient A8 was in the dayroom during his/her assigned Competency Restoration Program Group.

During interview on 10/20/15 at 9:20 a.m., RN3 stated that Patient A8 "often sleeps till lunch." RN3 further stated that Patient A8 was "crabby" in the mornings and staff lets him/her sleep.

During interview on 10/20/15 at 9:25 a.m., Patient A8 stated that he/she spent most of the day sleeping. When asked about groups, he/she stated, "I hardly ever go." When asked specifically about the "Fitness Walk" groups, Patient A8 stated " hate to walk. I just go outside and sit down by myself."

3. Patient A9 was admitted on 10/02/15. The Psychiatric Evaluation dated 10/02/15 listed the diagnoses as "Psychosis, NOS." The documented reason for hospitalization was the presence of auditory and visual hallucinations and "acting strangely". At the time of admission, Patient A9 was in jail for starting a fire at his/her mother's apartment.

The Master Treatment Plan Update (MTP) dated 10/6/15 listed the problem, "Psychosis as evidenced by starting a fire at an apartment complex and exhibiting bizarre behaviors while in jail (e.g. self-talk, standing in cell with [his/her] eyes closed while smiling, poor hygiene, urination in places besides the toilet) that led to [his/her] current legal charges." The short-term goal for this problem was, "In the next two weeks [patient] will meet daily with staff to discuss [his/her] mental health and participate in two groups daily to increase [his/her] understanding of [his/her] illness."

The interventions included "BAPA [Behavior Analyst Program Assistant] will assist in keeping [patient] engaged in groups." The goals and interventions on the MTP were not amended to address Patient A9's non-interaction with staff and non-participation in groups.
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The Attendance Record posted from 10/5/15 to 10/19/15 revealed that Patient A9 failed to attend 58% of his/her assigned groups. The total number of hours spent in assigned groups during this period was 5 hours.

Review of the Progress Notes dated 10/19/15 revealed the following documentation:

10:44 a.m. - "Client was in bed resting and declined to come to group."

3:30 a.m. - "[He/She] has minimal interaction with staff and peers."

9:32 p.m. - "[He/She] took [his/her] medication this evening but spent lots of [his/her] time in [his/her] room."

Observation on the E Unit on 10/19/15 at 2:15 p.m. revealed that Patient A9 was in bed during his/her assigned Focus Group. Observation on the E Unit on 10/20/15 at 10:15 a.m. revealed that Patient A9 was in bed during his/her assigned Coping with Emotions Group.
Observation on the E Unit on 10/20/15 from 9:45 a.m. - 11:30 a.m. revealed that Patient A9 was in bed during this entire time.

During interview on 10/19/15 at 11:40 a.m., RN1stated that Patient A9 did not often go to groups and that "[He/She] is fairly new." (Patient A9 was admitted on 10/2/15). During interview on 10/20/15 at 10:15 a.m., RN5 stated that Patient A9 had gotten up for breakfast but went back to bed and refused to get up.

During interview on 10/19/15 at 2:50 p.m., Patient A9 stated that he/she did not go to group "much" and stayed in his/her room most of the day.

The Clinical Director failed to adequately monitor and evaluate the quality of care provided to patients at the facility. Specifically, the Clinical Director failed to ensure that:

1) The clinical staff develop MTP's based on individualized needs of six (6) of nine (9) (A1, A2, A3, A4, A6 and A9) active sample patients. (See B118)

2) The clinical staff identify and document for nine (9) of nine (9) (A1, A2, A3, A4, A5, A6, A7, A8 and A9) active sample patients in the MTPs, patient centered short-term and long-term treatment goals in observable, measurable and behavioral terms. (See B121)

3) The clinical staff identify in the MTPs of nine (9) of nine (9) (A1, A2, A3, A4, A5, A6, A7, A8 and A9) active sample patients, specific treatment modalities/interventions for identified patient problems. (See B122)

4) Active treatments including alternative interventions are offered to three (3) of nine (9) (A6, A8 and A9). (See A125)

In an interview with the Clinical Director on 10/20/15 at 3 p.m., the Clinical Director concurred with the above deficiencies and further stated "looks like boiler plate treatment plans, do not reflect patient's clinical problems".

Based on record review and interview, the Director of Nursing failed to ensure that nursing interventions listed on patients' MTPs addressed individualized patient needs for four (4) out of nine (9) active patients (A4, A7, A8 and A9). Instead, the interventions were preprinted, stated in vague terms and were non-individualized, generic discipline functions rather than individualized patient specific nursing interventions. This deficiency results in failure to guide nursing staff regarding the specific treatment purpose of each intervention and limits the therapeutic nursing interventions available to patients. Findings include:

A. Record Review

1. Patient A4 was admitted on 09/10/15 with a principal diagnosis of "Antisocial Personality Disorder" and Axis I: Polysubstance Dependence, Schizoaffective Disorder" had listed on MTP of 09/15/15 the following STG: "Over the next two weeks (patient name) will cooperate with treatment plan as evidenced by taking (his/her) medications as ordered". The treatment interventions listed were: "Daily nurse will meet with (patient name) and encourage (him/her) to take (his/her) medications as ordered and also giving him praise for doing so".

2. Patient A7 admitted on 10/2/15 with a diagnosis of Schizoaffective Disorder vs Delusional Disorder vs Psychosis NOS vs Schizophrenia had listed on the Master Treatment Plan dated 10/10/15, the following Short-Term Goal: "[Patient] will check in with staff to monitor moods and maintain safe behaviors incase [sic] of any changes that might occur with [him/her] during the day." The treatment interventions listed included: "Nursing will check in with [patient] daily to discuss any psychiatric symptoms or changes in mood/behavior [he/she] may be having and offer feedback."

3. Patient A8 admitted on 5/15/15 with a diagnosis of Schizoaffective disorder, bipolar type; Gender Identity Disorder; Substance Abuse Disorder had listed on the Master Treatment Plan dated 10/14/15, the following Short-Term Goal: "In the next two weeks, [Patient] will gain more knowledge about [his/her] mental illness AEB [As Evidenced By] attending 3 treatment groups per week." The treatment interventions listed included: "Nursing staff will engage [patient] in 1:1 conversation daily and as needed to assess for [his/her] needs and to build rapport" and "Nursing staff will administer medication to [patient] as ordered and provide medication education as needed, to answer any questions [patient] may have about [his/her] medications."

4. Patient A9 admitted on 10/2/15 with a diagnosis of Psychosis, NOS had listed on the Master Treatment Plan dated 10/6/15, the following Short-Term Goal: "In the next two weeks [Patient] will meet daily with staff to discuss [his/her] mental health and participate in two groups daily to increase [his/her] understanding of [his/her] illness." The treatment interventions listed included: "Nursing staff will meet with [patient] daily to build rapport and to assess the progress of [his/her] treatment goal" and "BAPA [Behavior Analyst Program Assistant] will assist with keeping [patient] engaged in groups."

B. Interview

In interview on 10/20/15 at 2:30 p.m., the Assistant Director of Nursing agreed that the nursing interventions were not individualized to patient needs but rather were generic nursing interventions that were routine nursing duties for all patients.