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Based on record review and interview, the governing body failed to ensure staff followed governing body's policies and procedures to conduct and evaluate staff performance to ensure care was provided in a safe and effective manner on 6 of 7 licensed staff, L, M, N, O, P, and Q. This deficient practice extends to all licensed staff at this hospital and has the potential to affect the quality of care received by all 21 inpatients at this facility during this survey.

Findings include:

Review of policy titled Fond Du Lac County Policy and Procedure Governing Annual Performance Evaluations dated 3/2/2012 was completed on 4/19/17 at 10:55 AM. The policy states "all employees will receive an annual performance evaluation performed by their immediate supervisor... Purpose of the Evaluation Program ... To improve performance by describing strengths and weaknesses of employee performance, urging improvement of any weaknesses, and identifying areas where employees can gain additional knowledge and skills."

Review of credentials with Payroll Assistant S on 4/18/2017 at 1:10 PM revealed Alcohol and Other Drug Abuse (AODA) Counselor L with hire date of 8/03/81, last performance evaluation (PE) was done in 2008, Occupational Therapist M hire date was 7/09/01, last PE done in 2009, Registered Nurse N with hire date of 5/09/88, last PE done in 2002, Licensed Practical Nurse O with hire date of 6/29/82, no PE completed, Nurse Assistant P with hire date of 6/03/08, last PE done in 2013, and Nursing Assistant Q with hire date of 7/18/14 with no PE completed. Payroll Assistant S stated the credentials folders included the last performance evaluation records for the listed staff.

An interview was conducted with Deputy Director A on 4/19/2017 at 10:55 AM which confirmed the lack of annual performance evaluations. A stated that there was not enough time to conduct performance evaluations or "shuffle the paperwork" on each employee on an annual basis.

Based on medical record review and staff interview, the governing body failed to establish a policy that allowed staff to review patient complaints in 3 of 3 patient complaints reviewed (patient #2, 3, and 4). This deficient practice has the potential to affect all patients receiving care at this facility who filed a complaint.

Findings include:

Per review on 4/19/2017 at 2:00 pm of Facility policy titled Grievance Procedure, Directive # 01-074-01, revision date 11/26/2012 stated in part on page 5. The Client Rights Specialist shall have full access to all information needed to investigate the grievance, all relevant areas of the program names in the grievance, and all records pertaining to the matters raised in the grievance. If necessary the Client Rights Specialist shall obtain all the appropriate consents by signed release of information documentation to assess all records. The inquiry of the Client Rights Specialist may include questioning staff, the client or clients on whose behalf the grievance was presented, other clients, reviewing applicable records and charts, examining equipment and materials, and other necessary activity in order to form an accurate, factual basis for the resolution of the grievance.

When an inquiry requires access to confidential information protected under s.51.30 Stats., and the Client Rights Specialist does not otherwise have access to the information under the exception found in s. 51.30(4)(b), Stats., the client, or the guardian or parent of the client, if the guardian or parent's consent is required, may be asked to consent in writing to release of that information to the Client Rights Specialist and other persons involved in the grievance resolution process. The Client Rights Specialist may proceed with the inquiry only if written consent is obtained.

Per review on 4/19/2017 at 2:00 PM of the complaint report completed by patient #2, the complaint is documented as being received on 6/20/2016. Patient #2 stated the staff was unprofessional and talked about confidential patient information in front of other patients. There was no documentation of investigation or follow up of patient #2's complaint.

Per review on 4/19/2017 at 2:05 PM of the complaint report completed by patient #3, the complaint is documented as being received on 6/20/2017. Patient #3 stated the staff was heard by other patients discussing patient issues. There was no documentation of investigation or follow up of patient #3's complaint.

Per review on 4/19/2017 at 2:10 PM of the complaint report completed by patient #4, the complaint is documented as being received on 6/21/2016. Patient #4 stated that staff talks negatively about one another around patients and staff have shared confidential patient information in front of other patients. Clients Right Specialist K completed a letter to complainant/patient #4 on 7/14/2016 stating "I received a written complaint from you, while you were on our inpatient unit. I attempted to call your cell phone but the number has been changed or disconnected. I believe the issue has resolved itself since you are no longer at our facility. If you disagree, please contact me by: July 25th, 2016 if you would like a resolution to your grievance". There was no documentation indicating an investigation or follow up of patient #4's complaint.

Per interview with Client Rights Specialist K on 4/18/2017 at 1:15 PM, Client Rights Specialist K stated once a complaint report is received, an attempt is made to reach out to the complainant to obtain details regarding the complaint. If the complainant does not respond to the phone call, a letter is sent out to the complainant and the complaint is considered closed. Client Rights Specialist K stated did not complete an investigation for complainant #2, 3, or 4, as no response was received from the complainants. Client Rights Specialist K sent an email to Director of Nursing C to pass along the patient concerns in the complaints.

Per interview with Director of Nursing C on 4/19/2017 at 8:40 AM, Director of Nursing C stated "just because a patient is discharged does not dismiss the complaint, all complaints need to be investigated". Director of Nursing C also stated that the "patient complaints could have been investigated by staff and patient interviews".

Based on record review and interview, the facility failed to include information in patient rights brochure regarding not restricting visitation based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability in 1 of 1 patients rights brochure review. This deficient practice has the potential to affect all patients admitted to this facility.

Finding include:

Per review of Client Rights and Grievance Procedure Brochure on 4/17/17 at 11:00 AM, the brochure dated 12/2008, stated "You may see visitors daily. You may designate who may visit." There is no indication that the facility may not restrict visitation based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.

Per interview with Director of Nursing C on 4/18/17 at 2:00 PM, Director of Nursing C confirmed that the "brochure does not list that the facility can not restrict visitation based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability".

Based on observation, record review and interview the facility failed to minimize verbal orders and do a proper read back per policy in 1 of 1 observations. This deficient practice has the potential to affect all 21 current inpatients at the time of this survey.

Findings include:

Reviewed facility policy titled "Verbal M.D. Orders" dated December 1, 1991 on 4/18/17. This document states "When the nurse talks with the M.D. [Medical Doctor], the nurse should repeat the order to the M.D. The nurse is responsible for asking any questions about the order.

On 4/18/17 between 12:00 PM and 12:45 PM observed Medical Director D give verbal orders to RN H repeatedly during the care planning conference for all current inpatients. RN H took notes on these orders throughout the conference. At 12:45 PM, after the care planning conference, RN H went to the nursing station on the Acute Inpatient Unit and proceeded to write the verbal orders in the patient's charts. At no time did RN H repeat back or confirm the orders with Medical Director D.

On 4/18/17 at 3:45 PM conducted an interview with Director of Nursing C. Director of Nursing C agreed that verbal orders should be kept to a minimum and confirmed that RN H and Medical Director D did not follow the facility policy to repeat back orders to promote safety.

A recertification survey for the Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 4/17/17. The Fond du Lac County Acute Psych Unit, Fond du Lac, was found to be NOT in substantial compliance with the requirements of the following applicable regulations:

42 CFR 482.41 Condition of Participation: Physical environment was NOT MET
42 CFR 482.41 (b) Standard: Life safety from fire was NOT MET
NFPA 101 (2012 edition) - Life Safety Code was NOT MET

Findings include:

The Fond du Lac County Acute Psych Unit was found not to have a safe environment, properly constructed and maintained to protect the health and safety of patients based on the following.

K281 - failure to provide 2-bulb lighting fixture, or two lighting units in all exit discharge;
K324 - failure to provide automatic electric power shut-off to all electric cooking equipment;
K345 - failure to ensure automatic dialer components of fire alarm system are tested for phone line failure.

Based on observation and interview the staff failed to ensure the hospital environment was maintained in a manner that was safe and sanitary to control the spread of infection and promote patient safety in 1 of 1 acute hospital units. This deficiency has the potential to affect all 21 inpatients in the facility during this survey.

Findings include:

On 4/17/17 at 9:30 AM observed vanity with sink in patient room number 3 with the corner chipped/broken. This corner was covered with white tape. The vanity with sink in room number 4, 6 and 13 were also chipped and cracked with wood showing.

Per interview with Deputy Director A at on 4/17/17 at 9:40 AM, at the time of discovery, Deputy Director A stated the facility recently updated the sinks but not the vanities.


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On 4/17/17 at 9:35 AM on tour of nursing unit patient room doors #2, 4, 5, 6, 9, 10, 12, and 13 were noted to have chipped and marred wood present on hinged side of door. On wall outside of patient room #9 & 12 paint chipped below room sign. In seclusion room there is a 12 inch vertical crack in the drywall on wall, 2 areas of chipped paint and 1 area of missing/chipped baseboard not allowing for smooth cleanable surface.

The above findings were confirmed in interview with Deputy Director A at the time of unit tour who agreed areas were in "need of repair".

A recertification survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 4/17/17. The Fond du Lac County Acute Psych Unit, Fond du Lac, was found to be NOT in substantial compliance with the requirements of the following applicable regulations:

42 CFR 482.41 Condition of Participation: Physical environment was NOT MET
42 CFR 482.41 (b) Standard: Life safety from fire was NOT MET
NFPA 101 (2012 edition) - Life Safety Code was NOT MET

Findings include:

The Fond du Lac County Acute Psych Unit was found not to have a safe environment, properly constructed and maintained to protect the health and safety of patients based on the following.

K281 - failure to provide 2-bulb lighting fixture, or two lighting units in all exit discharge;
K324 - failure to provide automatic electric power shut-off to all electric cooking equipment;
K345 - failure to ensure automatic dialer components of fire alarm system are tested for phone line failure.

Based on interview, the facility failed to have a mechanism in place for ongoing reassessment to track readmissions rates and identify potentially preventable readmissions and the effectiveness of the discharge planning and include in the hospital wide Quality Program in 1 of 1 discharge planning process. This deficiency has the potential to affect all 21 inpatients in the facility during this survey.

Findings include:

An interview was conducted with the Director of Nursing C on 4/17/17 at 2:00 PM who stated "Readmits happen frequently but I do not track them".

Based on medical record review and staff interview it was determined that five (5) of eight (8) patients (Patients A1,A2,A3,A4 and B1) had incomplete Psychosocial Assessments that failed to include a description of the role of the social service staff in discharge planning. This failure results in no information being available to other members of the multidisciplinary treatment team about what efforts the social service staff anticipate might be necessary toward discharge planning.

The findings include:

I. Medical Record Review:

1. Patient A1: The Psychosocial Assessment dated 4/07/2017 stated "Social service staff will assist the patient with aftercare appointments as well as discharge planning"

2. Patient A2: The Psychosocial Assessment dated 4/11/2017 stated "At this time, it is anticipated Dodge County and Care Wisconsin will be looking for alternative placements for the patient to discharge to once stable on the Acute Care Unit.

3. Patient A3: The Psychosocial Assessment dated 4/13/2017 stated "Social service staff will keep contact with the patient regarding discharge."

4. Patient A4: The Psychosocial Assessment dated 4/11/2017 stated "Therefore, writer will assist with scheduling follow-up appointments" and "Prior to discharge the patient's discharge social work staff will arrange follow-up appointments if the patient is motivated to seek further treatment."

5. Patient B1: The Psychosocial Assessment dated 4/07/2017 stated "Social service staff will be in contact with the patient regarding discharge."

II. Staff Interview:

On 4/18/2017 at 12:00 p.m. the Director of Social Work was interviewed. The Director was shown several of the Psychosocial Assessments described in Section I, above. The Director agreed that these were not descriptions of the anticipated role of the social service staff in discharge efforts.

Based on medical record review and staff interview it was determined that the Psychiatric Evaluations for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, B1, B2, B3 and B4) failed to describe patient assets in descriptive, not interpretive fashion. This failure results in no information such as interests, goals, achievements, or other inherent attributes that might be useful in the selection of treatment modalities.

The findings include:

I: Medical Record Review:

1. Patient A1: The Psychiatric Evaluation dated 4/06/2017 stated as the sole patient asset "average intelligence."

2. Patient A2: The Psychiatric Evaluation dated 4/11/2017 stated as the sole asset "Fairly good health."

3. Patient A3: The Psychiatric Evaluation dated 4/13/2017 had no assets described.

4. Patient A4: The Psychiatric Evaluation dated 4/11/2017 stated "Fairly good health" as the sole asset identified.

5. Patient B1: The Psychiatric Evaluation dated 4/06/2016 stated "Average intelligence" as the sole asset identified.

6. Patient B2: The Psychiatric Evaluation dated 4/07/2017 stated "Pleastness" {sic} as the sole identified asset.

7. Patient B3: The Psychiatric Evaluation dated 4/13/2017 stated "Average intelligence" as the sole asset identified.

8. Patient B4: The Psychiatric Evaluation dated 4/14/2017 stated "Average intelligence" as the sole asset identified.

II. Staff Interview:

On 4/18/2017 at 1:40 p.m. the facility's clinical director was interviewed. The clinical director was told of the findings described in Section I, above. The clinical director agreed that these statements did not describe patient assets that might be utilized in the selection of treatment modalities.

Based on medical record review and staff interview it was determined that the Treatment Plans for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, B1, B2, B3 and B4) failed to:

1. Ensure that Problems identified as focus of treatment were written in behavioral terms and not generalized statements. (See, B 120 for details).

2. Ensure that short and long term goals were written in measurable terms and were patient goals not staff goals. (See, B121 for details).

3. Ensure that treatment modalities were patient specific and not routine discipline functions. (See, B122 for details).

4. Ensure that responsible staff were identified for monitoring the results of selected treatment modalities. (See, B123 for details).

Based on medical record review and staff interview it was determined that for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, B1, B2, B3 and B4) the Treatment Plans failed to identify and precisely describe problem behaviors that would substantiate a diagnosis. This failure results in problems being described in either generalized statements or generic terminology.

The findings include:

I. Medical Record Review:

1. Patient A1: The Treatment Plan dated 4/07/2017 stated as the Problem "Psychosis: loose, inappropriate and impaired reality; thought blocking; angry affect; auditory hallucinations; and paranoia."

2. Patient A2: The Treatment Plan dated 4/12/2017 stated as the Problem "Psychosis: agitated mood, loose and inappropriate conversation, disorganized thoughts, auditory hallucinations, delusions of communication, and delusions of grandiosity. Uncontrollable behavior: unpredictable and aggressive behaviors."

3. Patient A3: The Treatment Plan dated 4/13/2017 stated as the Problem "Mood disorder: Irritability, labile mood, mania, poor sleep, increased agitation."

4. Patient A4: The Treatment Plan dated 4/12/2017 stated as the Problem "Mood disorder: mild anxiety, mild depression, irritable mood."

5. Patient B1: The Treatment Plan dated 4/07/2017 stated as the Problem "Psychosis: delusional thinking, paranoid, and delusions of communication."

6. Patient B2: The Treatment Plan dated 4/07/2017 stated as the Problem "Psychosis: pressured speech, auditory hallucinations, delusions of persecution and paranoia."

7. Patient B3: The Treatment Plan dated 4/13/2017 stated as the Problem "Mood disorder: depressed mood, tearful affect. SI (suicidal ideation): Potential harm to self."

8. Patient B4: The Treatment Plan dated 4/14/2017 stated as the Problem "Mood Disorder: lacks insight and judgment is impaired. SI: potential for self harm."

II. Staff Interview:

On 4/18/2017 at 2:30 p.m. the Deputy Director of the Department of Community Programs was interviewed with the focus being the expression on Treatment Plans of the identified Problem requiring treatment. The Director agreed that the examples described in Section I, above were not behaviorally described i.e. as evidenced by and were instead generalized statements that lacked patient specificity.

Based on record review and interview, the facility failed to formulate treatment physician and nursing goals that were relevant to the patients' psychiatric condition for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). Many of the goals were either not measurable or were staff goals (what the staff wanted the patient to achieve) rather than an outline of a mental status or functional status level to be obtained. Without a set of defined goals against which to measure progress, it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress.

Findings include:

A. Record Review

1. Facility policy No. 02-072-01, last revised 6/11, stated - "The initial treatment plan addresses the patient's Axis I diagnosis, patient strength, immediate problem(s) requiring hospitalization, a short and long-term goals for each problem, and approaches each discipline will use to treat the problems."

The policy did not include any guidelines about how these goals should be written. The physician and nursing goals and interventions were in one section away from other disciplines such as social workers and activity therapists. Discipline listed their own goals and interventions separately from each other. The long and short-term goals listed below for the active sample patients were ones identified by physician and nursing staff in their section.

2. In patient A1's Master Treatment Plan (MTP), dated 4/7/17, the identified problem was "Psychosis: Loose, inappropriate and impaired reality; thought blocking; angry affect; addition hallucinations and paranoia."
The long-term goal was "[Name of patient] will remain compliant with [his/her] medication and treatment plan developed by [his/her] [name of county] once discharged from the Fond du Lac County Department of Community Programs Acute Unit."

The short-term goal was "[Name of patient] will have a decrease in loose, inappropriate and impaired reality; thought blocking; angry affect, auditory hallucinations and paranoia by discharge from the Fond du Lac County Department of Community Program Acute Unit."

Neither long nor short-term goals, as written, were measureable. The inclusion of specific observable behaviors for wording such as "decrease in loose, inappropriate and impaired reality, thought blocking, angry affect, etc., were not described.

3. In patient A2's MTP, dated 4/12/17, the identified problem was "Psychosis: Agitated mood, loose and inappropriate conversation, disorganized thoughts, auditory hallucinations, delusions of communication, and delusions of grandiosity. Uncontrollable behavior: Unpredictable and aggressive behaviors."

The long-term staff goal was "[Name of patient] will continue to be compliant with [his/her] medications and treatment plan developed for [him/her] by Dody County once discharged from the Fond du Lac County Department of Community Programs Acute Unit."

The difficult to measure short-term goal was "[Name of patient] will have a decrease in agitated mood, loose and inappropriate conversation, disorganized thoughts, auditory hallucinations, delusions of communication, and delusions of grandiosity by discharge from the Fond du Lac County Department of Community Programs Acute Unit." The specific behaviors were not described.

4. In patient A3's MTP, date 4/13/17, the identified problem was "Mood disorder: Irritability, labile mood, mania, poor sleep, increased agitation."

The long-term staff goal was "[Name of patient] will continue to be compliant with [his/her] medication and treatment plan developed for [him/her] by Fond du Lac County Community Program Acute Unit."

The short-term staff goals were "[Name of patient] will have a reduction in symptoms on mania while on the Fond Du Lac County Community Program Acute Unit", and "[Name of patient] will take medications and participate in group and individual therapy from day one."

5. In patient A4's MTP, dated 4/12/17, the identified problem was "Mood disorder: Mild anxiety, mild depression, irritable mood. SI [suicidal ideation]: Potential harm to self."

A long-term difficult to measure goal was "[Name of patient] will be free from suicidal ideations by discharge from the Fond Du Lac County Community Program Acute Unit." The specific behaviors and/or verbal conversation that staff should look for to determine that patient was no longer suicidal was not described

The difficult to measure short-term goal was "[Name of patient] will have a decrease in mild anxiety, mild depression, and irritable mood by discharge from Fond Du Lac Community Program Acute Unit." The short-term staff goal was "[Name of patient] will not harm [him/herself] from day one of admission to Fond Du Lac Community Program Acute Unit."

6. In patient B1's MTP, dated 4/7/17, the identified problem was "Psychosis: delusional thinking, paranoid, and delusional communication."

The long-term staff goal, which was also difficult to measure, was "[Name of patient] will continue to be compliant with [his/her] medications and treatment plan developed for [him/her] by Fond Du Lac Community Program Acute Unit."

A difficult to measure short-term goal was "[Name of patient] will have a reduction in symptoms of psychosis while on the Fond Du Lac Community Program Acute Unit."

A short-term staff goal was "[Name of patient] will take medications and participate in group and individual therapy from day one of admission to Fond Du Lac Community Program Acute Unit."

7. In patient B2's MTP, dated 4/7/17, the identified problem was "Psychosis: Pressured speech, auditory hallucinations, delusions of persecution and paranoia."

The long-term staff goal was "[Name of patient] will continue to be compliant with [his/her] medication and treatment plan developed for [him/her by [name of county] once discharge [sic] from the Fond Du Lac Community Program Acute Unit."

The difficult to measure short-term goal was [name of patient] will have a decrease in pressured speech, auditory hallucinations, delusions of persecution, and paranoia by discharge from the Fond Du Lac Community Program Acute Unit ." Visual behaviors and verbal information from patient to let staff know what to look for were not described.

8. In patient B3's MTP, dated 4/13/17, the identified problem was "Mood disorder: Depressed mood, tearful affect. SI: Potential harm to self."

The long-term staff goal was "[Name of patient] will remain compliant with medications and [his/her] treatment plan developed for [him/her] by [name of county] once discharged from Fond Du Lac Community Program Acute Unit."

A difficult to measure short term goal was "[name of patient] will have a decrease in depressed mood and tearful affect by discharge from Fond Du Lac Community Program Acute Unit."

9. In patient B4's MTP, dated 4/14/17, the identified problem was "Mood disorder: Lacks insight and judgment, mildly impaired."

The difficult to measure long-term goal was "[Name of patient]" will be free from suicidal ideation by discharge from the Fond Du Lac Community Program Acute Unit."

A difficult to measure short-term goal was "[Name of patient] will have a decrease in suicidal ideation prior to discharge from the Fond du Lac Acute Unit."

No specific behaviors that could be observed were described for both the long and short-term goals listed above.

B. Interview

In an interview with the Nursing Director on 4/17/17 at 9:30 a.m., the difficult to measure and/or staff physician and nursing goals were discussed. She did not dispute the findings.

Based on record review and interview, the facility failed to develop Master Treatment Plans for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4) that consistently included individualized treatment physician and nursing, interventions with a specific focus, frequency and/or mode of delivery (individual or group). The physician interventions were actual goal statements for patients. The nursing interventions were general discipline functions/tasks. Failure to clearly describe specific modalities on patients' Master Treatment Plans (MTPs) can hamper staff's ability to provide treatment based on individual patient needs.

Findings include:

A. Record Review

1. Patient A1 (MTP dated 4/7/17)

For problem identified as "Psychosis: Loose, inappropriate and impaired reality; thought blocking; angry affect; addition hallucinations and paranoia-"

The physician intervention was "[Name of patient] will take medicine prescribed by [name of physician] in form of Ativan 1mg (milligram) t.i.d.(three times a day), Prolixin 10mg tid, and Depakote ER (Extended Release) 500mg bid [two times a day] for [his/her] psychosis, and Artane 2 mg tid for side effect."

Nursing intervention - "[Name of patient's] mental health and treatment compliance will be documented by nursing staff."

2. Patient A2 (MTP dated 4/12/17)

For problem identified as "Psychosis: Agitated mood, loose and inappropriate conversation, disorganized thoughts, auditory hallucinations, delusions of communication, and delusions of grandiosity. Uncontrollable behavior: Unpredictable and aggressive behaviors-"

The physician intervention was "[Name of patient] will take medication prescribed by [name of physician] in form of Haldol po (by mouth) TID 20 mg, Artane po tid 2 mg, Tegretol po BID 100mg, and Ativan po TID 1mg for the treatment of[his/her] for the treatment of [his/her] psychosis."

Nursing intervention - "[Name of patient's] compliance and mental health symptoms will be monitored and documented by nursing staff."

3. Patient A3 (MTP date 4/13/17)

For problem identified as "Mood disorder: Irritability, labile mood, mania, poor sleep, increased agitation."
The physician intervention was "[Name of patient] will take medication prescribed by [name of physician]in form of Haldol 20mg TID for mania, Artane 2mg TID for side effects, and Artane 1mg QID [four times a day] for anxiety and agitation."

Nursing intervention - "[Name of patient] medication compliance and mental health symptoms will be monitored and documented by nursing staff."

4. Patient A4 (MTP dated 4/12/17)

For problem identified as "Mood disorder: Mild anxiety, mild depression, irritable mood. SI [suicidal ideation]: Potential harm to self."

The physician intervention was "[Name of patient] will take medication prescribed by [name of physician] in form of Seroquel po qhs(every hour of sleep) 200mg and Effexor XR9extended release) po qd (daily) 150 mg for treatment of mood disorder."

Nursing intervention - "[Name of patient] medication compliance and mental health symptoms will be monitored and documented by nursing staff."

5. Patient B1 (MTP dated 4/7/17)

For the problem identified as "Psychosis: delusional thinking, paranoid, and delusional communication."

The physician intervention was "[Name of patient] will take medication prescribed by [name of physician] in form of Prolixin 10mg TId to treat symptoms of psychosis, Artane 2mg TID to treat possible side effect due to antipsychotic medication and Depakote ER 500mg BID to treat symptoms of mood disorder"

Nursing intervention - "[Name of patient's] medication compliance and mental health symptoms will be monitored and documented by nursing staff."

6. Patient B2 (MTP dated 4/7/17)

For the problem identified as "Psychosis: Pressured speech, auditory hallucinations, delusions of persecution and paranoia."

The physician intervention was "[Name of patient] will take medication prescribed by [name of physician] in form of Prolixin po bid 10mg, Depakote ER po BID 500mg, Artane po QID 2mg, and Ativan po QID 0.5mg for the treatment of [her/his] psychosis."

Nursing intervention - "[Name of patient's] medication compliance and mental health symptoms will be monitored and documented by nursing staff."

7. Patient B3 (MTP dated 4/13/17)

For the problem identified as "Mood disorder: Depressed mood, tearful affect. SI: Potential harm to self."
The physician intervention was "[Name of patient] will take medication prescribed by [name of physician] in the form of Trazodone po qhs 100mg, Effexor XR po qd 150mg, Compazine po TID 10mg one hour before meals for treatment of her disorder."

Nursing intervention - "[Name of patient's] mental health and treatment compliance will be documented by nursing staff."

8. Patient B4 (MTP dated 4/14/17)

For the problem identified as "Mood disorder: Lacks insight and judgment, mildly impaired."
The physician intervention was "[Name of patient] will take medication as prescribed by [name of physician] in the form of Trileptal 300mg bid, Seroquel 200mg q HS, Effexor XR 150mg BId, Haldol 20mg TID to Treat symptoms of a mood disorder and Artane 2mg TID to treat possible side effect due to antipsychotic medication.

Nursing intervention - "[Name of patient's] mental health and medication compliance will be monitored and documented by nursing staff."

B. Interview

In an interview on 4/17/17 at 9:30 a.m., the generic nursing intervention on the Master Treatment Plans was discussed with the Nursing Director. She agreed with the findings.

Based on record review and interview, the facility failed to ensure that the name and discipline of the specific nurse responsible for seeing that nursing intervention(s) on the Master Treatment Plan(s) (MTP) were carried out for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4).This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings include:

A. Record Review

Review of the following multidisciplinary treatment plans (MTPs) revealed that they did not have a nurse's name to be held accountable for seeing that nursing staff carried out the intervention(s) listed for each psychiatric problem on the MTPs of eight (8) of eight (8) active sample patients (dates of MTPs in parenthesis): patient A1 (4/7/17), patient A2 (4/12/17), patient A3 (4/13/17), patient A4 (4/12/17), patient B1 (4/7/17), patient B2 (4/7/17), patient B3 (4/13/17) and patient B4 (4/7/17). All of the MTPs listed above had the names of at least five (5) registered nurses and four (4) licensed practical nurses following each nursing intervention.

B. Interview

In an interview on 4/17/17 at 9:30 a.m., the multiple names of nursing staff listed as responsible persons to see that the nursing interventions were carried out was discussed with the Nursing Director. She stated that she thought she had to put all the names. When it was explained that only one (1) person should be assigned as the responsible person, the DON stated she would only assign one (1) person from now on.

Based on medical record review, facility policy review and staff interview it was determined that the clinical director failed to:

1. Ensure that Psychiatric Evaluations contained a description of patient assets in descriptive, not interpretive fashion. See B117 for details.

2.Ensure that Treatment Plans contained a substantiated diagnosis. See B120 for details.

3. Ensure Treatment Plans contained behaviorally measurable short and long term goals. See B121 for details.

4. Ensure Treatment Plans described patient specific treatment modalities. See B122 for details.

5. Ensure Treatment Plans identified responsible staff for treatment interventions. See B123 for details.

These failures result in Treatment Plans that fail to inform both the patient and the multidisciplinary treatment team of all required elements.

Based on record review and interview, the Nursing Director failed to monitor the quality of nursing interventions on the Master Treatment Plans of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). Specifically, the Nursing Director failed to include individualized treatment nursing interventions with a specific focus, purpose, frequency and mode of delivery (1:1 or group). The nursing intervention was a generic discipline functions/task. Failure to clearly define specific modalities on patients' Master Treatment Plans (MTPs) can hamper staff's ability to provide treatment based on individual patients' needs.

Findings include:

A. Medical Records

1. Patient A1 (MTP dated 4/7/17)

For problem identified as "Psychosis: Loose, inappropriate and impaired reality; thought blocking; angry affect; addition hallucinations and paranoia."

Nursing intervention - "[Name of patient's] mental health and treatment compliance will be documented by nursing staff."

2. Patient A2 (MTP dated 4/12/17)

For problem identified as "Psychosis: Agitated mood, loose and inappropriate conversation, disorganized thoughts, auditory hallucinations, delusions of communication, and delusions of grandiosity. Uncontrollable behavior: Unpredictable and aggressive behaviors."

Nursing intervention - "[Name of patient's] compliance and mental health symptoms will be monitored and documented by nursing staff."

3. Patient A3 (MTP date 4/13/17)

For problem identified as "Mood disorder: Irritability, labile mood, mania, poor sleep, increased agitation."
Nursing intervention - "[Name of patient] medication compliance and mental health symptoms will be monitored and documented by nursing staff."

4. Patient A4 (MTP dated 4/12/17)

For problem identified as "Mood disorder: Mild anxiety, mild depression, irritable mood. SI [suicidal ideation]: Potential harm to self."

Nursing intervention - "[Name of patient] medication compliance and mental health symptoms will be monitored and documented by nursing staff."

5. Patient B1 (MTP dated 4/7/17)

For the problem identified as "Psychosis: delusional thinking, paranoid, and delusional communication."
Nursing intervention - "[Name of patient's] medication compliance and mental health symptoms will be monitored and documented by nursing staff."

6. Patient B2 (MTP dated 4/7/17)

For the problem identified as "Psychosis: Pressured speech, auditory hallucinations, delusions of persecution and paranoia."

Nursing intervention - "[Name of patient's] medication compliance and mental health symptoms will be monitored and documented by nursing staff."

7. Patient B3 (MTP dated 4/13/17)

For the problem identified as "Mood disorder: Depressed mood, tearful affect. SI: Potential harm to self."
Nursing intervention - "[Name of patient's] mental health and treatment compliance will be documented by nursing staff."

8. Patient B4 (MTP dated 4/14/17)

For the problem identified as "Mood disorder: Lacks insight and judgement, mildly impaired."
Nursing intervention - "[Name of patient's] mental health and medication compliance will be monitored and documented by nursing staff."

B. Interview

In an interview on 4/17/17 at 9:30 a.m., the generic nursing intervention and multiple staff names for being accountable to carry out interventions were discussed with the Nursing Director. She did not dispute the findings.

Based on record review and interview, the facility failed to provide adequate numbers of qualified therapeutic activity staff to offer services to meet the needs of the patient population seven (7) days per week on days and evenings for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). This failure results in patients not receiving a full complement of therapies that were individualized and goal directed active treatment.

Findings include:

A. Record Review

A review of the daily schedule revealed that activity therapist provided four (4) groups on Mondays from 9:15 a.m. to 2:45 p.m., five (5) groups on Tuesdays from 9:20 a.m. to 2:45 p.m., two (2) groups on Wednesdays from 9:00 a.m. to 1:30 p.m., six (6) groups on Thursdays from 9:20 a.m. to 5:30 p.m. (the only day with evening groups), two (2) groups on Fridays from 9:00 a.m. to 11:10 a.m., one (1) group on two (2) Saturdays out of four (4) a month at 10:00 a.m. and none on Sundays.

B. Interview

In an interview on 4/17/17 at 8:41 a.m. with the occupational therapist (OT). She stated that the OT staff consisted of 1:5 FTEs [full time equivalents]. There was one (1) COTA [Certified Occupational Therapy Assistant] who works full time from Monday to Friday. The OT, who works part time (0.5ftes) on the inpatient unit works two (2) weekends a month. The two (2) weekends she does not work, the groups are carried out by CNAs [Certified Nursing Assistants] who provide leisure type groups without a specific focus for any patient who wants to attend. She admitted that in order for OT people to carry out groups seven (7) days per week days and evenings, the facility would need to hire another person in the department.