HospitalInspections.org

Based on observation, interview and document review, the hospital failed to:

I. Ensure that the Psychosocial Assessments (called Social Assessments by the facility) for 2 of 8 active sample patients (A2 and A5) were completed in a timely manner, and that the Psychosocial Assessments for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) documented the anticipated role of the Social Worker in treatment and discharge planning. These failures hamper the treatment team ability to formulate appropriate social service interventions for patients. (Refer to B108).

II. Revise the Master Treatment Plan (MTP) after multiple episodes of restraint and seclusion for 1 of 8 active sample patients (A2). The MTP was not updated to address less restrictive interventions to be used before seclusion/restraint to help Patient A2 control episodes of aggressive behavior. Failure to revise the MTP to adequately reflect current patient treatment needs potentially delays improvement and discharge. (Refer to B118-I)

III. Ensure that the MTP for 1 of 8 active sample patients (A2) addressed physical problems needing attention during the hospitalization. According to the progress notes, Patient A2 had unstable diabetes mellitus. The treatment plan did not mention the unstable diabetes. Failure to include physical problems on the treatment plan hampers the staff's ability to provide coordinated multidisciplinary care and can result in the patient's treatment needs not being met, potentially leading to a significant medical crisis for the patient. (Refer to B118-II)

IV. Provide comprehensive MTPs that included all required components for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). The MTPs were missing observable and/or measurable short term goals with specified target dates (Refer to B121); individualized treatment interventions and modalities (Refer to B122); and/or specific names of staff responsible for the interventions (Refer to B123). These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment, potentially leading to patients' treatment needs not being met. (Refer to B118-III)

V. Provide individualized active treatment for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) and all patients in the facility on evenings and week-ends. Scheduled groups and activities for evenings, Saturdays and Sundays were only leisure oriented and were optional for patients. There was no evidence that individualized treatment was being offered. There also was no tracking of these activities or documentation of attendance in the patients' medical records. This deficient practice hinders the patients' participation in active treatment, potentially prolonging hospitalization. (Refer to B125)

Based on record review, interview and policy review, the facility failed to ensure that the Psychosocial Assessments (called Social Assessments by the facility) for 2 of 8 active sample patients (A2 and A5) were completed in a timely manner. The Psychosocial Assessments for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) also failed to document the anticipated role of the Social Worker in treatment and discharge planning. These failures hamper the treatment team ability to formulate appropriate social service interventions for patients.

Findings include:

A. Record Review

The Social Assessment was a two page preprinted form completed in hand writing by the assigned social worker. The form contained questions to be asked of patients for collection of baseline psychosocial information to be used in treatment and discharge planning. The last three lines on the form were labeled "Issues that need immediate attention", "Community resources needed" and "Recommendations" with spaces to add brief notes. The specific roles for social work in treatment were not identified, and the information written on each patient's anticipated discharge plan was very limited.

1. Patient A1, admitted 9/22/11, had a Social Assessment completed 9/26/11. The "Issues that need immediate attention" listed "place to stay." "Community resources needed" listed "housing/SSI," and "Recommendations" were "Continue Outpatient." No further role for the Social Worker was identified.

2. Patient A2, admitted 9/27/11, had an undated Social Assessment in the chart that was essentially blank. The answer to the question "Why were you admitted here?" was "Under police protection," despite the fact that the patient had 22 previous admissions. The other 2 assessment questions were not answered. There was nothing else written on the last three lines of the assessment regarding the social worker's role in treatment or discharge planning.

3. Patient A3, admitted 10/1/11, had a Social Assessment completed 10/2/11. The "Issues that need immediate attention" listed "Moods and Medication." "Community resources needed" listed "Counseling" The "Recommendations" were "Continue IP (inpatient)." No further role for the Social Worker was identified.

4. Patient A4, admitted 10/9/11, had a Social Assessment completed 10/14/11. The "Issues that need immediate attention" listed "Counseling/ Medicaid/SSI/SSDI,"
"Community resources needed" listed "Intensive counseling." The "Recommendations" were "Continue IP." No further role for the Social Worker was identified.

5. Patient A5, admitted 10/17/11, had a Social Assessment completed 10/26/11, nine days after admission. The "Issues that need immediate attention" listed "help find a job." "Community resources needed" listed "Counseling." The "Recommendations" were "Continue Inpatient a few more days." No further role for the Social Worker was identified.

6. Patient A6, admitted 10/18/11, had a Social Assessment completed 10/21/11. The "Issues that need immediate attention" listed "help with Voc Rehab." "Community resources needed" listed "none counseling." The "Recommendations" were "Continue Inpatient." No further role for the Social Worker was identified.

7. Patient A7, admitted 10/21/11, had a Social Assessment completed 10/24/11. The Issues that need immediate attention listed "Counseling/Half Way House." "Community resources needed" listed "Half way house." The "Recommendations" were "Continue IP." No further role for the Social Worker was identified.

8. Patient A8, admitted 10/24/11, had a Social Assessment completed 10/26/11. The "Issues that need immediate attention" listed "Stabilize Moods." "Community resources needed" listed "Housing and Social Security." The "Recommendations" were "Continue IP (inpatient)." No further role for the Social Worker was identified.

B. Staff Interview

In an interview on 10/27/11 at 2:50PM, the Director of Social Work, who is also the social worker doing most of the Social Assessments, agreed that the Social Assessment should include more information written into the planning section, and that the role of the Social Worker in the assessment should be more specific and complete. The Director also acknowledged that Social Assessments should be completed within 48 hours of admission but stated that she had been trained to put in only what the patient said and that Patient A2 would not cooperate.

C. Policy Review

Policy # II-H-2, titled "Social Assessments," was reviewed. It stated the Social Worker should complete a full Social Assessment within 48 hours of admission.

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

I. Revise the Master Treatment Plan (MTP) after multiple episodes of restraint and seclusion for 1 of 8 active sample patients (A2). The MTP was not updated to address less restrictive interventions to be used before seclusion/restraint to help Patient A2 control episodes of aggressive behavior. Failure to revise the MTP to adequately reflect patient treatments needs potentially delays improvement and discharge.

II. Ensure that the MTP for 1 of 8 active sample patients (A2) addressed physical problems needing attention during the hospitalization. According to the progress notes, Patient A2 had unstable diabetes mellitus. The treatment plan did not mention the unstable diabetes. Failure to include physical problems on the treatment plans hampers the staff's ability to provide coordinated multidisciplinary care and can result in the patient's treatment needs not being met and potentially could lead to a significant medical crisis for a future patient.

III. Provide MTPs that included all required components for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). The MTPs were missing observable and/or measurable short term goals with specified target dates (Refer to B121); individualized treatment interventions and modalities (Refer to B122); and specific names of staff responsible for the interventions (Refer to B123). These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment, potentially leading to patient's treatment needs not being met.

Findings include:

I. Failure to revise MTP after Seclusion/Restraint

A. Record Review

Patient A2 was admitted on 9/27/2011. The MTP dated 10/3/2011 documented one problem: "Schizophrenia Paranoid Type."

Review of the facility's "Restraint and Seclusion Log" showed that Patient A2 had the following seclusion and/or restraint events:

9/28/2011: 9:05a.m. Until 9:35a.m. (restrained and secluded).
9/29/2011: 11:34a.m. to 11:35a.m. (physical hold).
9/30/2011: 8:55a.m. to 8:56a.m.; 10:56p.m. to 10:57p.m. (physical holds).
10/5/2011: 7:02a.m. to 7:18a.m. (physical hold).
10/20/2011: 9:30a.m. to 9:55a.m. (physical hold).
10/24/2011: 2:22p.m. to 2:34p.m. (physical hold).

The MTP reviews dated 10/10/2011, 10/17/2011, and 10/24/2011 had no revisions regarding the multiple episodes of seclusion/restraint.

B. Policy Review

The facility "Policy # III-C-1 Comprehensive Treatment Planning Process - Inpatient" states: "II Procedure for Comprehensive Treatment Planning Revision: Each Team Member...Reviews patient contacts for the period and assess the patient's progress in meeting objectives. Treatment Team...Discusses progress and agrees on new short - term goals/objectives. Social Worker...Documents on above treatment plan or review form. Patient...Is invited to discuss progress and new short-term goal/objectives. Patient...Is allowed time to give input. Signs the treatment plan. Treatment Team...Signs the treatment plan." The facility policy for treatment planning does not address anything regarding revisions or updates for the treatment plan.

C. Interviews

1. In an interview on 10/27/2011 at 10:30a.m., the Director of Nursing (DON) acknowledged that the MTP for Patient A2 had not been revised to address the multiple episodes of restraint and seclusion.

2. In an interview on 10/27/2011 at 12:15p.m., RN2 agreed that the MTP for Patient A2 had not been revised to address the multiple episodes of restraint and seclusion.

3. In an interview with the Medical Director on 10/27/11 at 12p.m., the treatment plans were discussed. The problem of treatment plans not addressing new problems and needed treatment changes was discussed. The Medical Director agreed that this was not being done and is a problem. He stated that he was "99.5% in the outpatient department" and spent very little time in the inpatient service.

II. Failure to address physical problems on MTP

Findings include:

A. Record Review

1. Patient A2 was admitted on 9/27/2011. The MTP dated 10/3/2011 only documented one problem -- "Schizophrenia Paranoid Type." However, the "Psychiatric Evaluation" dated 9/27/2011 stated, "Medical History...Diabetes. Other observations...Pt [sic] has refused all meds, is sleeping on the street...seems to be a danger to [self] at this time due to inability to care for self."

2. In a progress note dated 10/18/2011, MD1 stated, "Patient has been refusing FSBS (Finger stick blood sugar) but on encouragement pt [sic] did FSBS (fasting blood sugar); it was 363 and s/he got reg [regular] insulin per sliding scale."

3. In a progress note dated 10/20/2011, MD1 documented, "Pt again refusing FSBS, on encouragement did FSBS, was 422, pt was given 12 units of regular insulin, will send to ER for uncontrolled DM [sic] and to be put on Lantus insulin as patient refuses oral antidiabetic meds [sic]. Patient A2 returned later after a liter of fluids.

B. Interviews

1. In an interview on 10/27/2011 at 10:30a.m., the Director of Nursing (DON) agreed that the MTP for Patient A2 did not contain any reference to diabetes.

2. In an interview on 10/27/2011 at 12:15p.m., RN2 agreed that the MTP for Patient A2 did not contain any reference to diabetes.

3. In an interview on 10/27/11 at 12p.m., the Medical Director agreed that treatment plans did not incorporate physical problems such as unstable medical problems, or treatment needed for these conditions. The Medical Director stated that he was "99.5% in the outpatient department" and spent very little time in the inpatient service.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTP's) that identified short term goals (called "objectives") and long term goals (called "Goals") stated in observable, measurable, behavioral terms for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). In addition, the goals and objectives were identical for some patients. For 3 sample patients (A4, A5 and A6), some of the goals were stated as staff goals for patient participation in treatment activities. For one patient (A8), there were no goals or objectives listed. Lack of measurable, patient-specific goals hampers the treatment team's ability to measure change in the patient's condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient needs.

Findings include:

A. Record Review

1. Patient A1, admitted 9/22/11; last MTP review=10/10/11)

The patient's only problem listed in the MTP was "Depression." The one "Goal" (long term goal) was "To decrease the severity of symptoms to the degree to which the client can return to a less restrictive environment." The only "Objective" (short term goal) was "Identify and verbalize ways to cope with stressors that lead to depression within 7 days." The goal and the objective were not measurable as stated

2. Patient A2 (admitted 9/27/11; last MTP review=10/24/11)

The patient's only problem listed in the MTP was "Schizophrenia Paranoid Type." The only Goal was "To decrease the severity of symptoms to the degree to which client can return home." The goal was not measurable as stated, nor was it specific to the patient who had no home.

3. Patient A3 (admitted 10/1/11; most recent MTP review=10/25/11)

The patient's MTP listed problem #1 as "Depressive Disorder NOS." The corresponding Goal was "To decrease the severity of symptoms to the degree to which client can return to a less restrictive environment." The Objective was "Identify and verbalize ways to cope with stressor and verbalize two reality based thoughts within 7 days" which was not specific to the patient who did not exhibit problems with reality. Problem #2 was "Cocaine Abuse." the listed long term goal was "Learn effective ways to cope with stressors without the use of drug and alcohol"; the Objective (short term goal) was "Client will be able to function daily with a decrease in drug and alcohol use" These goals and objectives were not measurable as stated.

4. Patient A4 (admitted 10/9/11; most recent MTP review=10/24/11)

The patient's MTP listed the problem of "Depression as Evidenced by Suicidal Thoughts" with the Goal of "To decrease the severity of symptoms to the degree to which client can return home." The Objectives were "Attend groups and activities" and "Identify and verbalize ways to cope with stressor that lead to depression within 7 days." The goal and the objectives were not measurable as stated nor were they specific to the patient's problem. The objectives also were written as staff goals for patient participation in treatment.

5. Patient A5 (admitted 10/17/11; MTP=10/19/11)

The patient's problem of "Delusions as evidenced by statements made and confusion" was listed in the MTP. The corresponding Goal was "To decrease the severity of symptoms to the degree to which client can return home." The Objectives were "Attend groups and activities" and "Identify and verbalize ways to cope with stressor that lead to depression within 7 days." The goal and the objectives were not measurable as stated, nor were they specific to the stated patient problem. The first objective was also written as a staff goal for patient participation in treatment.

6. Patient A6 (admitted 10/18/11; MTP=10/21/11)

The patient's problem of "Depression as Evidence by Suicidal Thoughts" was noted in the MTP. The corresponding Goal was "To decrease the severity of symptoms to the degree to which client can return home." The only Objectives were "Attend groups and activities" and "Identify and verbalize ways to cope with stressor that lead to depression within 7 days." The goal and the objectives were not measurable as stated, nor were they specific to the patient's problem. The first objective was written as a staff goal for patient participation in treatment.

7. Patient A7 (admitted 10/21/11; MTP= 10/24/11)

The patient's MTP listed the problem of "PTSD" with the Goal of "To decrease the severity of symptoms to the degree to which client can return home" and the Objective was "Identify and verbalize ways to cope with stressors that lead to depression within 7 days." The goal and objective were not measurable as stated, nor were they correlated with the patient's problem of PTSD.

8. Patient A8 (admitted 10/24/11; MTP=10/27/11)

This patient did not have a computerized MTP in the record. A handwritten MTP dated 10/27/11 listed "Depression as evidence by suicidal tendencies, hopelessness and feelings of worthlessness" as the problem. There were no listed goals on the treatment plan.

B. Interviews

1. In an interview with the Medical Director on 10/27/11 at 12p.m., the sample patients' treatment plans were discussed. The problem of treatment plans lacking specific goals and objectives was discussed. The Medical Director agreed that this was a problem.

2. In an interview with the Director of Social Work on 10/27/11 at 2:50p.m., the treatment plans were discussed. The issues of the MTP goals and objectives not addressing specific problems and being non-measurable were reviewed. The Director of Social Work said that she understood these deficiencies, but that this was not how she was trained to do treatment plans.

Based on record review and interview, the facility failed to develop MTPs that clearly delineated interventions to address the specific problems of 8 of 8 active sample patients (A1, A2, A3, A4, A4, A6, A7 and A8). The treatment plans did not list the specific intervention modalities or their frequency of use for the psychiatrist (MD), nurse (RN), social worker (SW), or recreation therapy staff (RT). The interventions were also stated as generic functions instead of being individualized for patients. Failure to document specific treatment approaches on patients' treatment plans hampers staff's ability to provide focused and consistent treatment for each patient's problems.

Findings include:

A. Record Review

1. Patient A1 (admitted 9/22/11). The MTP dated 10/10//2011 documented one problem -- "Depression." There were four interventions listed: "1A. Stabilize on meds [sic]; attend groups and activities, take medications as ordered." "1B. 1-1 follow-up with social worker 2-3 times weekly to develop discharge plan, and follow-up out-patient services." "1C. Learn to practice appropriate ways to deal with depression through structured RT activities and develop positive coping skills." "1D. Engage behavior in conversations to get goals (realistic) also methods of relieving stress."

2. Patient A2 (admitted 9/27/2011). The MTP dated 10/24/2011 documented one problem "Schizophrenia Paranoid Type." There were four interventions listed: "1A. Stabilize on meds [sic], attend groups and activities, and take medications as ordered." "1B. 1-1 with the social worker to develop discharge plan, and follow-up with out-patient services. Place in residential care." "1C. Develop positive coping skills to help decrease mood swings and paranoid thoughts by expressing feelings (1-2X ' s) daily to staff." "1D. Administer meds [sic] as prescribed continue to monitor for safety, behavior and offer emotional support."

3. Patient A3 (admitted 10/1/2011). The MTP dated 10/25/2011 documented two problems "Depressive Disorder NOS" and "Cocaine Abuse." There were four interventions listed for "Depression: 1A. Stabilize on meds [sic]; attend groups and activities, take medications as ordered." "1B. 1-1 follow-up with social worker 2-3 times weekly to develop discharge plan, and follow-up out-patient services. Help find placement." "1C. Learn to practice appropriate ways to deal with depression through structured RT activities and develop positive coping skills." "1D. Administer meds [sic] as prescribed continue to monitor for safety, behavior and offer emotional support." For "Cocaine Abuse" the interventions were: 2A. Stabilize on meds [sic], attend groups and activities, take medications as ordered." "2B. 1-1 with social worker to discuss the effects of substance abuse on mental illness." "2C. Provide RT activities to improve coping skills to maintain drug/alcohol free through structured groups." "2D. Administer meds [sic] as prescribed continue to monitor for safety, behavior and offer emotional support."

4. Patient A4 (admitted 10/9/11). The MTP dated 10/24/2011 documented one problem "Depression as evidenced suicidal thoughts." There were four interventions listed: "1A. Stabilize on meds [sic]; attend groups and activities, take medications as ordered." 1B. 1-1 follow-up with social worker 2-3 times weekly to develop discharge plan, and follow-up out-patient services. 1C. Learn to practice appropriate ways to deal with depression through structured RT activities and develop positive coping skills. 1D. Encourage participation in group and activities daily, monitor for sign and symptoms of adverse effect of medication."

5. Patient A5 (admitted 10/17/11). The MTP dated 10/19/2011 documented one problem: "Delusions as evidence by statement made and confusion" There were four interventions listed: "1A. Stabilize on meds [sic]; attend groups and activities, take medications as ordered. 1B. 1-1 follow-up with social worker 2-3 times weekly to develop discharge plan, and follow-up out-patient services. 1C. Improve reality based thoughts by success fully participating in structured RT activities. 1D. Encourage participation in group and activities daily, monitor for sign and symptoms of adverse effect of medication."

6. Patient A6 (admitted 10/17/11). The MTP dated 10/19/2011 documented one problem: "Depression as evidenced suicidal thoughts." There were four interventions listed: "1A. Continue medication therapy, continue ward therapy and consider rehab [sic] options. 1B. 1-1 follow-up with social worker 2-3 times weekly to develop discharge plan, and follow-up out-patient services. 1C. Learn and practice appropriate ways to deal with depression through structured RT activities. 1 D. Administer meds [sic] as prescribed, provide emotional support as needed."

7. Patient A7 (admitted 10/21/11). The MTP dated 10/24/2011 documented one problem: "PTSD." There were four interventions listed: "1A. Stabilize on meds [sic], attend groups and activities, take medications as ordered. 1B. 1-1 follow-up with social worker 2-3 times weekly to develop discharge plan, and follow-up out-patient services. 1C. Decrease feelings of hopelessness/helplessness by learning how to deal with depression daily through structured RT activities. 1 D. Administer meds [sic] as prescribed, provide emotional support as needed."

8. Patient A8 (admitted 10/24/11). The MTP dated 10/27/2011 documented one problem: "Depression as evidence by suicidal tendencies, hopelessness and feelings of worthlessness." There were three interventions listed: "1A. Stabilize on medication, attend groups and activities; take medications as ordered and co-occurrence group. 1B. 1-1 follow-up with social worker 2-3 times weekly to develop discharge plan, and follow-up out-patient services. 1C. Administer medications as prescribed provide emotional support as needed."

B. Interviews

1. In an interview on 10/27/2011 at 10:30a.m., both the Director of Nursing (DON) and the Executive Director agreed that the listed interventions on the sample patients' treatment plans were stated as generic functions, not individualized interventions for the patients.

2. In an interview on 10/27/2011 at 12:15p.m., RN2 agreed that the MTP interventions were stated as generic functions.

3. In an interview with the Medical Director on 10/27/11 at 12p.m., the problem of treatment plan interventions being too generic and not specific to the patient was discussed. The Medical Director agreed that this is a problem.

Based on record review and interview, the facility failed to ensure that the name and discipline of the staff persons responsible for specific aspects of care were listed on the MTPs of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

A. Record Review

The Master Treatment Plans for all sample patients (A A1, A2, A3, A4, A5, A6, A7 and A8) neglected to document the name and discipline of staff responsible for the listed interventions. Instead, "Staff: Unknown" was recorded.

B. Interview

In an interview on 10/27/2011 at 10:30a.m., the Director of Nursing (DON) agreed that the names and disciplines were omitted from the treatment plans.

Based on document review and interview, the facility failed to provide individualized active treatment for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) and all patients in the facility on evenings and week-ends. The scheduled groups and activities for evenings, Saturdays and Sundays were only leisure oriented (examples = "Stretching, Activities, Movies"), and were optional for patients. There was no documented evidence that these activities were offered on a regular basis. There also was no evidence that any other individualized treatment was offered to patients during week-ends. This deficient practice results in patients being hospitalized without receiving all interventions for recovery, potentially prolonging hospitalization.

Findings include:

A. Record/Document Review

1. The "Jim Taliaferro Community Mental Health Center Inpatient Unit Schedule" does not have any activities/groups scheduled on any evening. For Saturday and Sunday, there are activities for "10:30a.m. to 11:30a.m." and from "2:15p.m. to 3p.m."

2. There was no documentation in the progress notes of any of the 8 active sample patients that that scheduled activities or other treatment groups occurred during evenings or weekends, or that the patient participated in these activities.

B. Interviews

1. In an interview 10/27/2011 at 11a.m., RT1 stated that neither he nor the other RT worked weekends. He stated that he did not know whether any groups occurred on evenings or weekends.

2. In an interview on 10/27/2011 at 2:30p.m., the (DON) acknowledged that groups were not being held on evenings and weekends.

Based on document review and interview, the facility failed to ensure that RN group leaders consistently completed progress notes for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This deficiency can results in lack of monitoring of patient response to interventions. It also results in lack of evidence regarding whether the groups actually occurred. There was no documentation of other methods for tracking whether the groups occurred.

Findings are:

A. Record/Document Review

1. The "Jim Taliaferro Community Mental Health Center Inpatient Unit Schedule" states that that "RN Wellness Group" was scheduled on Tuesday and Thursday from 12:15p.m. to 1p.m.

2. There was no documentation in any of the sample patients' progress notes that the above groups were held or that the patient attended.

B. Interviews

1. In an interview on 10/27/2011 at 2:30p.m., the (DON) agreed that patient attendance at the RN Wellness groups was not documented.

Based on record review, interview and policy review, the social worker failed to write regular and timely progress notes for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) which contained information to specifically address patient progress towards treatment goals and safe discharge planning. This failure hampers the treatment team's ability to assess or evaluate the patient's response to treatment or progress toward a discharge.

Findings Include:

A. Policy Review

The facility's Policy # III-C-4 titled "Progress Notes," dated 2/11, was reviewed. It stated the Inpatient Social Work Staff records progress notes a minimum of three times a week.

A. Record Review

Progress notes are entered sequentially into a computerized patient record. Social work notes are titled "Note Type: Social Services." A review of these notes for the sample patients on 10/26/11 revealed the following findings:

1. Patient A1 was admitted 9/22/11. By the review on 10/26/11, there were 6 progress notes written by social workers, three of which were group notes and three addressed placement issues. According to the progress note policy, there should have been 13 SW notes.

2. Patient A2 was admitted 9/27/11. By the review on 10/26/11, there were 9 progress notes written by social workers, one of which was a group note. The other notes were related to commitment, nursing home placement and phone calls with a family member, most of which were entered on the same day, 10/17/11. Several of the notes were entered into the record on 10/17/11 which was 4 to 7 days after the interactions. According to the progress note policy, there should have been 11 SW notes.

3. Patient A3 was admitted on 10/1/11. By the review on 10/26/11 there were 6 progress notes by a social worker. The last note entered on 10/13/11 described a trip to buy eyeglasses on 10/11/11. Only one note, also entered on 10/13/11, reported on helping the patient with a discharge plan and there were no notes that indicated the patient had attended a SW led group. According to the progress note policy, there should have been 10 SW notes.

4. Patient A4 was admitted on 10/9/11. By the review on 10/26/11, there were 3 progress notes by a social worker. None of the notes documented that the patient had attended a SW led group. According to the progress note policy, there should have been 6 SW notes.

5. Patient A5 was admitted on 10/17/11. By the review on 10/26/11, there was only one progress note by a social worker. It recorded the Treatment Team meeting of 10/19/11. According to the progress note policy, there should have been 3 SW notes.

6. Patient A6 was admitted on 10/18/11. By the review on 10/26/11, there were only two progress notes by a social worker -- one describing an interaction on 10/21/11 and the other describing an interaction on 10/24/11. Both notes were entered into the computerized record on 10/26/11. There were no notes that indicated that the patient attended a SW led group.

7. Patient A7 was admitted on 10/21/11. By the review on 10/26/11, the only social worker progress note recorded that the initial evaluation (Social Assessment) had been done. There were no notes that indicated that the patient attended a SW led group.

8. Patient A8 was admitted on 10/24/11. By the review on 10/26/11, there were no progress notes by a social worker.

B. Staff Interview

In an interview on 10/27/11 at 2:50PM, the Director of Social Work, who is also the social worker entering most of the progress notes, acknowledged that social work progress notes should be written more frequently according to the progress note policy. She said she did not have the time to do it.

Based on document review, record review and interview, the facility failed to ensure that the Recovery Center Staff and the Triage Staff consistently completed progress notes for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This deficiency can result in lack of monitoring of patient response to interventions. It also can result in lack of evidence regarding whether the groups actually occurred if there is no other method for tracking the groups.

Findings are:

A. Document Review

According to the "Jim Taliaferro Community Mental Health Center Inpatient Unit Schedule," the Recovery Center staff was scheduled to lead a substance abuse and recovery group every Monday and Wednesday from 1:10p.m. to 2p.m. A "Consumer Rights" group was scheduled for every Friday from 12:15 to 1p.m. The Triage staff was scheduled to lead a group every Tuesday and Thursday from 1:10 to 2p.m.

B. Record Review

1. Review of the sample patients' medical records revealed only the following isolated notes in the sample patients' progress notes of attendance in the Recovery Center groups:

Patient A1, admitted 9/22/11, was noted on 10/10 to attend a "Substance Abuse Group" on that day.

Patient A2, admitted 9/27/2011, did not have any progress notes documented by recovery staff.

Patient A3, admitted 10/1/2011, was noted on 10/10 to attend a "Substance Abuse Group" on that day and a "Counseling Group" focusing on sobriety 10/13.

Patient A4 admitted 10/9/11 did not have any progress notes documented by recovery staff.

Patient A5 admitted 10/17/11 did not have any progress notes documented by recovery staff.

Patient A6 admitted 10/17/11 did not have any progress notes documented by recovery staff.

Patient A7 admitted 10/21/11 did not have any progress notes documented by recovery staff.

Patient A8 admitted 10/24/11 did not have any progress notes documented by recovery staff.

2. There was no documentation in any of the sample patients' progress notes that the Consumer Rights groups were held or attended.

3. There was no documentation in any of the sample patients' progress notes that the Triage staff groups were held or attended.

C. Interview

In an interview on 10/27/11 at 12p.m., the Medical Director stated that he was "99.5% in the outpatient department" and spent very little time in the inpatient service. This resulted in lack of oversight to ensure that treatment groups were provided and documented.

Based on record review, observation and interview, the facility failed to provide adequate medical, nursing, and social work clinical leadership. The Medical Director failed to assure that patients had comprehensive Master Treatment Plans and that all patients received active treatment during week-ends. The Medical Director stated that he "was 99.5% in the outpatient department" and spent very little time in the inpatient service. (Refer to B144). The Director of Nursing failed to assure that nursing interventions were clearly specified on patient's treatment plans, and that there was adequate documentation that scheduled nursing groups were offered as scheduled. (Refer to B148) The Director of Social Work failed to assure timely completion of psychosocial assessments and documentations of patient participation in social work treatment groups. (B152) Lack of monitoring, direction, and supervision of the inpatient services results in patients not receiving all needed treatment for recovery. In addition, it is a potential safety risk for patients.

Based on record review and interview, the Medical Director failed to assure quality and appropriateness of care for patients. Specifically, the Medical Director failed to:

I. Ensure that the Master Treatment Plan (MTP) of 1 of 8 active sample patients (A2) was revised after multiple episodes of restraint and seclusion. The MTP was not updated to address less restrictive interventions to be used before seclusion/restraint to help Patient A2 control episodes of aggressive behavior. Failure to revise the MTP to adequately reflect current patient treatment needs potentially delays improvement and discharge. (Refer to B118-I)

II. Ensure that the MTP for 1 of 8 active sample patient (A2) addressed physical problems needing attention during the hospitalization. According to the progress notes, Patient A2 had unstable diabetes mellitus. The treatment plan did not mention the unstable diabetes. Failure to include physical problems on the treatment plans hampers the staff's ability to provide coordinated multidisciplinary care and can result in the patient's treatment needs not being met and potentially could lead to a significant medical crisis for the patient. (Refer to B118-II)

III. Ensure that the Master Treatment Plans (MTPs) 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) included all required components. The MTPs were missing observable and/or measurable short term goals with specified target dates (Refer to B121); individualized treatment interventions and modalities (Refer to B122); and/or the specific names of staff responsible for the interventions (Refer to B123). These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment, potentially leading to patient's treatment needs not being met.

IV. Ensure that individualized active treatment was provided for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) and all patients in the facility on evenings and week-ends. The scheduled groups and activities for evenings, Saturdays and Sundays for were only leisure oriented. There was no documented evidence of individualized treatment being offered to patients during weekends. This deficient practice results in patients being hospitalized without all interventions for recovery being provided, potentially prolonging hospitalization. (Refer to B125)

Based on document review and interview the DON failed to:

I. Ensure that the MTPs of 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) included specific and individualized nursing interventions to address the patients' identified problems. The MTPs did not include the discipline or names of staff responsible for any of the listed interventions. Therefore it was impossible to identify which of the listed interventions was the responsibility of the RN or other nursing staff. This failed practice results in lack of nursing staff accountability for treatment modalities.

Record Review:

Review of the sample patient's MTPs revealed lists of generic interventions with no disciplines identified. There were some interventions that were typical nursing functions, but these did not specify the discipline of nursing and had no nursing staff assignments. Thus, it was not possible to identify which interventions were the responsibilities of the RN and/or other nursing staff.

1. Patient A1 (admitted 9/22/11) The MTP dated 10/10/2011 documented the problem as "Depression." The listed interventions included: "1A. Stabilize on meds [sic]; attend groups and activities, take medications as ordered." "1D. Engage behavior in conversations to get goals (realistic) also methods of relieving stress. The nursing interventions were not specified.

2. Patient A2 (admitted 9/27/2011) The MTP dated 10/24/2011 documented the problem as "Schizophrenia Paranoid Type." The listed interventions included: "1A. Stabilize on meds [sic], attend groups and activities, and take medications as ordered. Develop positive coping skills to help decrease mood swings and paranoid thoughts by expressing feelings (1-2X's) daily to staff. 1D. Administer meds [sic] as prescribed continue to monitor for safety, behavior and offer emotional support." The nursing interventions were not specified.

3. Patient A3 (admitted 10/1/2011). The MTP dated 10/25/11 documented two problems -- "Depressive Disorder NOS" and "Cocaine Abuse." The listed interventions inlcuded: "Depression: 1A. Stabilize on meds [sic]; attend groups and activities, take medications as ordered. 1D. Administer meds [sic] as prescribed continue to monitor for safety, behavior and offer emotional support "Cocaine Abuse 2A. Stabilize on meds [sic], attend groups and activities, take medications as ordered. 2D. Administer meds [sic] as prescribed continue to monitor for safety, behavior and offer emotional support." The nursing interventions were not specified.

4. Patient A4 (admitted 10/9/11). The MTP dated 10/24/2011 documented the problem as "Depression as evidenced suicidal thoughts." The listed interventions included: "1A. Stabilize on meds [sic]; attend groups and activities, take medications as ordered. 1D. Encourage participation in group and activities daily, monitor for sign and symptoms of adverse effect of medication". "The nursing interventions were not specified.

5. Patient A5 (admitted 10/17/11). The MTP dated 10/19/2011 documented the problem as "Delusions as evidence by statement made and confusion." The listed interventions included: "1A. Stabilize on meds [sic]; attend groups and activities, take medications as ordered. 1D. Encourage participation in group and activities daily, monitor for sign and symptoms of adverse effect of medication." The nursing interventions were not specified.

6. Patient A6 (admitted 10/17/11). The MTP dated 10/19/2011 documented the problem as "Depression as evidenced suicidal thoughts." The listed interventions included: "1A. Continue medication therapy, continue ward therapy and consider rehab [sic] options. 1D. Administer meds [sic] as prescribed provide emotional support as needed." The nursing interventions were not specified.

7. Patient A7 (admitted 10/21/11). The MTP dated 10/24/2011 documented the problem as "PTSD." The listed interventions included: "1A. Stabilize on meds [sic], attend groups and activities, take medications as ordered. 1D. Administer meds [sic] as prescribed, provide emotional support as needed." The nursing interventions were not specified.

8. Patient A8 (admitted 10/24/11). The MTP dated 10/27/2011 documented the problem as "Depression as evidence by suicidal tendencies, hopelessness and feelings of worthlessness." The listed interventions included: "1A. Stabilize on medication], attend groups and activities; take medications as ordered and co-occurrence group. 1C. Administer medications as prescribed provide emotional support as needed." The nursing interventions were not specified.

B. Interview

In an interview on 10/27/2011 at 10:30a.m., the Director of Nursing (DON) agreed that the names of nursing staff responsible for specific interventions on the sample patients' MTPs were omitted.

II. Ensure that "RN Wellness" groups scheduled Tuesday and Thursday from 12:15 to 1p.m. were conducted and that the content was documented. Failure to document provision of assigned treatment groups potentially results in patients not receiving all needed interventions for recovery.

A. Record reviews

There was no documentation in the progress notes of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) medical records that the Nursing Wellness groups were held or attended.

B. Interview

In an interview on 10/27/2011 at 2:30p.m. the Director of Nursing (DON) agreed that attendance at the RN Wellness Group was not documented in the patients' medical records.

Based on record review, interview and policy review, the Director of Social Services failed to monitor and evaluate the quality and appropriateness of social services provided for 8 of 8 active patients (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, the Director of Social Services failed to:

I. Ensure that the Psychosocial Assessments (called Social Assessments by the facility) for 2 of 8 active sample patients (A2 and A5) were completed in a timely manner, and that the Assessments documented the anticipated role of the Social Worker in treatment and discharge planning for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). These failed practices result in a lack of information to formulate social service interventions for patients. (Refer to B108)

II. Ensure that social workers wrote regular and timely progress notes for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) which contained information to specifically address patient progress towards treatment goals and safe discharge planning. This failure hampers the treatment team's ability to determine patients' responses to social work interventions or progress toward discharge. (Refer to B128)