HospitalInspections.org

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

I. Ensure that the Master Treatment Plans for 3 of 3 active sample patients from the Gero/Psych Unit (A2, A5 and A11) were revised when the patients failed to participate in the prescribed treatment. The Master Treatment Plans for these patients were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

II. Ensure that adequate active treatment measures and care were provided for 3 of 3 active sample patients (A2, A5 and A11) on the Acute Gero/Psych (Geriatric and Adult Psychiatric) Unit to move the patients to a higher level of functioning and a less restrictive environment. This failure results in patients being hospitalized without receiving all interventions to meet their treatment needs, potentially delaying their improvement. (Refer to B125-I)

III. Ensure appropriate use and documentation of seclusion/restraints as external controls of violence toward self and others for 1 of 1 active sample patient (A11) and 4 of 9 discharged patients (E6, E7, E8, and E9) for whom the use of seclusion and restraints were reviewed. For these patients, seclusion or restraints were initiated or continued without adequate documented justification, and nurses failed to release the patients in a timely manner. For patient E9, there also was no documentation of a physician order or assessment of the patient's response to a physical hold (restraint). These failures expose patients to potential harm from unnecessary restraint. They also violate patients' rights to safe treatment in the least restrictive manner possible. (Refer to B125-II)

IV. Ensure confidentiality of patient information for all patients admitted to the "Gero/Psych (Geriatric-Psychiatric)" ward. Staff discussed patients with other staff or on the telephone in the open nursing station in the dayroom area of the Gero/Psych ward where patients overheard staffs' discussions about other patients. During the survey, staff was observed assessing Patient A16 and administering intramuscular medication next to the nursing station in the dayroom. These staff behaviors result in a breach of patients' privacy and confidentiality. (Refer to B125-III)

Based on record review, document review and interview, the facility failed to ensure that the Master Treatment Plans for 3 of 3 active sample patients from the Gero/Psych Unit (A2, A5 and A11) were revised when the patients failed to participate in the prescribed treatment. The Master Treatment Plans for these patients were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Patient A2 was admitted with a diagnosis of major depressive disorder on 6/26/11, based on a review of the initial psychiatric evaluation dated 6/26/11. The patient was observed on both the "low functioning unit" and the "high functioning unit" during the survey.

1. The Master Treatment Plan for Patient A2, dated 6/26/11 and last updated 7/9/11, listed the following group modalities to be used as treatment interventions: "Psycho education groups to educate on symptoms and treatment for depression"; "teach Pt. (patient) how to manage and cope safely and effectively with symptoms of depression (1 x daily)"; "Process groups to allow discussion on SI triggers and ways to modify/avoid/cope with life stressors", and "encourage peer interaction (1 x daily)."

2. A 7/5/11 Nursing Summary Note in the Record of Patient A2 read, "Still on LOS [line of sight] on low functioning side where [patient] can be watched to prevent self-harm."

3. In an interview on 7/12/11 at 10:00a.m., Patient A2 stated, "I'm on this side (low functioning) quite a bit. When I am here, I don't go to any groups. I don't do anything except go out for a smoke."

4. The Master Treatment Plan for Patient A2, updated on 7/2/11 and 7/9/11 indicated no revision in the interventions to address the needs of Patient A2 when the patient was on the "low functioning unit" and unable to attend groups on the "high functioning unit."

5. In an interview at 8:30a.m. on 7/13/11, the Medical Director stated that patients on "line-of sight" should be attending all prescribed treatment groups.

6. Facility policy number CRPM 2.4 entitled "Level 2 Continuous Observation" [line of sight observation], reviewed 11/2010, states on page 2: "While on Level 2 Continuous Observation. The patient is expected to attend all applicable groups and continues to receive individualized therapy."

B. Patient A5 was admitted with psychosis NOS (not otherwise specified) on 7/2/11, based on a review of the initial psychiatric evaluation dated 7/2/11. The patient remained on the "low functioning unit" throughout the survey, other than one time (noon, 7/12/11) when s/he went to the hospital cafeteria for lunch.

1. The Master Treatment Plan for Patient A5, dated 7/2/11, listed the following group modalities to be used as treatment interventions: "Therapist will assist Pt. with learning safe ways to manage symptoms without harm to self/others" (daily frequency)' and "RT (recreation therapist) to provide relaxation/meditation/treatment art interventions to help pt. manage upset moods or irritability and improve coping skills (daily frequency)."

2. A review of the "Acute Therapy Group" notes from 7/2/11 through 7/11/11 revealed that Patient A5 attended none of the 17 assigned group sessions during this time period. A review of the medical record revealed no documented individual therapy sessions.
A review of the medical record revealed that, as of 7/12/11, there was a failure to address Patient A5's lack of attendance in group therapy and other programming activities, and no revisions had been made in the treatment plan to address the non-attendance.

3. During an interview on 7/12/11 at 5:00p.m., the Director of Social Work acknowledged that the Master Treatment Plan for Patient A5 had not been revised, despite the patient's failure to attend the assigned therapeutic groups. She stated, "We would expect [the treatment team] to modify treatment plans if a person isn't attending group."

C. Patient A11was admitted with bipolar, manic type, with psychosis on 7/6/11, based on a review of the initial psychiatric evaluation dated 7/7/11. The patient remained on the "low functioning unit" from the time of admission (7/6/11) through the end of the survey (7/13/11).

1. The Master Treatment Plan for Patient A11, dated 7/6/11, listed the following group modalities to be used as treatment interventions: "Therapist will assist [patient name] with learning safe ways to manage symptoms without harm to self/others (Daily)"; "Process group to identify and discuss consequences of aggression, and how negative behaviors affect others (1 x daily)"; "Psycho-education groups to each [sic] alternative methods of expressing feelings without use of physical aggression (Daily)"; "RT to provide relaxation, meditation, treatment art interventions to help [patient] manage upset mood or irritability and improved coping skills (Daily)" and "The therapist will provide psycho-education on the importance of respecting others' personal boundaries (Daily)."

2. A review of the "Acute Therapy Group" notes from 7/6/11 through 7/11/11 revealed that Patient A11 attended none of the 8 assigned group sessions during this time period. A review of the medical record revealed no documented individual therapy sessions.
A review of the medical record revealed that, as of 7/12/11, there was a failure to address Patient A11's lack of attendance in group therapy and other programming activities, and no revisions had been made in the treatment plan.

3. During an interview on 7/12/11 at 5:00p.m., Director of Social Work acknowledged that the Master Treatment Plan for Patient A11 had not been revised, despite the patient's failure to attend the assigned therapeutic groups. She stated, "We would expect [the treatment team] to modify treatment plans if a person isn't attending group."

D. Policy Review

The policy and procedure document entitled "Interdisciplinary Treatment Plan," Number CRTP 1.0, dated 09/2010, states, "2.0 At regular intervals, at least every seven days, members of the treatment team shall further develop the Treatment Plan that is based on a comprehensive assessment of the patient's presenting problems, physical health, emotional and behavioral status.... 10.0 The Treatment Plan shall be reviewed, updated, and signed by treatment team members as frequently as clinically indicated by the patient's anticipated length of stay and treatment issues, but at a minimum, the treatment plan is to be reviewed every seven days."

Based on record reviews and interviews, the facility failed to ensure that the Master Treatment Plans of 8 of 8 active sample patients (A2, A5, A11, B1, C1, C4, C7, and C8) included physician and nursing interventions that were individualized and based on patient needs. Instead, interventions were listed as generic monitoring, assessing and documenting functions. This failure results in treatment plans that do not reflect an individualized, comprehensive, and integrated approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient A2 was admitted with a diagnosis of major depression, single episode and generalized anxiety disorder with panic attacks. The Master Treatment Plan dated 6/26/11 identified the patient problem as "depression with SI (suicidal ideations)." The only listed MD intervention was "MD will meet the Pt. to assess mental status and effectiveness or need for medication." The only nursing interventions were "Nursing staff will monitor for signs of increased depression, and will administer meds as ordered by MD" and "Nursing groups to educate on symptoms of depression, and treatment modalities."

2. Patient A5 was admitted with a diagnosis of psychosis NOS. The Master Treatment Plan dated 7/2/11 identified the patient's problem as "psychosis." The only listed MD intervention was "MD will ax [assess] for signs of psychosis and will make medication adjustments as necessary." The only nursing intervention was "Nursing staff will assess for presence of psychosis and will administer meds as ordered."

3. Patient A11 was admitted with a diagnosis of bipolar disorder, most recent manic episode with psychotic features. The Master Treatment Plan dated 7/6/11 identified the patient's problems as "psychosis"; "aggression/agitation" and "sexually inappropriate behaviors." The only listed MD interventions were "MD will ax [assess] for signs of psychosis and will make adjustments as necessary"; "The MD will assess pt's mood, mental status, and necessity or effectiveness of medication" and "The MD will ax [assess] daily for signs of SIB [sexually inappropriate behavior] and will ax [assess] the need for medication to help pt control impulses." The only nursing interventions were "Nursing staff will assess for presence of psychosis and will administer meds as ordered"; "Nursing staff will monitor pt's mood, educate about treatment methods, and will administer meds if ordered" and "Nursing staff will encourage good boundaries and will monitor for observed SIB [sexually inappropriate behavior]."

4. Patient B1 was admitted with a diagnosis of alcohol dependence, polysubstance dependence, bipolar disorder. The Master Treatment Plan dated 6/21/11 identified the patient's problems as "polysubstance dependence"; "PTSD [posttraumatic stress disorder]"; "potential to harm others" and "SI [suicidal ideation]." The only listed MD intervention was "Physician will meet with [patient's name] daily to assess mental status, medications and progress in treatment." (The same physician intervention was written for each of the four patient problems). The only nursing interventions were "Nursing will educate [patient's name] on medications to assist in detox, administer to him daily as prescribed, and monitor [patient's name] for s/s [signs and symptoms] of withdrawal/adverse side effects to meds"; "Nursing will educate [patient's name]on and administer medications as prescribed by physician" and "Nursing will educate [patient's name] on medication as prescribed, administer to her [sic] daily as prescribed, and monitor [patient's name] for s/s [signs and symptoms] of adverse affects [sic]."

5. Patient C1 was admitted with a diagnosis of bipolar disorder. The Master Treatment Plan dated 6/29/11 identified the patient's problems as "auditory/visual command hallucinations and HI [homicidal ideation]" and "family conflict." The only listed MD interventions were "MD will ax [assess] for psychosis and will order meds as needed" and "MD will assess pt's mood and mental status, and will prescribe meds as needed." The only nursing intervention was "Nurse will educate on symptoms and will observe for additional signs of psychosis."

6. Patient C4 was admitted with a diagnosis of major depressive disorder with SI [suicidal ideation] and psychosis. The Master Treatment Plan dated 7/7/11 identified the patient's problems as "SI [suicidal ideation]/self harm" and "A/V [auditory/visual] Command Hallucinations." The only listed MD interventions were "The MD will assess pt's mood, mental status, and necessity or effectiveness of meds" and "MD will ax [assess] for psychosis and will order meds as needed." The only nursing interventions were "Nursing staff will monitor pat's mood, educate about treatment methods, and will administer meds" and "Nurse will educate on symptoms and will observe for additional signs of psychosis."

7. Patient C7 was admitted with a diagnosis of major depressive disorder with suicidal thoughts. The Master Treatment Plan dated 7/9/11 identified the patient's problem as "self harm." The only listed MD intervention was "MD will ax [assess] [patient's name]'s mood, mental status, and necessity or effectiveness of meds." The only nursing intervention was "Nursing staff will monitor [patient's name]'s mood, educate about treatment methods, and will administer meds if needed."

8. Patient C8 was admitted with a diagnosis of schizoaffective disorder. The Master Treatment Plan dated 7/10/11 listed the MD interventions as "MD will Ax (assess) pt's mood, mental status, and necessity or effectiveness of meds" and "MD will assess pt's mood and mental status, and will prescribe meds as needed." The only nursing interventions were " Nursing staff will monitor pt's mood, educate about treatment methods, and will administer meds" and "Nursing staff will observe and monitor pt's behavior for signs of escalation."

B. Staff Interviews

1. In an interview on 7/12/11 at 3:00p.m. the Director of Nursing (DON) stated, "The nurses try to help patients monitor their moods and help with their psychiatric issues, but they don't get to do that very often because they are busy with the nursing functions." She confirmed that nursing interventions on the treatment plan are primarily generic nursing functions and are not specific to patients' individual psychiatric needs.

2. In an interview on 7/13/11 at 8:30a.m., the Medical Director agreed that the physician interventions listed on the patents' treatment plans were generic, non-specific tasks, not individualized interventions.

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

I. Provide adequate active treatment measures and care for 3 of 3 active sample patients (A2, A5, and A11) on the Acute Gero/Psych (Geriatric and Adult Psychiatric) Unit to move the patients to a higher level of functioning and a less restrictive environment. This failure results in patients being hospitalized without the receiving interventions to meet their identified treatment needs, delaying their improvement.

II. Ensure appropriate use and documentation of seclusion/restraints as external controls of violence toward self and others for1 of 1 active sample patient (A11) and 4 of 9 discharged patients (E6, E7, E8 and E9) for whom the use of seclusion and restraints were reviewed. For these patients, seclusion or restraint was initiated or continued without adequate documented justification, and nurses failed to release the patients in a timely manner. For patient E9, there was also no documentation of a physician order or assessment of the patient's response to a physical hold (restraint). This failure exposes patients to potential harm from unnecessary restraint and violates patients' right to safe treatment in the least restrictive manner possible.

III. Ensure confidentiality of patient information for all patients admitted to the "Gero/Psych (Geriatric-Psychiatric)" ward. Staff discussed patients with other staff or on the telephone in the open nursing station in the dayroom area of the Gero/Psych ward where patients overheard staffs' discussions about other patients. During the survey, staff was observed assessing Patient A16 and administering an intramuscular medication next to the nursing station in the dayroom. These staff behaviors result in a breach of patient privacy and confidentiality.

Findings include:

I. Active Treatment

A. Observations

1. The Gero/Psych Unit was a 25-bed ward that had two separate physical locations, one of which was a dayroom area shared with a nursing station. The nursing station was open to the dayroom and included a desk that was dining-table-level with a patient chair on one side (in the dayroom) and a staff chair on the other side (in the nursing station). There was virtually no separation of the dayroom and the nursing station. Staff members referred to this area of the Gero/Psych Unit as the "lower functioning side" (according to a 7/11/11, 9:30a.m. interview with the Director of Quality Improvement). The second physical area of the Gero/Psych Unit was across the hall from the first dayroom and nursing station area. Two locked doors and the hall divide the two physical locations. The second area had a small dayroom, a patient kitchen, and a group room. Staff referred to this second area of the Gero/Psych Unit as the "higher functioning side" (according to a 7/11/11, 10:30 a.m. interview with the RN4).

Throughout the day on 7/11/11 and 7/12/11, patients on the "lower functioning side" were observed sitting in the dayroom without participating in any structured groups or treatment programming.

a. Active sample patients A5 and A11 were observed on 7/11/11 at 10a.m., 11a.m., 12p.m., 2p.m., 3p.m., and 4p.m., sitting in the "lower functioning dayroom" and not engaged in any activity or interaction with staff or other patients. According to the daily schedule, the following activities should have been available at the times of the observations: 9:45a.m. - 10:45a.m. "Process Group Therapy" led by a social worker; 10:45a.m. - 11:30a.m. "AM Exercise/ Life Skills" led by the MHA (mental health worker; "RN Group" led by the RN or "Therapeutic Relaxation" ed by the MHA (mental health worker) and 3:00p.m. - 4:00p.m. "Psych Education" led by the social worker.

b. Active sample patients A2, A5, and A11 were observed on 7/12/11 at 8:30a.m., 9:00a.m., 9:30a.m., and 10:30a.m. sitting in the "lower functioning dayroom" not engaged in any activity or interaction with staff or other patients. According to the daily schedule, the following activities should have been available at the times of the observations: 8:00a.m. - 8:45a.m. "Breakfast"; 9:00a.m. - 9:30a.m. "Goals Group" led by the MHA (mental health worker); and 9:45a.m. - 10:45a.m. "Process Group Therapy" led by the social worker.

c. Active sample patients A5 and A11 were observed on 7/12/11 at 1:30p.m., 2p.m., 2:30p.m. and 3p.m. sitting in the "lower functioning dayroom" not engaged in any activity or interaction with staff or other patients. According to the daily schedule, the following activities should have been available at the times of the observations: 1:00p.m.- 2:00p.m. "RN Group" led by the RN or "Therapeutic Relaxation" led by the MHA (mental health worker) and 3:00p.m. - 4:00p.m. "Psych Education" led by the social worker.

2. Patient A2 was observed on 7/11/11 at noon sitting in the dayroom of the "higher functioning side" not engaged in any activity or conversation. An activity group (board game: "Apples-to-Apples") was being offered down the hall. No alternative activity was being offered to Patient A2 who lay on a couch in the dayroom with a blanket wrapped over her/his head and around her/his body.

B. Record Review

1. Patient A5 was admitted on 7/2/11 with a diagnosis of schizoaffective disorder. A review of the Master Treatment Plan revealed a problem of "Psychosis." To meet the patient's needs, the therapeutic intervention (initiated on 7/2/11) was for the therapist to assist the patient with learning safe ways to manage symptoms without harm to self/others. According to the Master Treatment Plan, the patient was to attend a therapy group one hour a day. Patient A5's medical record contained 17 acute therapy group notes from 7/2/11 to 7/11/11. The following documentation as written on the notes:

On 7/2/11 at 9:45a.m., for the "Psycho educational" group: patient "was not in group due to disruptive behaviors..."

On 7/2/11 at 3:30p.m., for the "Process" group: "Pt refused to attend group..."

On 7/3/11 at 9:45a.m., for the "Process" group: Pt. "was not in group due to disruptive behaviors..."

On 7/3/11 at 3:30p.m., for the "Psycho educational" group: Pt. "did not attend group due to disruptive behaviors..."

On 7/4/11 at 9:45a.m., for the "Psycho educational" group: Pt. "did not attend group due to disruptive behaviors..."

On 7/4/11atr 3:00p.m., for the "Process" group: Pt. "refused to attend group..."

On 7/5/11 at 9:45a.m., for the "Process-Anger" group: "Pt. did not attend group due to psychosis/behaviors..."

On 7/5/11 at 3:00p.m., for the "Psycho educational" group: "Pt. refused to attend session..."

On 7/6/11 at 3:00p.m., for the "Psycho educational" group: "Patient did not attend group even after therapist's prompting..."

On 7/7/11 at 9:45a.m., for the "Psycho educational" group: "Pt. refused to attend group..."

On 7/7/11 at 3:00p.m., for the "Psycho educational" group: Pt. "did not attend group due to disruptive behaviors..."

On 7/8/11 at 9:45a.m., for "Psycho educational" group: Pt. "did not attend group due to disruptive behaviors..."

7/8/11 at 3:00p.m., for "Process" group: "Pt. refused to attend session..."

7/9/11 at 9:45a.m., for "Process" group: Pt. "did not attend group this morning..."

7/9/11 at 3:30p.m., for "Psycho educational" group: Pt. "did not attend group due to symptoms of her illness."

7/10/11 at 9:45a.m., for "Process" group: Pt. "did not attend group this morning..."

7/10/11 at 3:30p.m., for "Psycho educational" group: "Pt. did not attend group due to psychosis/behaviors..."

A review of Patient A5's clinical record revealed no documentation of attendance, participation, or response to alternative treatment for 17 of the 17 unattended therapy groups.

2. Patient A11 was admitted on 7/6/11 with the diagnosis "bipolar [disorder], manic type." The medical record contained 8 acute therapy group notes from 7/7/11 through 7/10/11. The following documentation was written on the notes:

7/7/11 at 9:45a.m., for Psycho educational group: "Pt refused to attend group."

7/7/11 at 3:00p.m. for Psycho educational group: "[Pt. A11's name] did not attend group due to disruptive behaviors."

7/8/11 at 9:45a.m. for Psycho educational group: "[Pt. A11's name] did not attend group due to disruptive behaviors."

7/8/11 at 3:00p.m. for Process group: "Pt. refused to attend session."

7/9/11 at 9:45a.m. for Process group: "[Pt. A11's name] did not attend group this morning due to the symptoms of his illness."

7/9/11 at 3:30p.m. for Psycho Educational group: "[Pt. A11's name] did not attend group this morning due to the symptoms of his illness."

7/10/11 at 9:45a.m. for Process group: "[Pt. A11's name] did not attend group due to the severity of his symptoms and behaviors."

7/10/11 at 3:30p.m. for Psycho educational group: "Pt. did not attend group due to psychosis/behaviors."

A review of Patient A11's clinical record revealed no documentation of attendance of, participation in, or response to alternative treatment for 8 of the 8 unattended therapy groups.

C. Patient Interviews

1. In an interview on 7/11/11 at 12p.m., Patient A2 stated that s/he was not attending the activity group being offered because s/he "hated that game of Apples-to-Apples." "I don't find the activities helpful - like throwing ping pong balls in cups and throwing a ring around a water bottle - so I don't go to those groups. I just sit in the dayroom when those groups are happening."

2. In an interview on 7/12/11 at 10a.m. on the "lower functioning unit," Patient A2 stated, "I have to be on this side today because I am on line-of-sight and the staff need to watch me." The patient stated that during the 3-week hospitalization, s/he "stayed on this side [lower functioning] quite a bit." When asked what activities s/he did on the lower functioning side, s/he replied, "Nothing. I just sit here except when we go out for a smoke." "We don't go to the cafeteria if we are on this side. We eat in the dayroom."

D. Staff Interviews

1. In an interview on 7/11/11 at 11:30a.m., the Director of Social Services stated, "We don't document response to alternative treatment in the patient's chart. " "[Pt. A11's] interventions don't fit." "[Pt. A11] doesn ' t participate in any of these groups because of his/her level of functioning." "The interventions are not as individualized as much as I'd like them to be." In an additional interview on 7/12/11 at 4:50p.m., the Director of Social Services stated, "The lower functioning patients are not getting the level of care that they should."

2. In an interview on 7/11/11 at 10:45a.m., the Program Manager of the Adult Unit stated that the "lower functioning patients do not go to the scheduled programming." She stated that these patients "should be doing something on this side [lower functioning side], like games, or cards, or music, or playing with the ball. The Mental Health Assistants do unstructured activities with the patients on this side, but there are no structured activities."

3. In an interview on 7/11/11 at 2p.m., RN4 stated that on that day (7/11/11) only one MHA was available on the "lower functioning side" and that she [the MHA] was responsible for watching the patients on the 15-minute checks and watching the patients on line-of-sight. Neither the registered nurse nor the MHA appeared to be available to offer treatment programming.

E. Document Review

1. The facility policy number CRPM 2.4 entitled "Level 2 Continuous Observation" (last reviewed 11/2010) states, "While on Level 2 Continuous Observation. The patient is expected to attend all applicable groups and continues to receive individualized therapy."

2. The facility's "Written Plan for Professional Services: Adult Acute Services" (8/4/2010), pages 11-12 reads: "During hospitalization the multi-disciplinary treatment team provides services designed to rapidly stabilize the patient. These include:... c) Daily structured environment including therapy process groups, recreation therapy and goals/community groups..."

II. Failure to ensure appropriate use and documentation of seclusion/restraints

A. Record Review

1. Patient A11

According to the "Restraint/Seclusion Record," Patient A11 was placed in locked seclusion on 7/8/11 from 6p.m. until 8:45p.m. for "manic, threatened staff, swinging at staff, screaming." Behaviors of Patient A11 that were documented while in seclusion this entire period of time were "walking/pacing" or "lying/sitting." Patient A11 was maintained in seclusion without documentation of behaviors that reflected a threat to self or others, justifying the need for continued external control.

2. Patient E6

According to the "Restraint/Seclusion Record," Patient E6 was placed in locked seclusion on 4/14/11 from 3:20p.m. until 5:25p.m. for "became angry because nurse was requesting prn [medication] for escalating behavior threatened to hit nurse threatened to hurt other staff." Behaviors of Patient E6 that were documented while in seclusion this entire period of time were "walking/pacing" or "quiet/resting." Patient E6 was maintained in seclusion without documentation of behaviors that reflected a threat to self or others, justifying the need for continued external control.

3. Patient E7

a. The "Acute Service Daily Flow Sheet - Special Precautions" form dated 5/26/11 stated that from 3:15p.m. to 4:30p.m., Patient E7 was in the MCU (seclusion room). The flow sheet did not document why the patient was placed in seclusion.

b. The "Restraint/Seclusion Records" documented that Patient E7 also was placed in seclusion as follows:

5/27/11 (7:30a.m. to 8:50a.m.): "[Patient E7] ran out of the unit doors; asking everyone to kill him. Pt. was placed in a TH (therapeutic hold) and placed in seclusion. MD ordered PRN (as needed medication) to be given." The only behaviors of Patient E7 that were documented while in seclusion this entire period of time were "lying/sitting." Patient E7 was maintained in seclusion without documentation of behaviors that reflected a threat to self or others, justifying the need for continued external control.

5/30/11 (10:55a.m. to 5:15p.m.): "[Patient E7] jumped on RN and had a choke hold. Ran RN's head into the wall and tried to cause unconsciousness to the RN. It took multiple people to make him let loose. Patient was then placed in seclusion." The only behaviors of Patient E7 that were documented while the patient was in seclusion this entire period of time were "lying/sitting" or "walking/pacing." Patient E7 was maintained in seclusion without documentation of behaviors that reflected a threat to self or others, justifying the need for continued external control.

4. Patient E8

The "Restraint/Seclusion Records" documented that Patient E8 was placed in seclusion as follows:

a. 3/9/11 (7:15a.m. to 9:27a.m.): "[Patient E8] came behind nurse's desk to get the telephone and grabbed RN before other patients could pin his arms to prevent further battery." The only behaviors by Patient E8 that were documented while in seclusion this entire period of time were "walking/pacing." Patient E8 was maintained in seclusion without documentation of behaviors that reflected a threat to self or others justifying the need for continued external control.

b. 3/9/11 (11:58a.m. to 4:36p.m.): The patient attempted to "attack staff in the nurse's station. The patient was put in a TH (therapeutic hold) and then placed in seclusion." The only behaviors by Patient E8 that were documented while in seclusion this entire period of time were "walking/pacing" or "lying/sitting." Patient E8 was maintained in seclusion without documentation of behaviors that reflected a threat to self or others justifying the need for continued external control.

c. 3/11/11 (6:25a.m. to 11:25p.m.): The patient was "pacing & threatening staff members then attempting to run into another pt's room." From 4:30p.m. to 8:15p.m., the only documented behaviors of the patient were "sleeping," or "standing still" and "quiet." From 9:30p.m. to 11:45p.m., the only documented behavior of the patient was "standing still." Patient E8 was maintained in seclusion during these times without documentation of behaviors that reflected a threat to self or others justifying the need for continued external control.

d. 3/13/11 (7:49a.m. to 8:10p.m.): The patient was "walking towards staff (with) fist clenched & threatening to leave." From 10:00a.m. to 10:45, the only documented behaviors of the patient were "Lying or sitting," "quiet," or "walking/pacing," From 2:30p.m. to 3:30p.m., the only documented behaviors were "sleeping" or "lying or sitting." From 3:45p.m. to 8:15p.m., the only documented behaviors were "sleeping," "lying or sitting," or "walking/pacing." Patient E8 was maintained in seclusion during these times without documentation of behaviors that reflected a threat to self or others justifying the need for continued external control.

e. 3/14/11 (7:30a.m. to 3:30p.m.): The patient "struck a staff member; took time out; then proceeded to jump and hit the counter of the nurse's desk." The patient was "placed back in time out room (with) door closed this time." Except for the 10a.m. check, the only behaviors of Patient E8 that were documented while in seclusion were "walking/pacing" or "lying/sitting." Patient E8 was maintained in seclusion without documentation of behaviors that reflected a threat to self or others justifying the need for continued external control.

f. 3/14/11 (4:56p.m. to 6:15p.m.): The patient was "violent, cursing staff, banging against locked doors." The only behaviors of Patient E8 that were documented while in seclusion this entire period of time were "walking/pacing" or "lying/sitting" Patient E8 was maintained in seclusion without documentation of behaviors that reflected a threat to self or others justifying the need for continued external control.

5. Patient E9

An incident report dated 3/14/11 at 3:30p.m. stated that Patient E9 was placed in a physical hold on 3/14/11 at 3:05p.m. The medical record for Patient E9 had no documentation of the physician order for the restraint. There also was no evidence of staff monitoring or the required assessments for the physical hold (restraint).

B. Interviews

1. During an interview on 7/12/11 at 12:40p.m. with RN4 including a review of the documentation of the seclusion episode for Patient A11, RN4 stated that the documentation did not include evidence for the continued seclusion of Patient A11 (on 7/8/11).

2. In an interview on 7/12/11 at 3:05p.m., the DON stated that when a resident was placed in seclusion she would expect nursing staff to document the incident of seclusion on the "Restraint/Seclusion Order/Record," the "Daily Flow Sheet," and in the nursing progress note. She acknowledged that all required documentation for the patient E7's seclusion on 5/26/11 was not present in the medical record.

3. During an interview on 7/12/11 at 3:45p.m., the Director of Quality Assurance stated that when she audited the chart for Patient E9 approximately a week after the 3/18/11 physical hold for the patient, she found no physician's order or evidence of staff monitoring or required assessments.

4. During an interview on 7/12/11 at 3:15p.m., which included a review of above medical records, the Director of Nursing (DON) verified the above findings and agreed that the documentation for the seclusion episodes did not justify the continued use of seclusion for these patients. She stated that if a patient was in seclusion, had calmed down and fallen asleep, the MHA (Mental Health Aide) should have notified the nurse so that an assessment could have been completed to consider discontinuing the seclusion. She also acknowledged that for Patient E9, there was no documentation of a physician's order, monitoring, or assessment for the physical hold on 3/18/11.

5. In an interview 7/13/11 at 9:15a.m., which included a review of the above patient records, the Medical Director agreed that the documentation for these seclusion episodes did not justify the continued use of seclusion for these patients.

III. Ensure privacy and confidentiality

A. Observations

1. During an observation while in the nursing station of the Gero/Psych ward on 7/11/11 at 2:30p.m., the surveyor saw Patient A15 sitting in a chair on one side of the nurses' station desk. RN4 was sitting on the other side of the desk. RN4 was completing the patient's admission nursing assessment. Other patients sitting in the dayroom at the time were able to hear the questions and answers regarding the patient's personal health issues.

2. During an observation while in the nursing station of the Gero/Psych ward on 7/11/11 at 3:45p.m., the surveyor saw RN2 talking on the phone in the nursing station. During the phone conversation, RN2 stated that an order for Oxycotin would require a separate prescription because it was a controlled substance. During this conversation, six patients were sitting in the dayroom within hearing distance.

3. During an observation on the Gero/Psych ward on 7/11/11 at 3:50p.m., Patient A16 returned to the ward reporting chest pain. RN2 assessed the patient in the dayroom area, including vital signs. RN2 stated "it looks ok. It looks like anxiety...extreme anxiety." S/he instructed Patient A16 to breathe deeply. Patient A16 began crying. After the interaction, RN2 discussed Patient A16's condition with a physician on the phone in the nursing station and obtained an order for Ativan. During the phone call, she described Patient A16 as "crying," "shaking," and "very anxious." S/he repeated a read-back order that included "2 mg Ativan now." At 3:55p.m., LPN1 gave Patient A16 an intramuscular injection in his arm in the dayroom area. During this event, six patients were sitting in the dayroom within visual and hearing distance.

4. During an observation while in the nursing station of the Gero/Psych ward on 7/12/11 at 10:20a.m., LPN1 was in the medication room (a room connected to the back of the nursing station), dispensing medication to patients. Each patient walked behind the nursing station desk, through the nurses' station, and beside the shelves of patient charts. During an interview with the charge nurse at this time, LPN1stated that all patients are expected to walk into and through the nursing station to go to the medication room for their medications.

5. During an observation while in the nursing station of the Gero/Psych ward on 7/12/11 at 12:00p.m., RN3 was "checking in" a new patient at the nursing station. During this nurse--patient interview, information such as the amount of money possessed by the patient, the social security number, and whether the patient brought medications to the hospital was discussed. During this conversation, seven patients were sitting in the dayroom within hearing distance.

6. During an observation while in the nursing station of the Gero/Psych ward on 7/12/11 at 2:50p.m., RN3 was using the phone at the nursing station. During this time, RN3 discussed the reasons for transfer of a patient from one physician to another. During this conversation, seven patients were sitting in the dayroom within hearing distance.

7. During an observation while in the nursing station of the Gero/Psych ward on 7/12/11 at 14:55p.m., RN2 was discussing patients with MHT1. During this conversation, these staff made statements about patients in the dayroom including "that's the quietest I've seen him," "he hyperventilated... he'll be playing that for a few days...but he does have panic attacks"; "he was lying on the floor...twenty minutes later he was up," and "he is very labile." During this conversation, seven patients were sitting in the dayroom within hearing distance.

B. Interviews

1. During an interview with RN2 on 7/11/11 at 4:05p.m., when asked about giving the intramuscular injection to Patient A16 in front of other patients, RN2 stated, "This is the way it is done here (at the facility)."

2. During an interview on 7/12/11 at 3:15p.m., the Director of Nursing (DON) stated that the open nursing stations were a "concern" because there was "no barrier to sound." "Everyone in the milieu can hear (what is being said in the nursing station)." The DON stated that issues of privacy on the Gero/Psych ward "have come up multiple times" but that no changes had been made. She stated that giving an intramuscular injection in the dayroom area was not appropriate and that the patient should have been taken to a private area.

3. During an interview on 7/13/11 at 9:15a.m., the Medical Director agreed that the description of the above events indicated breaches of patient privacy and confidentiality. He stated that intramuscular injections "shouldn't happen" within the sight of other patients.

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

I. Ensure that the Master Treatment Plans of 8 of 8 active sample patients (A2, A5, A11, B1, C1, C4, C7 and C8) included physician interventions that were individualized and based on patient needs. Instead, interventions were listed as generic monitoring, assessing and documenting functions. This results in the facility not delineating the role of the physician in the treatment of patients.

Findings include:

A. Record Review

1. Patient A2 was admitted with a diagnosis of major depression, single episode and generalized anxiety disorder with panic attacks. The Master Treatment Plan dated 6/26/11 identified the patient problem as "depression with SI (suicidal ideations)." The only listed MD intervention was "MD will meet the Pt. to assess mental status and effectiveness or need for medication."

2. Patient A5 was admitted with a diagnosis of psychosis NOS. The Master Treatment Plan dated 7/2/11 identified the patient problem as "psychosis." The only listed MD intervention was "MD will ax [assess] for signs of psychosis and will make medication adjustments as necessary."

3. Patient A11 was admitted with a diagnosis of bipolar disorder, most recent manic episode with psychotic features. The Master Treatment Plan dated 7/6/11 identified patient problems as "psychosis"; "aggression/agitation" and "sexually inappropriate behaviors." The only listed MD interventions were "MD will ax [assess] for signs of psychosis and will make adjustments as necessary"; "The MD will assess pt's mood, mental status, and necessity or effectiveness of medication" and "The MD will ax [assess] daily for signs of SIB [sexually inappropriate behavior] and will ax [assess] the need for medication to help pt control impulses."

4. Patient B1 was admitted with a diagnosis of alcohol dependence, polysubstance dependence, bipolar disorder. The Master Treatment Plan dated 6/21/11 (update 7/6/11) identified patient problems as "polysubstance dependence"; "PTSD [posttraumatic stress disorder]"; "potential to harm others" and "SI [suicidal ideation]." The only listed MD intervention was "Physician will meet with [patient's name] daily to assess mental status, medications and progress in treatment" (The same physician intervention was written for each of the four patient problems).

5. Patient C1 was admitted with a diagnosis of bipolar disorder. The Master Treatment Plan dated 6/29/11 identified the patient problems as "auditory/visual command hallucinations and HI" [homicidal ideation] and "family conflict." The only listed MD interventions were "MD will ax [assess] for psychosis and will order meds as needed" and "MD will assess pt's mood and mental status, and will prescribe meds as needed."

6. Patient C4 was admitted with a diagnosis of major depressive disorder with SI [suicidal ideation] and psychosis. The Master Treatment Plan dated 7/7/11 identified the patient problems as "SI [suicidal ideation]/self harm" and "A/V [auditory/visual] Command Hallucinations." The only listed MD interventions were "The MD will assess pt's mood, mental status, and necessity or effectiveness of meds" and "MD will ax [assess] for psychosis and will order meds as needed."

7. Patient C7 was admitted with a diagnosis of major depressive disorder with suicidal thoughts. The Master Treatment Plan dated 7/9/11 identified the patient problem as "self harm." The only listed MD intervention was "MD will ax [assess] [patient's name]'s mood, mental status, and necessity or effectiveness of meds."

8. Patient C8 was admitted with a diagnosis of schizoaffective disorder. The Master Treatment Plan dated 7/10/11 identified patient problems as "self-harm" and "aggression/anger/property destruction." The only listed MD interventions were "MD will Ax (assess) pt's mood, mental status, and necessity or effectiveness of meds" and "MD will assess pt's mood and mental status, and will prescribe meds as needed."

B. Staff Interview

In an interview on 7/13/11 at 8:30a.m., the Medical Director, acknowledged that the physician interventions on the sample patient's treatment plans were generic, non-specific, and not individualized for the patients.

II. Ensure that the Master Treatment Plans for 3 of 3 active sample patients from the Gero/Psych Unit (A2, A5, and A11) were revised when the patients failed to participate in the prescribed treatment. The Master Treatment Plans for these patients were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

III. Ensure that adequate active treatment measures and care were provided for 3 of 3 active sample patients (A2, A5, and A11) on the Acute Gero/Psych (Geriatric and Adult Psychiatric) Unit to move the patients to a higher level of functioning and a less restrictive environment. This failure results in patients being hospitalized without the opportunity to receive interventions that meet identified treatment needs, delaying their improvement. (Refer to B125-I)

IV. Ensure appropriate use and documentation of seclusion/restraints as external controls of violence toward self and others. For 1 of 1 active sample patient (A11) and 4 of 9 discharged patients (E6, E7, E8, and E9) for whom the use of seclusion and restraints were reviewed, the seclusion or restraint procedures were initiated or continued without documented justification. For patient E9, there also was no documentation of a physician order or the required assessment of the patient's response to a physical hold (restraint). This failure exposes patients to potential harm from unnecessary restraint and violates patients' rights to safe treatment in the least restrictive manner possible. (Refer to B125-II)

V. Ensure confidentiality of patient information for all patients admitted to the "Gero/Psych (Geriatric-Psychiatric)" ward. Staff discussed patients with other staff or on the telephone in the open nursing station in the dayroom area of the Gero/Psych ward where patients could overhear staffs' discussions about other patients. During the survey, staff was observed assessing Patient A16 and administering intramuscular medication next to the nursing station in the dayroom. These staff behaviors result in a breach of patients' privacy and confidentiality. (Refer to B125-III)

Based on observation, medical record reviews and staff interviews, it was determined that the Director of Nursing (DON) failed to provide guidance to the nursing staff in areas of assessment, monitoring, treatment planning, provision of active treatment measures to ensure patient health and safety, and ensuring patient privacy and confidentiality. Specifically, the DON failed to:

I. Ensure that the Master Treatment Plan of 8 of 8 active sample patients (A2, A5, A11, B1, C1, C4, C7 and C8) included individualized nursing interventions. The nursing interventions on these patients' treatment plans were routine non-specific nursing functions rather than individualized interventions based on the patients' assessed needs. This failure results in the facility not delineating the role of the nurse in the patient's treatment. (Refer to B122)

Findings include:

A. Record Review

1. Patient A2 was admitted with a diagnosis of major depression, single episode and generalized anxiety disorder with panic attacks. The Master Treatment Plan dated 6/26/11 identified patient problem as "depression with SI." (suicidal ideations). The only nursing interventions were "Nursing staff will monitor for signs of increased depression, and will administer meds as ordered by MD" and "Nursing groups to educate on symptoms of depression, and treatment modalities."

2. Patient A5 was admitted with a diagnosis of psychosis NOS. The Master Treatment Plan dated 7/2/11 identified the patient problem as "psychosis." The only nursing intervention was "Nursing staff will assess for presence of psychosis and will administer meds as ordered."

3. Patient A11 was admitted with a diagnosis of "bipolar disorder, most recent manic episode with psychotic features." The Master Treatment Plan dated 7/6/11 identified patient problems as "psychosis"; "aggression/agitation" and "sexually inappropriate behaviors." The only nursing interventions were "Nursing staff will assess for presence of psychosis and will administer meds as ordered"; "Nursing staff will monitor pt's mood, educate about treatment methods, and will administer meds if ordered" and "Nursing staff will encourage good boundaries and will monitor for observed SIB [sexually inappropriate behavior]."

4. Patient B1 was admitted with a diagnosis of "alcohol dependence, polysubstance dependence, bipolar disorder." The Master Treatment Plan dated 6/21/11 identified the patient problems as "polysubstance dependence"; "PTSD"; "potential to harm others" and "SI [suicidal ideation]." The only nursing interventions were "Nursing will educate [patient's name] on medications to assist in detox, administer to him daily as prescribed, and monitor [patient's name] for s/s [signs and symptoms] of withdrawal/adverse side effects to meds"; "Nursing will educate [patient's name]on and administer medications as prescribed by physician" and "Nursing will educate [patient's name] on medication as prescribed, administer to her [sic] daily as prescribed, and monitor [patient's name] for s/s [signs and symptoms] of adverse affects [sic]."

5. Patient C1 was admitted with a diagnosis of "bipolar disorder." The Master Treatment Plan dated 6/29/11 identified patient problems as "auditory/visual command hallucinations and HI" [homicidal ideation] and "family conflict." The only nursing intervention was "Nurse will educate on symptoms and will observe for additional signs of psychosis."

6. Patient C4 was admitted with the diagnoses "major depressive disorder with SI [suicidal ideation]" and "psychosis." The Master Treatment Plan dated 7/7/11 identified patient problems as "SI/self harm" [suicidal ideation] and "A/V Command Hallucinations." [auditory/visual]. The only nursing interventions were "Nursing staff will monitor pat's mood, educate about treatment methods, and will administer meds" and "Nurse will educate on symptoms and will observe for additional signs of psychosis."

7. Patient C7 was admitted with a diagnosis of major depressive disorder with suicidal thoughts. The Master Treatment Plan dated 7/9/11 identified the patient problem as "self harm." The only nursing intervention was "Nursing staff will monitor [patient's name]'s mood, educate about treatment methods, and will administer meds if needed."

8. Patient C8 was admitted with a diagnosis of schizoaffective disorder. The Master Treatment Plan dated 7/10/11 identified patient problems as "self-harm" and "aggression/anger/property destruction." The only nursing interventions were "Nursing staff will monitor pt's mood, educate about treatment methods, and will administer meds" and "Nursing staff will observe and monitor pt's behavior for signs of escalation."

B. Staff Interview

In an interview on 7/12/11 at 3:00p.m., the DON stated, "The nurses try to help patients monitor their moods and help with their psychiatric issues, but they don't get to do that very often because they are busy with the nursing functions." The DON confirmed that nursing interventions in the treatment plan are primarily generic nursing functions and are not specific to patients' psychiatric needs.

II. Ensure appropriate documentation of seclusion/restraints as external controls of violence toward self and others for 1 of 1 active sample patient (A11) and 4 of 9 discharged patients (E6, E7, E8, and E9) for whom the use of seclusion and restraints were reviewed. For these patients, the seclusion was initiated or continued without adequate documented justification, and nurses failed to release the patient from in a timely manner. For patient E9, nurses put the patient in a physical hold (restraint) with no documented physician order or assessment of the patient's response to the procedure. This failure exposes patients to potential harm from unnecessary restraint and violates patients' rights to safe treatment in the least restrictive manner possible. (Refer to B125-II)

III. Ensure that adequate active nursing treatment measures and care were provided to 3 of 3 active sample patients (A2, A5, A11) on the Acute Gero/Psych (Geriatric and Adult Psychiatric) Unit to move the patients to a higher level of functioning and a less restrictive environment. This failure results in a lack of guidance for nursing staff to provide individualized patient treatment that is purposeful and appropriate for the patient. (Refer to B125-I)

V. Ensure confidentiality of patient information for all patients admitted to the Gero/Psych (Geriatric-Psychiatric) ward. Nursing staff discussed patients with other nursing staff or on the telephone in the open nursing station in the dayroom area of the Gero/Psych ward where other patients could overhear the discussions. During the survey, staff was observed assessing Patient A16 and administering intramuscular medications next to the nursing station in the dayroom. These staff behaviors result in a breach of patients' right to privacy and confidentiality. (Refer to B125-III)