HospitalInspections.org

Based on record review and interview, the facility failed to ensure that the social work assessments for 10 of 10 sample patients (A7, A25, B4, C3, C10, D10, E5, F1, G15, and H3) included recommendations regarding the role of the social worker in treatment and discharge planning and specified the community resources and support systems needed for effective discharge of the patient. The section labeled "Initial Treatment Recommendations" contained 6 check-off options all of which were generic descriptions of potential presenting problems and short-term/long-term goals rather than specific treatment interventions that the social worker would address during the course of treatment. All the assessments lacked specificity relevant to the particular patient's unique reasons for admission, psychosocial functioning, family relations, available support systems/community resources, and/or high-risk issues. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient's discharge plan, ensuring safe re-entry into the community.

Findings include:

A. Record Review

The psychosocial assessments of the following patients were reviewed (dates of assessments are in parentheses): A7 (4/22/11); A25 (4/15/11); B4 (4/18/11); C3 (4/25/11); C10 (4/04/11); D10 (4/21/11); E5 (4/11/11); F1 (12/07/10); G15 (5/02/11) and H3 (4/22/11). This review revealed that none of the assessments included treatment recommendations based on meeting the unique needs of the identified patient. Only pre-printed generic statements of problem areas and generic statements of short-term/long-term goals were listed, such as "patient needs intensive aftercare planning," and "short-term goal - pt/family will discuss with staff problem severity and the need for a specific discharge plan;" or "patient is distant from family or patient lacks positive social supports," and "short-term goal - pt will discuss risks/benefits of family/significant other involvement in treatment and discharge planning;" or "patient has a history of being non-compliant with medications and/or psychotherapy" and "short-term goal - pt/family will discuss reasons and contributing factors for non-compliance with previous discharge plan." No evaluating social worker elected to write in any recommendations for specific treatment interventions to be provided by the social worker during the patient's inpatient course of treatment.

B. Staff Interview

In an interview with the Director of Social Work on 5/04/11 at 9:30am, the Social Work Director stated that "the (reviewed sample) assessments do not contain enough detail" and "all relevant recommendations for social worker interventions are not included in the (reviewed sample) assessments."

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

I. Provide Master Treatment Plans (MTPs) that were individualized and comprehensive, with all necessary elements to direct the treatment team in patient care for 10 of 10 active sample patients (A7, A25, B4, C3, C10, D10, E5, F1, G15 and H3). The treatment plans were selected from preprinted checklists and were very similar across different situations and patients. The organization of the MTP document was disjointed and did not flow in a manner that was comprehensible. Failure to develop treatment plans with all components hampers staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met.

II. Assure that the Psychosocial Assessments were completed prior to the development of the Master Treatment Plan for 4 of 10 sample patients (C3, F1, G15, and H3). Failure to have psychosocial clinical information available for treatment planning compromises the ability of the team to fully and completely address the patient's social and discharge needs.

Findings include:

I. Individualized and comprehensive MTPs

1. The MTPs did not include substantiated diagnoses. Rather the provisional diagnoses on the psychiatric evaluation performed at the time of admission were carried over to the Master Treatment Plans, without confirming or amending the provisional diagnoses by incorporating information from assessments performed by other disciplines, from laboratory studies, and/or from additional information obtained from collateral sources, or from patient and family interactions between the admission and the planning meeting. In addition the appropriate revisions to the diagnoses were not made based on patients' clinical presentation. (Refer to B120);

2. The MTPs failed to include individualized short-term and long-term goals, stated in observable, measurable, behavioral terms for 10 of 10 active sample patients (A7, A25, B4, C3, C10, D10, E5, F1, G15 and H3). Goals ("Objectives") on the treatment plans were selected from preprinted checklists of goals ("Objectives") for identified problems and were very similar across different situations and patients. They were not measureable and did not include target dates. (Refer to B121);

3. The MTPs did not include individualized treatment interventions and modalities. Choices were made from a checklist and were routine and generic tasks for various disciplines inappropriately identified as treatment interventions; the lists failed to specify how interventions would be delivered (as group or individual modalities); in the case of group interventions, failed to include the specific group interventions that the patient would attend; and failed to specify the frequency and focus of staff contact for treatment interventions. (Refer to B122).

II. Lack of integration of psychosocial clinical information into the MTPs

1. Patient C3 - The psychosocial assessment was completed on 4/25/11, five days after the date of the MTP (4/20/11).
2. Patient F1 - The psychosocial assessment was completed on 12/07/10, one day after the date of the MTP (12/06/10).
3. Patient G15 - The psychosocial assessment was completed on 5/02/11, three days after the date of the MTP (4/29/11).
4. Patient H3 - The psychosocial assessment was completed on 4/22/11, one day after the date of the MTP (4/21/11).

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

I. Ensure that the Master Treatment Plans included substantiated diagnoses that would serve as a basis for treatment for 10 of 10 sample patients (A7, A25, B4, C3, C10, D10, E5, F1, G15, and H3). Instead, the provisional diagnoses on the psychiatric evaluation performed at the time of admission were carried over to the Master Treatment Plans, without confirming or amending the provisional diagnoses by incorporating information from assessments performed by other disciplines, from laboratory studies, and/or from additional information obtained from collateral sources, or from patient and family interactions between the admission and the planning meeting. This practice compromises the staff's ability to deliver focused and relevant treatment.

II. Ensure that Treatment Plans of 2 of 10 sample patients (A25 and F1) were updated to include diagnostic revisions and new diagnoses that would serve as a basis for treatment. This practice compromises the staff's ability to deliver treatment relevant to the patient's specific needs. In the case of sample patient A25, this omission resulted in a lack of focused medical and nursing attention to an ongoing medical problem. In the case of sample patient F1, this omission specifically resulted in the continued use of an antipsychotic medication without substantiation of either a psychotic illness or mood disorder that would justify its use.

Findings include:

I. Failure to substantiate diagnoses

A. Record Review

The Master Treatment Plans (MTPs) for the following patients were reviewed (dates of MTPs are in parentheses): A7 (4/22/11); A25 (4/15/11); B4 (4/18/11); C3 (4/20/11); C10 (4/04/11); D10 (4/21/11); E5 (4/11/11); F1 (12/06/10), G15 (4/29/11) and H3 (4/21/11). The review revealed that on all records, the provisional diagnoses on the Psychiatric Assessments were copied onto page one of the Master Treatment Plans. There was no documentation that the attending psychiatrist and other members of the treatment team had reviewed and confirmed (or amended) the preliminary diagnoses, based on data from the additional assessments.

B. Staff Interview

In an interview on 5/03/11 at 9:50am, MD3 stated, "the nurse copies the diagnoses from the psychiatric assessment onto the treatment plan."

II. Failure to include revised and/or new diagnoses

A. Record Review

1. The Master Treatment Plan (dated 4/15/11) for sample patient A25 did not list "nocturnal enuresis" as an Axis III diagnosis nor was there an update to the original Master Treatment Plan, despite MD Progress Notes (dated 4/25/11, 4/27/11, 4/28/11, and 4/29/11) that documented the problem as ongoing.

2. The Treatment Plan Review of 1/03/11 and all subsequent Treatment Plan Reviews (dated 01/21/11, 03/02/11, 04/01/2011, and 04/29/11) for sample patient F1 failed to eliminate the diagnosis of "R/O Psychotic Disorder" or revise the diagnosis of "Panic Disorder with Agoraphobia" in light of the Psychodiagnostic Evaluation of 12/28/10, which confirmed the absence of a "thinking disturbance" or "gross or pervasive lapses in reality testing that are likely to indicate the presence of a psychotic disorder," and data suggesting the presence of "social anxiety" and "separation anxiety." This omission specifically resulted in the continuing use of an antipsychotic medication without substantiation of either a psychotic illness or mood disorder that would justify its use.

B. Staff Interview

1. In an interview on 5/03/11 at 3:25pm, RN7 and the Lodge Program Director agreed that the medical problem of "nocturnal enuresis" was not included on the MTP dated 4/15/11 for sample patient A25.

2. In an interview on 5/02/11 at 2:05pm, SW1 stated that the diagnosis of "Panic Disorder with Agoraphobia" for sample patient F1 had been revised, but she could not show where this was documented on a Treatment Plan Review.

Based on record review and interview, the facility failed to provide MTPs that included individualized short-term and long-term goals, stated in observable, measurable, behavioral terms for 10 of 10 active sample patients (A7, A25, B4, C3, C10, D10, E5, F1, G15 and H3). Goals ("Objectives") on the treatment plans were selected from preprinted checklists of goals ("Objectives") for identified problems and were very similar across different situations and patients. The "Objectives" listed under each patient problem listed on the plan were pre-printed and were usually staff goals, were not individualized and often not measureable. In addition, instead of completion target dates for the goals/objectives, each objective listed was followed by dates when the objective was reviewed by an individual team member in the progress notes. This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, as well as to patient stays beyond the resolution of the behaviors requiring admission.

Findings include:

A. Record Review

1. Patient A7. MTP dated 4/22/11 stated "Problem# 1 Dangerous Behaviors in response to emotion dysregulation-Depression SI [Suicidal Ideation]-adolescent. The Objectives listed were: "Pt [patient] will comply c [with] ordered medication regime," with a "Status/Date 4/27 C (continued);"
"Patient will participate in on DBT [sic] based group each day," with a "Status/Date 4/27 C (continued);" and
"Patient will complete a behavior chain analysis on the events that led to hospitalization and on subsequent events as needed," with a "Status/Date 4/29 C (continued)."

2. Patient A25. MTP dated 4/15/11 stated "Problem #1 Dangerous Behaviors in response to emotion dysregulation-SI [sic], SIB [sic], and Aggression-adolescent. The Objectives listed were:
"Patient will demonstrate 'distress tolerance' skills," with a "Status/Date" 4/21, 4/28 C (continued);"
"Patient will demonstrate the 'mindfulness' skill of deep breathing three times in one week," with a "Status/Date 4/21, 4/28 C (continued);"
"Patient will participate in one DBT [sic] based group each day," with a "Status/Date 4/21, 4/28 C (continued);" and
"Patient will comply with medications as prescribed," with a "Status/Date 4/21, 4/28 C (continued)."

3. Patient B4. MTP dated 4/18/11 stated, "Problem #1 "Treatment interfering Behaviors- Stays out late without permission, poor ADLs[sic]; shoplifting; poor communication with parents; conflictual relationship-adolescent. The Objectives listed were:
"Patient will identify + (and) use coping skills," with a "Status/Date 4/20, 4/27 C (continued);"
"Patient will identify treatment interfering behaviors," with a "Status/Date 4/20, 4/27 C (continued)".

4. Patient C3. MTP dated 4/20/11 stated "Problem #1 Dangerous behaviors liability/psychosis in response to emotion dysregulation-adolescent. The Objectives listed were:
"Patient will participate in one DBT [sic] based group each day," with a "Status/Date 4/20, 4/27 C (continued);"
"Patient will complete a behavior chain analysis on events that led to hospitalization and on subsequent events as needed," with a "Status/Date 4/20, 4/27 C (continued);"
"Pt [sic] will attend therapeutic activities," with a "Status/Date 4/20, 4/27 C (continued); "Patient will comply with medications as prescribed," with a "Status/Date 4/20, 4/27 C(continued);" and
"Patient will comply with recommended diagnostic tests and medical treatment, as documented by RN/MD/NP," with a "Status/Date 4/21 C (continued)."

5. Patient C10. MTP dated 4/4/11 stated "Problem #1 Dangerous Behaviors Suicidality [sic], mood instability c [with] substance abuse, Med (medication) noncompliance in response to emotion dysregulation -adolescent. The Objectives listed were:
"Patient will participate in one DBT [sic] based group each day," with a "Status/Date 4/14, 4/21, 4/28 C (continued);"
"Patient will complete a behavior chain analysis on the events that led to hospitalization and on subsequent events as needed," with a "Status/Date 4/8, 15, 21, 28 C (continued);"
"Patient will comply with medications as prescribed," with a "Status /Date 4/14, 4/21, 4/28 C (continued);"
"Attend therapeutic activities," with a "Status/Date 4/14, 4/21, 4/22, 4/28 C (continued)."

For "Problem II Medical Problems Asthma" the Objective listed was: "Patient will comply with recommended diagnostic tests and medical treatment, as documented by RN/MD/NP," with a "Status/Date 4/14, 4/21, 4/28 C (continued)."

6. Patient D10. MTP dated 4/21/11 stated "Problem #1 Dangerous Behaviors SIB [sic], Impulsive/Aggression sx [sic] in response to emotion dysregulation-Child. The Objectives listed were: "Patient will report to staff any urges to self harm," with a "Status /Date 4/28 C (continued);"
"Patient will not threaten or assault others," with a "Status /Date 4/28 C (continued);" and "Patient will take Medications as prescribed," with a "Status /Date 4/28 C (continued)."

For "Problem #II Medical problems asthma" the Objective listed was: "Patient will comply with recommended diagnostic tests and medical treatment, as documented by the RN/MD/NP," with a "Status/Date 4/28 C (continued)."

For "Problem #II Medical Problems 1 Kidney (has RT) [sic]" the Objective listed was "Patient will comply with recommended diagnostic tests and medical treatment, as documented by RN/MD/NP No contact sports," with a "Status/Date 4/28 C (continued)."

7. Patient E5. MTP dated 4/11/11 stated "Problem #1 Dangerous Behaviors Impulsive/Aggressive behavior SI [sic] self injurious behavior in response to Emotion Dysregulation - Child." The Objectives listed were:
"Patient will complete a 'time away interview' or 'life space interview' for each event of emotion dysregulation at the conclusion of the event," with a "Status/Date 4/12 D/C (discontinued/continued);
"Patient will come to staff for coaching on coping skill to deal with impulsive behaviors hitting, threatening, throwing objects at least 3 times a week," with a "Status/Date 4/12,4/19/4/26/5/3 C (continued);"
"Patient will verbalize feelings +[and] report if experiencing SI[Suicidal Ideation] at least 1x per day," with a "Status/Date 4/12,4/19/4/26/5/3 C (continued);" and
"Patient will take medication as prescribed," with a "Status/Date 4/12, 4/19/4/26/5/3 C (continued)."

For "Problem #II Medical Problems: HX [sic] seizures" the Objectives listed were: "Patient will comply with recommended diagnostic tests and medical treatment, as documented by RN/MD/NP," with a "Status/Date 4/12, 4/19/4/26/5/3 C (continued)" and
"Patient will demonstrate by teach/show back an understanding of their medical condition and the benefits of recommended treatment, as documented by the RN/MD/ NP at least weekly," with a "Status/Date 4/12, 4/19/4/26/5/3 C (continued)."

For "Problem #III Medical problems Incontinence of bladder + [and] bowels" the Objectives listed were:
"Patient will comply with recommended diagnostic tests and medical treatment, as documented by RN/MD/NP," with a "Status/Date 4/12, 4/19/4/26/5/3 C (continued);"
"Patient will demonstrate by teach/show back an understanding of their medical condition and the benefits of recommended treatment, as documented by the RN/MD/ NP at least weekly," with a "Status/Date 4/12, 4/19/4/26/5/3 C (continued);"
"Patient will comply with standard precautions to reduce the risk of infecting others, as evidenced by staff observation and documentation," with a "Status/Date 4/12, 4/19/4/26/5/3 C (continued);" and
"Patient will comply with toileting plan to reduce episodes of enuresis/encopresis," with a "Status/Date 4/12, 4/19/4/26/5/3 C (continued)."

For "Problem # IV Medical problems: Mitochondrial Depletion Syndrome" the Objectives listed were:
"Patient will comply with recommended diagnostic tests and medical treatment, as documented by RN/MD/NP," with a "Status/Date 4/18/4/25/5/3 C (continued);"
"Patient will consume appropriate number of daily calories + [and] will maintain present weight," with a "Status/Date 4/18/4/25/5/3 C (continued);" and
"Patient will demonstrate by teach/show back an understanding of their medical condition and the benefits of recommended treatment, as documented by the RN/MD/NP at least weekly," with a "Status/Date 4/18, /4/25/5/3 C (continued)."

8. Patient F1. MTP dated 12/6/10 stated "Problem #1 Dangerous Behaviors fear of going outside impulsive/aggress [sic] in response to emotion dysregulation - child." Objectives listed were: "Patient 'time away interview' or 'life space interview' for each event of emotion dysregulation at the conclusion of the event," with a "Status/Date 12/7, 12/13, 12/21 , 12/28, 1/04, 1/11, 1/8, 1/20, 2/1, 2/8,C (continued) ,2/15 D/C (discontinued/continued);"
"Patient will come to staff for coaching on biting, screaming, pushing at least 3 times a week," with a "Status/Date 12/7, 12/13, 12/21, 12/28, 1/04, 1/11, 1/8, 1/20, 2/1, 2/8, 2/15,2/22, 3/1, 3/8,3/19, 3/5, 3/22, 3/29, 4/5, 4/13, 4/19/, 4/26, C (continued): "
"Patient will take medication as prescribed," with a "Status/Date 12/7, 12/13, 12/21 , 12/28, 1/04, 1/11, 1/8, 1/20, 2/1, 2/8, 2/15,2/22, 3/1, 3/8,3/19, 3/5, 3/22, 3/29, 4/5, 4/13, 4/19, 4/26, C (continued);" and
"Patient will state the problems behavior aggression for which they are taking medications," with a "Status/Date 12/7, 12/13, 12/21 , 12/28, ?, 1/11, 1/8, 1/20, 2/1, 2/8, 2/15,2/22, 3/1, 3/8,3/19, 3/5, 3/22, 3/29, 4/5, 4/13, 4/19/, 4/26, C (continued)."

9. Patient G1. MTP dated 4/29/11 stated "Problem#1 Dangerous behaviors Suicidal ideation Visual/auditory hallucinations in response to emotion dysregulation -Adult." Objectives listed were:
"Patient will demonstrate 'distress tolerance' skills to decrease SUDS [sic] to under 70 three times in a week.
Patient will participate in one DBT [sic] based group each day.
Patient will attend co-occurring treat [sic].
Patient will report scores of 8 or below on a scale of 'substance abuse urges' 48 hours prior to discharge. Patient will comply with medications as prescribed."

For "Problem #II Medical problems: On Librium protocol for ETOH [sic] withdrawal" the Objectives were:
"Patient will comply with the recommended diagnostic tests and medical treatment, as documented by the RN/MD/NP, VS[sic] q[sic] 4 hrs[sic] Librium PRN[sic].
Patient will demonstrate by teach/show back an understanding of their medical condition and the benefits of recommended treatment, as documented by the RN/MD/NP."

10. Patient H3. MTP dated 4/21/11 stated "Problem #1 Dangerous behaviors AH/VH [sic] impulsivity wants to start a crusade in response to emotion dysregulation-adult." Objectives listed were:
"Patient will demonstrate 'distress tolerance' skills to decrease SUDS [sic] to under 70 three times in a week," with a "Status/Date 4/28 C (continued);"
"Pt [sic] to demonstrate (decrease) psychotic thinking," with a "Status/Date 4/28 C (continued);" and
"Patient will comply with medications as prescribed," with a "Status/Date 4/28 C (continued)."

B. Policy Review

The facility policy titled "Four Winds Hospital Patient Care Manual Treatment Plan Guidelines II 9" states "5. The Problem Sheets shall be completed as follows: b. ...The status of each short term goal should be tracked by date and code. M means Met, D means Discontinued, C means Continued....7. The Treatment Plan shall be updated as follows: ...At least weekly the status of the goals and objectives shall be noted by dating the entry on the Problem sheet and indicated whether the goal/objective is continued, met or discontinued....."

C. Staff Interviews

1. In an interview on 5/3/11 at 11:00AM, RN1 and RN2 acknowledged that the treatment plans had non- measureable goals and that "they don't connect the dots."

2. In an interview on 5/3/11 at 11:10 AM, MD1 stated that the treatment plans were "generic" and acknowledged that the different parts of it were disconnected.

Based on record review and interview, the facility failed to: 1) identify individualized and focused interventions to address the presenting problems and treatment goals; many listed "interventions" were routine and generic tasks for various disciplines inappropriately identified as treatment interventions; 2) specify how interventions would be delivered (as group or individual modalities); 3) specify the frequency of staff contact for treatment interventions; and 4) include the specific group interventions that the patient would attend for 10 of 10 sample patients (A7, A25, B4, C3, C10, D10, E5, F1, G15, and H3). These deficiencies result in a failure to guide clinical staff in providing individualized patient treatment with reference to the specific treatment modalities/interventions to be carried out, and, as a result, potentially result in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review (MTP dates in parentheses)

1. Patient A7 (4/22/11)

For the problem "Dangerous Behaviors Depression, SI [suicidal ideation] in Response to Emotion Dysregulation - Adolescent," examples of listed MTP interventions included:

PSYCHIATRIST/NPP/PA: "Assess/adjust medications: [left blank] daily or as needed" without a specific focus and without a noted frequency or duration for the intervention.

THERAPIST: "Work with family and/or outpatient providers to coordinate discharge planning and aftercare" without a specific focus and without a noted frequency or duration for the intervention and "Group therapy per program schedule" without specifying the particular groups and without specifying the frequency or duration of the groups.

NURSING STAFF: "Reinforce teaching regarding medication as prescribed" without a specific focus and without a noted frequency or duration for the intervention, and "Coach identification and practice of coping skills" without a focus on specific coping skills and without a noted frequency or duration for the intervention.

MHAS: "Coach use of activity based interventions to promote socialization, mindfulness, emotion regulation & distress tolerance" without a noted frequency or duration; and "Provide education regarding substance free leisure activities" [note: no substance abuse diagnosis] without a noted frequency or duration.

2. Patient A25 (4/15/11)

For problem "Dangerous Behaviors SI [suicidal ideation], SIB [self-injurious behavior], Aggression in Response to Emotion Dysregulation - Adolescent," examples of listed MTP interventions included:

PSYCHIATRIST/NPP/PA: "Assess/adjust medications: as needed [sic] daily or as needed" without a specific focus and without a specified frequency or duration.

THERAPIST: "Work with family and/or outpatient providers to coordinate discharge planning and aftercare," without a specific focus and without a specified frequency or duration; and "Group therapy per program schedule," without specifying the particular groups and without specifying the frequency or duration.

NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a specific focus and without a noted frequency or duration; and "Coach identification and practice of coping skills," without a specified frequency or duration.

MHAS: "Coach use of activity based interventions to promote socialization, mindfulness, emotion regulation & distress tolerance," without a noted frequency or duration; and "Provide education regarding substance free leisure activities" [note: no substance abuse diagnosis], without a specified frequency or duration; and "Other interventions: deep breathing," without a specified frequency or duration.

3. Patient B4 (4/18/11)

a. For problem "Treatment Interfering Behaviors: stays out late without permission; poor ADLs, shoplifting; poor communication w. parents (conflictual relationship)," examples of listed MTP interventions included:

PSYCHIATRIST/NPP/PA: "Assess/adjust medications: as prescribed [sic] daily or as needed," without a specific focus and without a specified frequency or duration; and "1:1 with patient and family daily or as needed, monitor target symptom relief, educate regarding meds," with no target symptoms specified and without a specified frequency or duration.

THERAPIST: "Work with family and/or outpatient providers to coordinate discharge planning and aftercare," without a specific focus and without a specified frequency or duration; "Group therapy per program schedule," without specifying the particular groups and without specifying the frequency or duration; and "Develop behavioral plan to aid in managing impulsivity," without specifying a target date for completion.

NURSING STAFF: "Coach identification and practice of coping skills," without a specific focus and without a specified frequency or duration; and "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration.

MHAS: "Coach use of activity based interventions to promote socialization, mindfulness, emotion regulation & distress tolerance," without a noted frequency or duration; "Provide education regarding substance free leisure activities" [note: no substance abuse diagnosis], without a specified frequency or duration; "Teach and reinforce relaxation skills using yoga," without a specified frequency or duration; and "Other interventions: AA [alcoholics anonymous; note: no substance abuse diagnosis], music, athletics," without a specified frequency or duration.

b. For problem "Medical Problems: enuresis, encopresis," no modalities or interventions were listed on the MTP for the Psychiatrist or medical practitioner to carry out.

4. Patient C3 (4/20/11)

a. For the problem "Dangerous Behaviors lability/psychosis, examples of listed MTP interventions included:

PSYCHIATRIST/NPP/PA: "Assess/adjust medications: as prescribed daily or as needed," without a specific focus and without a noted frequency or duration.

THERAPIST: "Patient/Parent in vivo [sic] coaching," without a specific focus and without a noted frequency or duration; "Work with family and/or outpatient providers to coordinate discharge planning and aftercare," without a specific focus and without a noted frequency or duration; and "Group therapy per program schedule," without specifying the particular groups and without specifying the frequency or duration.

NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a specific focus and without a noted frequency or duration; "Coach/implement sleep hygiene," without a noted frequency or duration; "Provide wellness education, specify: [left blank]," without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a noted frequency or duration; "Coach identification and practice of coping skills," without a noted frequency or duration; and "Assist in identifying problematic behaviors/feelings" without specifying the problematic behaviors/feelings and without a specified frequency or duration.

MHAS: "Coach use of activity based interventions to promote socialization, mindfulness, emotion regulation & distress tolerance," without a noted frequency or duration; "Provide education regarding substance free leisure activities" [note: no substance abuse diagnosis], without a noted frequency or duration; and "Teach and reinforce relaxation skills using deep breathing," without a specified frequency or duration.

b. For problem "Medical Problems: allergic rhinitis," no modalities or interventions were listed on the MTP for the Psychiatrist or a medical practitioner to carry out.

5. Patient C10 (4/04/11)

a. For the problem "Dangerous Behaviors Suicidality, mood instability with substance abuse & med noncompliance in Response to Emotion Dysregulation - Adolescent," examples of listed MTP interventions included:

PSYCHIATRIST/NPP/PA: "Assess/adjust medications: as prescribed daily or as needed" without a specific focus and without a noted frequency or duration.

THERAPIST: "Patient/Parent in vivo [sic] coaching," without a specific focus and without a noted frequency or duration; "Work with family and/or outpatient providers to coordinate discharge planning and aftercare," without a specific focus and without a noted frequency or duration; and "Group therapy per program schedule," without specifying the particular groups and without specifying the frequency or duration.

NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a specific focus and without a noted frequency or duration; "Coach/implement sleep hygiene," without a noted frequency or duration; "Provide wellness education, specify: [left blank]," without a specific focus and without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a specific focus and without a noted frequency or duration; "Coach identification and practice of coping skills," without a specific focus and without a noted frequency or duration; "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration; and "Provide eating management protocol" [unclear relationship to the identified problem] without a specified frequency or duration.

MHAS: "Coach use of activity based interventions to promote socialization, mindfulness, emotion regulation & distress tolerance," without a noted frequency or duration; "Provide education regarding substance free leisure activities," without a specific focus and without a noted frequency or duration; and "Teach and reinforce relaxation skills using deep breathing," without a specified frequency or duration.

b. For problem "Medical Problems: asthma," no modalities or interventions were listed on the MTP for the Psychiatrist or a medical practitioner to carry out.

6. Patient D10 (4/21/11)

For the problem "Dangerous Behaviors SIB [self-injurious behavior], Impulsive/aggressive sx [symptoms] in Response to Emotion Dysregulation - Child," examples of listed MTP interventions included:

PSYCHIATRIST/NPP/PA: "Assess/adjust medications: as prescribed daily or as needed," without a specific focus and without a noted frequency or duration; and "1:1 with patient and family daily or as needed, monitor target symptom relief, educate regarding meds," without the delineation of specific target symptoms and without a noted frequency or duration.

THERAPIST: "Work with family and/or outpatient providers to coordinate discharge planning and aftercare," without a specific focus and without a noted frequency or duration; "Group therapy per program schedule," without specifying the particular groups and without specifying the frequency or duration; and "Develop behavioral plan to aid in managing impulses and emotions," without specifying a target date for completion.

NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a specific focus and without a noted frequency or duration; "Provide positive reinforcements for behavior," without a specific focus and without a specified frequency or duration; "Coach identification and practice of coping skills," without a specific focus and without a noted frequency or duration; "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration; and "Provide eating management protocol" [unclear relationship to the identified problem] without a specified frequency or duration.

MHAS: "Coach use of activity based interventions to promote socialization, mindfulness, emotion regulation & distress tolerance," without a noted frequency or duration; "Provide education regarding substance free leisure activities" [note: no substance abuse diagnosis in this 10 yo child], without a noted frequency or duration; and "Teach and reinforce relaxation skills using deep breathing," without a specified frequency or duration.

7. Patient E5 (4/11/11)

a. For the problem "Dangerous Behaviors Impulsive/Aggressive Behavior, SI [suicidal ideation], & self-injurious behavior in Response to Emotion Dysregulation - Child," examples of listed MTP interventions included:

PSYCHIATRIST/NPP/PA: "Assess/adjust medications: as prescribed daily or as needed," without a specific focus and without a noted frequency or duration

THERAPIST: "Patient/Parent in vivo [sic] coaching," without a specific focus and without a noted frequency or duration; "Work with family and/or outpatient providers to coordinate discharge planning and aftercare," without a specific focus and without a noted frequency or duration; and "Group therapy per program schedule," without specifying the particular groups and without specifying the frequency or duration.

NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a specific focus and without a noted frequency or duration; "Provide positive reinforcements for behavior," without a specific focus on adaptive behaviors and without a specified frequency or duration; "Coach identification and practice of coping skills," without a noted frequency or duration; "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration; and "Provide eating management protocol" [unclear relationship to the identified problem], without a specified frequency or duration.

MHAS: "Coach use of activity based interventions to promote socialization, mindfulness, emotion regulation & distress tolerance," without a noted frequency or duration; "Teach and reinforce relaxation skills using yoga, deep breathing" without a specified frequency or duration; and "Other interventions: ADL/personal hygiene" without describing what aspects of ADL/personal hygiene required attention and without a specified frequency or duration.

b. For problem "Medical Problems: Seizures," no modalities or interventions were listed on the MTP for the Psychiatrist or a medical practitioner to carry out.

c. For problem "Medical Problems: Incontinence of bladder & bowels," no modalities or interventions were listed on the MTP for the Psychiatrist or a medical practitioner to carry out.

d. For problem "Medical Problems: Mitochondrial Depletion Syndrome," no modalities or interventions were listed on the MTP for the Psychiatrist or a medical practitioner to carry out.

8. Patient F1 (12/06/10)

a. For the problem "Dangerous Behaviors Fear of going outside; impulsive/Aggress [sic] in Response to Emotion Dysregulation - Child," examples of listed MTP interventions included:

PSYCHIATRIST/NPP/PA: "Assess/adjust medications: as prescribed daily or as needed," without a specific focus and without a noted frequency or duration.

THERAPIST: "Patient/Parent in vivo [sic] coaching," without a specific focus and without a noted frequency or duration; "Work with family and/or outpatient providers to coordinate discharge planning and aftercare," without a specific focus and without a noted frequency or duration; "Group therapy per program schedule," without specifying the particular groups and without specifying the frequency or duration; and "Develop behavioral plan to aid in managing impulses and emotions," without specifying a target date for completion.

NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency or duration; "Coach/Implement sleep/hygiene program handwashing," without a noted frequency or duration; "Provide wellness education, specify [illegible]," without a specific focus and without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a specific focus and without a noted frequency or duration; "Provide positive reinforcements for behavior," without a specified frequency or duration; "Coach identification and practice of coping skills," without a specific focus and without a noted frequency or duration; and "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration.

MHAS: "Coach use of activity based interventions to promote socialization, mindfulness, emotion regulation & distress tolerance," without a noted frequency or duration; "Teach and reinforce relaxation skills using deep breathing, yoga," without a specified frequency or duration; and "Other interventions: ADL/personal hygiene," without describing what aspects of ADL/personal hygiene required attention and without a specified frequency or duration.

b. For multiple time-limited medical problems (neck pain, cold sore, chapped lips, cold/congestion, genital irritation, UTI [urinary tract infection], pharyngitis, lice), no modalities or interventions were listed on the MTP for the Psychiatrist or a medical practitioner to carry out.

9. Patient G15 (4/29/11)

a. For the problem "Dangerous Behaviors Suicidal Ideation, Visual/Auditory Hallucinations in Response to Emotion Dysregulation - Adult," examples of listed MTP interventions included:

PSYCHIATRIST/NPP/PA: "Assess/adjust medications: Depakote ER daily or as needed," without a specific focus and without a noted frequency or duration.

THERAPIST: "Work with family and/or outpatient providers to coordinate discharge planning and aftercare," without a specific focus and without a noted frequency or duration; and "Group therapy per program schedule" without specifying the particular groups and without specifying the frequency or duration.

NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a specific focus and without a noted frequency or duration; "Provide positive reinforcements for behavior," without a specified frequency or duration; "Coach identification and practice of coping skills," without a specific focus and without a noted frequency or duration; and "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration.

MHAS: "Coach use of activity based interventions to promote socialization, mindfulness, emotion regulation & distress tolerance," without a noted frequency or duration; "Provide education regarding substance free leisure activities," without a specified frequency or duration; "Teach and reinforce relaxation skills using DBT [dialectical behavioral therapy], mindfulness," without a specified frequency or duration; and "Other interventions: DBT, art, walks, theatre group, weight room," without a specific focus and without a specified frequency or duration.

b. For problem "Medical Problems: On Librium Protocol for ETOH Withdrawal," no modalities or interventions were listed on the MTP for the Psychiatrist or a medical practitioner to carry out.

10. Patient H3 (4/21/11)

a. For the problem "Dangerous Behaviors + [positive] AV [auditory hallucinations]/VH [visual hallucinations]; Impulsivity; Wants to start a crusade in Response to Emotion Dysregulation - Adult," examples of listed MTP interventions included:

PSYCHIATRIST/NPP/PA: "Assess/adjust medications: prn [sic] daily or as needed," without a specific focus and without a noted frequency or duration

THERAPIST: "Work with family and/or outpatient providers to coordinate discharge planning and aftercare," without a specific focus and without a noted frequency or duration; and "Group therapy per program schedule," without specifying the particular groups and without specifying the frequency or duration.

NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a specific focus and without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a noted frequency or duration; "Provide positive reinforcements for behavior," without a specified frequency or duration; "Coach identification and practice of coping skills," without a specific focus and without a noted frequency or duration; and "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration.

MHAS: "Coach use of activity based interventions to promote socialization, mindfulness, emotion regulation & distress tolerance," without a noted frequency or duration; "Provide education regarding substance free leisure activities" [note: no substance abuse diagnosis], without a specified frequency or duration; "Teach and reinforce relaxation skills using deep breathing," without a specified frequency or duration; and " Other interventions: DBT, distress tolerance skills," without a specific focus and without a specified frequency or duration.

C. Staff Interview

1. In an interview conducted on 5/03/11 at 11:20am, Physician's Assistant [PA1] said that she agreed that the "interventions" assigned to her on the Master Treatment Plan of sample patient H3 were not specific in nature and did not include either the frequency with which she would meet with her patient or the amount of time (duration) she would spend with him.

2. In an interview conducted on 5/03/11 at 4:05pm, the Medical Director agreed that the interventions on the MTPs were generic or non-specific in nature, and that neither the frequency nor the duration of the intervention was described for the vast majority of the interventions listed on the MTPs.

3. In an interview 5/3/11 at 3:45PM the Director of Nursing (DON) acknowledged that the patient goals and objectives were not specifically related to the staff interventions. The DON stated, "Somehow we can't get down what it is that we need to do".

Based on record review and interview, the facility failed to ensure that an appropriate medical practitioner (Psychiatrist, Internist, Nurse Practitioner, or Physician Assistant) was assigned to oversee identified medical problems for 6 of 10 sample patients (B4, C3, C10, E5, F1, and G15).
Failure to designate a responsible medical practitioner on the MTP compromises the ability of the nursing staff and other staff members to carry out integrated and effective treatment.

Findings include:

A. Record Review

1. Patient B4 (4/18/11) - For problem "Medical Problems: enuresis, encopresis," no modalities or interventions were listed on the MTP for the Psychiatrist or medical practitioner to carry out.

2. Patient C3 (4/20/11) - For problem "Medical Problems: allergic rhinitis," no modalities or interventions were listed on the MTP for the Psychiatrist or medical practitioner to carry out.

3. Patient C10 (4/04/11) - For problem "Medical Problems: asthma, no modalities or interventions were listed on the MTP for the Psychiatrist or a medical practitioner to carry out.

4. Patient E5 (4/11/11) -
a. For problem "Medical Problems: Seizures," no modalities or interventions were listed on the MTP for the Psychiatrist or medical practitioner to carry out.

b. For problem "Medical Problems: Incontinence of bladder & Bowels," no modalities or interventions were listed on the MTP for the Psychiatrist or medical practitioner to carry out.

c. For problem "medical Problems: Mitochondrial Syndrome," no modalities or interventions were listed on the MTP for the Psychiatrist or medical practitioner to carry out.

5. Patient F1 (12/06/10) - For multiple time-limited medical problems neck pain, cold sore, chapped lips, cold/congestion, genital irritation, UTI [urinary tract infection], pharyngitis, lice), no modalities or interventions were listed on the MTP for the Psychiatrist or medical practitioner to carry out.

6. Patient G15 (4/29/11) - For problem "Medical Problems: On Librium Protocol for ETOH Withdrawal," no modalities or interventions were listed on the MTP for the Psychiatrist or medical practitioner to carry out.

B. Staff Interview

In an interview conducted on 5/03/11 at 4:05pm, the Medical Director concurred that the MTPs did not specify the Psychiatrist or Nurse Practitioner or Physician Assistant (as the assigned independent practitioner) responsible for overseeing designated medical problems.

Based on record review and interview, the facility failed to ensure that progress notes recorded by the Psychiatrist or Physician Assistant responsible for the care of the patient contained a specific assessment of the patient's progress in accordance with the original or revised treatment plan for 6 of 10 sample patients (A7, A25, C10, D10, E5, and F1). Failure to provide sufficient documentation of a patient's progress compromises the ability of the treatment team to assess the effectiveness of the treatment interventions being provided and can lead to a delay in the patient's return to the community.

Findings include:

A. Record Review

1. Patient A7: the "Assessment" sections of the MD/NPP Progress Notes (selected dates 4/23/11, 4/24/11, 4/27/11, 4/29/11) contained no information on the patient's response to the treatment being provided.

2. Patient A25: the "Assessment" sections of the MD/NPP Progress Notes contained comments on symptoms or general statements regarding participation in the unit's programming, but did not assess the patient's overall response to the treatment being provided - the 4/25/11 note stated "pt. labile and irritable, but better engaged;" the 4/27/11 note stated "attend program, work on target behaviors for treatment;" the 4/28/11 note stated "attend program, work on target behaviors for treatment;" the 4/29/11 note stated "attend program, work on target behaviors for treatment."

3. Patient C10: the "Assessment" sections of the MD/NPP Progress Notes contained reiterations of the diagnoses, but did not assess the patient's overall response to the treatment being provided - the 4/07/11, 4/08/11, 4/11/11, 4/12/11, 4/13/114/19/11, 4/21/11, 4/27/11, 4/28/11 notes all made the same statement: "Bipolar D/O NOS, ADHD symptomatic as reported above" in the assessment section.

4. Patient D10: the "Assessment" sections of the MD/NPP Progress Notes contained reiterations of the diagnoses, but did not assess the patient's overall response to the treatment being provided; for example, the 4/29/11 note stated: "Dx: mood dis nos, adhd by hx" in the assessment section.

5. Patient E5: the "Assessment" sections of the MD/NPP Progress Notes contained general comments on symptoms, but did not assess the patient's overall response to the treatment being provided; for example, the 4/12/11 note stated: "Patient symptomatic" in the assessment section.

6. Patient F1: the "Assessment" sections of the MD/NPP Progress Notes contained general comments on patient participating in the unit's clinical program, but did not assess the patient's overall response to the treatment being provided; for example, the notes on 3/21/11, 3/23/11, 3/28/11, 4/04/11, 4/12/11, 4/18/11, 4/28/11 all stated: "Patient compliant with unit program" in the assessment section.

B. Policy Review

The Four Winds Hospital Patient Care Manual section on "Physician/NP/PA Progress Notes II-18" (most recent revision dated 01/11) states:
"6. Each written Progress Note should address:
a. The problem, clinical focus and objectives to which the note relates
b. Significant behavioral [sic] and symptomatology
c. Progress toward treatment goals
d. Changes in diagnosis
e. Medications, with doses and indications, or medication changes/plans
f. Medication consent, if not documented elsewhere
g. Significant medication side-effects or adverse drug reactions
h. Rationale for hospital level of care
i. Special events, such as Seclusion or Restraint
j. Medical problems and action on abnormal lab [sic] findings"

Based on record review and interview, the facility's Medical Director failed to monitor and evaluate the quality and appropriateness of the services and treatment provided by the medical staff. Master Treatment Plans were poorly developed, without necessary input from social work clinical assessments; without appropriate modifications to diagnoses as clinical situations changed; and used checklists which did not allow individualization of the plans to meet patient needs. In addition, for some medical problems, the plans did not indicate any medical staff involvement, and the progress notes written by medical staff were repetitious, without sufficient content to convey the patient's status.

Findings include:

I. MTPs were developed prior to the completion of psychosocial assessments in 4 of 10 sample records reviewed (C3, F1, G15, H3). In addition the plans were not individualized and comprehensive, with all necessary elements to direct the treatment team in patient care for 10 of 10 active sample patients (A7, A25, B4, C3, C10, D10, E5, F1, G15 and H3). The treatment plans were selected from preprinted checklists and were very similar across different situations and patients. The organization of the MTP document was disjointed and did not flow in a manner that was comprehensible. Failure to develop treatment plans with all components hampers staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met.

1. Psychosocial Assessments were not completed prior to the development of the Master Treatment Plan for 4 of 10 sample patients (C3, F1, G15, and H3). Failure to have psychosocial clinical information available for treatment planning compromises the ability of the team to fully and completely address the patient's social and discharge needs. (Refer to B118 for details.)

2. The MTPs did not include substantiated diagnoses. Rather the provisional diagnoses on the psychiatric evaluation performed at the time of admission were carried over to the Master Treatment Plans, without confirming or amending the provisional diagnoses by incorporating information from assessments performed by other disciplines, from laboratory studies, and/or from additional information obtained from collateral sources, or from patient and family interactions between the admission and the planning meeting. In addition the appropriate revisions to the diagnoses were not made based on patients' clinical presentation. (Refer to B120);

3. The MTPs failed to include individualized short-term and long-term goals, stated in observable, measurable, behavioral terms for 10 of 10 active sample patients (A7, A25, B4, C3, C10, D10, E5, F1, G15 and H3). Goals ("Objectives") on the treatment plans were selected from preprinted checklists of goals ("Objectives") for identified problems and were very similar across different situations and patients. They were not measureable and did not include target dates. (Refer to B121);

4. The MTPs did not include individualized treatment interventions and modalities. Checklist choices were routine and generic tasks for various disciplines inappropriately identified as treatment interventions; the lists failed to specify how interventions would be delivered (as group or individual modalities); in the case of group interventions, failed to include the specific group interventions that the patient would attend; and failed to specify the frequency and focus of staff contact for treatment interventions. (Refer to B122)

II. Review revealed a lack of necessary medical staff involvement in the plan and lack of appropriate medical staff progress notes.

1. The MTPs did not assign a Psychiatrist or other appropriate medical staff to carry out modalities or interventions related to medical problems for 6 of 10 sample patients (B4, C3, C10, E5, F1, and G15). Failure to designate a responsible medical practitioner on the MTP compromises the ability of the nursing staff and other staff members to carry out integrated and effective treatment. (Refer to B123)

2. Progress notes recorded by the Psychiatrist or Physician Assistant responsible for the care of the patient failed to contain a precise assessment of the patient's progress in accordance with the original or revised treatment plan for 6 of 10 sample patients (A7, A25, C10, D10, E5, and F1). Failure to provide sufficient documentation of a patient's progress compromises the ability of the treatment team to assess the effectiveness of the treatment interventions being provided, hampers staff's ability to provide coordinated multidisciplinary care, potentially can result in the patient's treatment needs not being met or lead to a delay in the patient's return to the community. (Refer to B132).

Based on record review and interview the DON failed to ensure that the MTP included nursing interventions addressing the identified problems of 10 of 10 sample patients (A7, A25, B4, C3, C10, D10, E5, F1, G15 and H3). The listed interventions for nurses were generic functions obtained from a pre-printed list and lacked a description of focus and frequency. This hampers nursing staff's ability to provide individualized treatment that is purposeful and goal directed.

Findings are:
A. Record Review
1. Patient A7 (4/22/11)
For the problem "Dangerous Behaviors Depression, SI [suicidal ideation] in Response to Emotion Dysregulation - Adolescent," examples of listed MTP interventions included:
NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency or duration; and "Coach Identification and practice of coping skills," without a noted frequency or duration.
2. Patient A25 (4/15/11)
For problem "Dangerous Behaviors SI [suicidal ideation], SIB [self-injurious behavior], Aggression in Response to Emotion Dysregulation - Adolescent," examples of listed MTP interventions included:
NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency; and "Coach identification and practice of coping skills," without a specified frequency or duration.
3. Patient B4 (4/18/11)
For problem "Treatment Interfering Behaviors stays out late without permission; poor ADLs, shoplifting; poor communication w. parents (conflictual relationship)," examples of listed MTP interventions included:
NURSING STAFF: "Coach identification and practice of coping skills," without a specified frequency or duration; and "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration.
4. Patient C3 (4/20/11)
For the problem "Dangerous Behaviors lability/psychosis, examples of listed MTP interventions included:
NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency or duration; "Coach/implement sleep hygiene," without a noted frequency or duration; "Provide wellness education, specify: [left blank]," without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a noted frequency or duration; "Coach identification and practice of coping skills," without a noted frequency or duration; and "Assist in identifying problematic behaviors/feelings" without specifying the problematic behaviors/feelings and without a specified frequency or duration.

5. Patient C10 (4/04/11)
For the problem "Dangerous Behaviors Suicidality, mood instability with substance abuse & med noncompliance in Response to Emotion Dysregulation - Adolescent," examples of listed MTP interventions included:
NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency or duration; "Coach/implement sleep hygiene," without a noted frequency or duration; "Provide wellness education, specify: [left blank]," without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a noted frequency or duration; "Coach identification and practice of coping skills," without a noted frequency or duration; "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration; and "Provide eating management protocol" [unclear relationship to the identified problem] without a specified frequency or duration.

6. Patient D10 (4/21/11)
For the problem "Dangerous Behaviors SIB [self-injurious behavior], Impulsive/aggressive sx [symptoms] in Response to Emotion Dysregulation - Child," examples of listed MTP interventions included:
NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a noted frequency or duration; "Provide positive reinforcements for behavior," without a specified frequency or duration; "Coach identification and practice of coping skills," without a noted frequency or duration; "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration; and "Provide eating management protocol" [unclear relationship to the identified problem] without a specified frequency or duration.

7. Patient E5 (4/11/11)
For the problem "Dangerous Behaviors Impulsive/Aggressive Behavior, SI [suicidal ideation], & self-injurious behavior in Response to Emotion Dysregulation - Child," examples of listed MTP interventions included:
NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a noted frequency or duration; "Provide positive reinforcements for behavior," without a specified frequency or duration; "Coach identification and practice of coping skills," without a noted frequency or duration; "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration; and "Provide eating management protocol" [unclear relationship to the identified problem], without a specified frequency or duration.

8. Patient F1 (12/06/10)
For the problem "Dangerous Behaviors Fear of going outside; impulsive/Aggress [sic] in Response to Emotion Dysregulation - Child," examples of listed MTP interventions included:
NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency or duration; "Coach/Implement sleep/hygiene program handwashing," without a noted frequency or duration; "Provide wellness education, specify [illegible]," without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a noted frequency or duration; "Provide positive reinforcements for behavior," without a specified frequency or duration; "Coach identification and practice of coping skills," without a noted frequency or duration; and "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration.

9. Patient G15 (4/29/11)
For the problem "Dangerous Behaviors Suicidal Ideation, Visual/Auditory Hallucinations in Response to Emotion Dysregulation - Adult," examples of listed MTP interventions included:
NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a noted frequency or duration; "Provide positive reinforcements for behavior," without a specified frequency or duration; "Coach identification and practice of coping skills," without a noted frequency or duration; and "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration.

10. Patient H3 (4/21/11)
For the problem "Dangerous Behaviors + [positive] AV [auditory hallucinations]/VH [visual hallucinations]; Impulsivity; Wants to start a crusade in Response to Emotion Dysregulation - Adult," examples of listed MTP interventions included:
NURSING STAFF: "Reinforce teaching regarding medication as prescribed," without a noted frequency or duration; "Work with patient on completion of treatment plan assignments," without a noted frequency or duration; "Provide positive reinforcements for behavior," without a specified frequency or duration; "Coach identification and practice of coping skills," without a noted frequency or duration; and "Assist in identifying problematic behaviors/feelings," without specifying the problematic behaviors/feelings and without a specified frequency or duration.

B. Staff Interview
In an interview 5/3/11 at 3:45PM the Director of Nursing (DON) acknowledged that the nursing interventions were generic and not individualized..The DON stated, "Somehow we can't get down what it is that we need to do."

Based on record review and interview, the Director of Social Work failed to:

I. Ensure that the social work assessments for 10 of 10 sample patients (A7, A25, B4, C3, C10, D10, E5, F1, G15, and H3) included recommendations regarding the role of the social worker in treatment and discharge planning and specified the community resources and support systems needed for effective discharge of the patient. The section labeled "Initial Treatment Recommendations" contained 6 check-off options all of which were generic descriptions of potential presenting problems and short-term/long-term goals rather than specific treatment interventions that the social worker would address during the course of treatment. All the assessments lacked specificity relevant to the particular patient's unique reasons for admission, psychosocial functioning, family relations, available support systems/community resources, and/or high-risk issues. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient's discharge plan, ensuring safe re-entry into the community.

II. Ensure that the psychosocial assessments for 4 of 10 sample patients (C3, F1, G15, and H3)
were completed prior to the development of the Master Treatment Plans. Failure to have psychosocial clinical information available for treatment planning compromises the ability of the team to fully and completely address the patient's social and discharge needs.

Findings include:

A. Record Review

I. Lack of recommendations in the psychosocial assessments

The psychosocial assessments of the following patients were reviewed (dates of assessments are in parentheses): A7 (4/22/11); A25 (4/15/11); B4 (4/18/11); C3 (4/25/11); C10 (4/04/11); D10 (4/21/11); E5 (4/11/11); F1 (12/07/10); G15 (5/02/11) and H3 (4/22/11). This review revealed that none of the assessments included treatment recommendations based on meeting the unique needs of the identified patient. Only pre-printed generic statements of problem areas and generic statements of short-term/long-term goals were listed, such as "patient needs intensive aftercare planning," and "short-term goal - pt/family will discuss with staff problem severity and the need for a specific discharge plan;" or "patient is distant from family or patient lacks positive social supports," and "short-term goal - pt will discuss risks/benefits of family/significant other involvement in treatment and discharge planning;" or "patient has a history of being non-compliant with medications and/or psychotherapy" and "short-term goal - pt/family will discuss reasons and contributing factors for non-compliance with previous discharge plan." No evaluating social worker elected to write in any recommendations for specific treatment interventions to be provided by the social worker during the patient's inpatient course of treatment.

II. Lack of integration of psychosocial clinical information into the MTPs

1. Patient C3 - The psychosocial assessment was completed on 4/25/11, five days after the date of the MTP (4/20/11).

2. Patient F1 - The psychosocial assessment was completed on 12/07/10, one day after the date of the MTP (12/06/10).

3. Patient G15 - The psychosocial assessment was completed on 5/02/11, three days after the date of the MTP (4/29/11).

4. Patient H3 - The psychosocial assessment was completed on 4/22/11, one day after the date of the MTP (4/21/11).

B. Staff Interview

In an interview with the Director of Social Work on 5/04/11 at 9:30am, the Director of Social Work stated "I do not (have a method to monitor social work assessments). The Program Directors and Nurse Managers oversee the social workers on the unit....They would let me know if there were any problems." After reviewing copies of the Psychosocial Assessments of the sample patients, the Social Work Director stated, "the assessments do not contain enough detail" and "all relevant recommendations for social worker interventions are not included in the assessments."