HospitalInspections.org

Based on record review, policy review and interview it was determined that the hospital is not primarily engaged in providing psychiatric services for the diagnosis and treatment of mentally ill persons.

I. The facility failed to assure that 5 of 5 active sample patients (A1, A2, A3, A4 and A7) who were admitted for behavior problems related to dementia with secondary psychiatric diagnoses had the cognitive capacity to benefit from psychiatric care. This failure prevents patients from receiving services at the appropriate level of care.

Findings include:

A. The primary diagnosis for active sample patients A1, A2, A3, A4 and A5 was dementia.

1. Patient A1. "Dementia, Vascular Type with Behavioral Dyscontrol. History of Bipolar disorder. Must consider fronto-temporal dementia as well." Patient A1 had a Mini-Mental Status Examination Score of 15/30 consistent with Moderate Dementia. Patient A1 received only Recreational Therapy groups and medication management. The Patient Activity Participation Record in the chart showed only limited attendance at the scheduled activities. No other groups or therapies were documented in the chart.

2. Patient A2. "Dementia, Alzheimer's type with vascular component, with anxiety, paranoia, depressive disorder NOS." Patient A2 had a Mini-Mental Status Examination Score of 15 of 28, consistent with Moderate Dementia. Patient A2 received only Recreational Therapy Groups and medication management. The Patient Activity Participation Record showed only limited attendance at the scheduled activities.

3. Patient A3. "Severe Alzheimer's Dementia with aggression". Patient A3 had a Mini-Mental Status Examination Score of 10/30 consistent with Moderate to Severe Dementia. Patient A3 initially showed limited attendance at groups as documented on the Patient Activity Participation Record. After 9/21/11, he was receiving comfort care measures only.

4. Patient A4, "Dementia, considered mixed in origin. Mood Disorder NOS. Anxiety Disorder NOS." Patient A4 had a Mini-Mental Status Examination score of 4/30 consistent with Severe Dementia. Patient A4 received only Recreational Therapy Groups and medication management. Patient Activity Participation Record shows only limited attendance at the scheduled activities.

5. Patient A7, "Dementia, likely vascular type, mood disorder NOS." Patient A7 had a Mini-Mental Status Examination score of 4/30. Patient A7 received only medication management and Recreational Therapy Groups. The Patient Activity Participation Record showed limited attendance at the scheduled activities.

B. In an interview with the Medical Director at around 10:45am on 9/27/11, he stated that the main diagnoses of patients admitted to the facility were dementia and a mood disorder diagnosis. He stated the mood disorder diagnosis is often based on the response of their agitation to psychiatric medications. He noted that most patients with dementia were really "out of it" and that they often didn't benefit from groups and activities. He stated that medication management and increased socialization were consistent with active treatment for this group.

C. In an interview at 2:45p.m. on 9/27/11, the Director of Recreation Therapy and the Recreation Therapist stated that RT provides most of the programming for the patients. The RT Director noted this is "more of a dementia hospital" and indicated that groups were geared to this level. Both indicated that the patients' attendance was voluntary and that typically about half of the patients were active attendees in their activities.

D. Patients were observed in groups and activities on the unit.

1. On 9/26/11, the group Trivia Games was observed. Patients were seated at the table with RT2 and were giving the answers to questions about old song lyrics and old sayings. Maximum attendance at the group was 12 patients; however, patients left or entered the group at different times. Active sample patients A1, A4 and A6 were present and participated. Patient A5 was present reading the paper. Patient A7 was present but not participating. Patient A2, A3, and A8 were not present. Patient notes for the group documented in the Patient Activity Participation Record was only a numerical documentation of presence and participation. No goals or outcomes of the group were recorded in the record.

2. On 9/27/11, RT 2 was leading a group of seven patients including patient A2 in the day room. The activity was coloring picture outlines. Patients had a selection of colored crayons to work with. There was little conversation or interaction among the patients. Some of the patients could not stay between the lines. One patient could barely keep the crayon on the paper.

II. The facility failed to assure that 3 of 3 active sample patients with documented dementia, but with a primary diagnosis of a psychiatric problem (A5, A6 and A8), received active psychiatric treatment. There was no documented treatment for these patients except medication prescription and medication management. Failure to provide psychiatric treatment modalities for patients with psychiatric diagnoses results in patients with psychiatric problems not receiving active treatment for their primary psychiatric problems.

Findings include:

A. Patient A5 had a diagnosis of "Paranoid Schizophrenia complicated by hypoxic encephalopathy, chronic for several years with resultant mild dementia." His Mini-Mental Status score was 13/20. Patient A5 was assigned to Treatment Track 1. Only patients on Track 2 received group psychotherapy and individual therapy. Patient A5 received only psychiatric medications. He was re-admitted for his fourth admission on 9/20/11. He had failed placement 10 days after discharge. The only other activities noted in his record were Games and Trivia, Reminisce/Spirit, Short Stories/Poems, Cooking and Hydration, News and Discuss, Movie Matinee/TV, Stations/patio/out [sic]. These activities were provided by RT2.

Patient A5 was interviewed on 9/26/11 after Trivia Games. He said he was not as "stupid" as the other patients and the activities were not helping him with his goal which was to return to living in his apartment. He stated he like RT2 because she was the only one "who did things with them."

MD1 was interviewed regarding this patient. She stated he had a progressive dementia due to recurrent hypoxia. She stated he was more impaired than he realized. I asked why he was not in Track 2. She said he did not benefit from therapy at his last admission.

B. Patient A6 had a diagnosis of "Mood disorder NOS, rule out bipolar affective disorder, depressed, consider early dementia" and was blind. Her initial Mini-Mental Status score was 14/25 with poor effort due to her symptoms. She was assigned to Treatment Track 1. Record review revealed that she participated in the same type of diversional groups as patient A5. She received medication management. She did not receive group or individual psychiatric treatment. She did not receive materials appropriate for a blind patient, such as taped patient education materials.

Patient A6 was interviewed on 9/26/11 in the day area. She said she enjoyed the activities but wasn't attending any groups for depression. She explained that RT2 helped her with activities because she is blind. She said "they are trying to find a home for me near my husband".

C. Patient A8 received a diagnosis of "Bipolar affective disorder, depressed by history, dementia seems likely at this point, mild to moderate." Her Mini-Mental Status Examination score was 27/30 consistent with a normal examination. She was admitted with stated suicidal ideation and was placed on suicide precautions. Record review revealed she received medication management and attended groups similar to patients A5 and A6. She did not receive group or individual psychotherapy. She did not receive any other documented assessment of her suicidal ideation while remaining on suicide precautions.

Patient A8 was interviewed on 9/28/11. She said she would be leaving soon. She said she had help from the social worker with her family but did not have individual or group therapy.

III. The facility failed to ensure that patients whose condition did not permit active psychiatric treatment were transitioned to appropriate levels of care. This failure was documented for 17 of 17 patients whose death records were reviewed (E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, E15, E16, E17) and 1 of 8 active sample patients (A3). For the 17 expired patients, prior to death " comfort measures" were instituted which resulted in the patients becoming increasingly unable to participate in activities. Treatment plans were not modified to reflect this alteration in status, and the patients were kept until death with no documented evidence of attempt to place them in a palliative care setting. This failure results in palliative care being provided at an acute care level for these patients.

Findings include:

A. Death records for the following 17 deaths in the one year period prior to the survey were reviewed. Patients were placed on comfort care and remained in the hospital until their death. None of the death cases reviewed showed transfer to a more appropriate level of care.

1. Patient E1 was admitted on 9/9/10, placed on comfort care and died on 9/15/10.

2. Patient E2 was admitted on 9/16/10, placed on comfort care on 9/21/10 and died on 9/22/10.

3. Patient E3 was admitted on 9/10/10, placed on comfort care on 9/27/10 and died on 9/30/10.

4. Patient E4 was admitted on 10/21/10, placed on comfort care on 10/29/10 and died on 10/30/10.

5. Patient E5 was admitted on 2/3/11, placed on comfort care on 2/23/11 and died 2/25/11.

6. Patient E6 was admitted on 3/14.11, placed on comfort care on 3/22/11 and died 3/25/11.

7. Patient E7 was admitted on 5/6/11, placed on comfort care on 5/13/11 and died 5/17/11.

8. Patient E8 was admitted on 6/1/11, placed on comfort care on 6/6/11 and died 6/12/11.

9. Patient E9 was admitted on 6/15/11, placed on comfort care and died on 6/21/11.

10. Patient E10 was admitted on 6/28/11, placed on comfort care on 6/30/11 and died 7/3/11.

11. Patient E11 was admitted on 8/24/11, placed on comfort care on 8/31/11 and died 9/2/11.

12. Patient E12 was admitted on 8/25/11, placed on comfort care on 9/1/11 and died 9/7/11.

13. Patient E13 was admitted on 12/10/10, placed on comfort care on 12/29/10 and died 1/8/11.

14. Patient E14 was admitted on 4/13/11, placed on comfort care and died on 5/2/11.

15. Patient E15 was admitted on 8/23/11, placed on comfort care on 9/6/11 and died 9/12/11.

16. Patient E16 was admitted on 6/15/11, placed on comfort care on 6/21/11 and died 7/14/11.

17. Patient E17 was admitted on 5/17/11, placed on comfort care on 6/8/11 and died 6/13/11.

B. In an interview on 9/27/11 at approximately 1 p.m. regarding active treatment, Comfort Care, and transition to lower levels of care, the Director of Social Work Services noted that Comfort Care was implemented at "end of life." There was not a standard for determining when this should begin. Usually the signs were when a patient was very agitated and resistive to care. She reported that the staff may attempt to move patients to a lower level of care although this was not indicated in the treatment plan. She also noted that the facility was the only Gero-Psych unit that takes patients with medical problems and this complicated discharge, and so patients often were allowed to stay at the facility until death.

C. Active sample patient A3 was admitted on 8/31/11. He was transitioned to comfort care on 9/21/11 after 3 weeks on medications for control of behaviors. The Patient Activity Participation Record showed he had attended some activities early in treatment. The treatment notes reveal that he had shown some improvement in behaviors prior to placement on comfort care. He had remained resistant to staff help and had poor sleep.

The surveyor asked to see the patient on 9/26/11 and was told he was dying. After the surveyors made further inquiries into the comfort care procedures, the patient was placed in another facility.

D. In an interview at around 10:45 a.m. on 9/27/11, the Medical Director stated that, with respect to the comfort care orders, the decision was usually driven by nursing concerns about the patient's resistiveness to care and failure to respond to treatment to reduce the behavioral dyscontrol and level of agitation. The Medical Director stated that refractory treatment resistance was considered an indicator for end stage dementia and impending death regardless of the patients level of alertness. He acknowledged that the clinical standards for moving to this level of care were not clearly outlined. He acknowledged that the amount of psychiatric medications needed to control agitation could potentiate a decline in dementia patients. He agreed that optimally, these patients could move to a lower level of care, but stated that they are often very difficult to place due to medical issues.

IV. The facility failed to assure that RN and LPN staff was psychiatrically trained to support active psychiatric treatment. The daily care activities were provided by CNA ' s (certified nursing assistants), and there were no mental health technicians to provide psychiatric care.

Findings include:

A. In an interview 9/27/11 at approximately 1:45p.m., the Director of Nursing and the Associate Director of Nursing acknowledged that the nurses were not trained psychiatric nurses, but were generally medical/surgical nurses. They noted that the nursing staff and CNA's do no counseling or psychiatric treatment, that nurses are trained to do mental status examinations when the patients are admitted, and that social work does the MMSE [Mini Mental Status Examination]. Follow-up MMSEs are done by Social Work and not nursing. RNs do not do medication education; the Treatment Planning LPN may run a medication group for Track II patients. They noted that nursing staff does not do shift or daily suicide risk assessments, but that the Treatment Planning LPN does an update of treatment plans on a weekly basis. They also noted that there are no specific nursing plans or interventions available for patients who are blind or who have other disabilities. (Refer to B148-I)

B. Nursing interventions were limited to medication administration and physical care. There was no evidence in the record for nursing psychiatric interventions, such as de-escalation of agitation, groups or other psychiatric interventions

1. Patient A5 was placed in a physical hold to walk to his room and given Haldol 5 mgm Ativan 1 mgm IM [intramuscular] on 7/23/11 at 1330 [1:30p.m.]., A nursing note read: "Pt [patient] came out of room yelling threatening, slamming counter with fist, pt unable to stop talking to listen. CPI [Crisis Prevention and Interventions] hold to walk pt to his room & administer Haldol 5 mgm/Ativan 1 mgm IM per new prn [as needed] orders. Pt remained in his room for 45 min." No attempts at de-escalation or debriefing were noted.

2. Patient R1 was given Haldol 5 mg/Ativan 1 mg IM At 1015 (10:15a.m.) on 7/5/11 as a chemical restraint for "Agitation - combative - unable to redirect - kicking - danger to self/others;" according to the "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation" form. Patient R1 also had physician orders on 7/13/11 at 1800 (6p.m.) on the "Physician's Orders" form for "Haldol 5 mgm PO X [times] 1 now for aggressive agitation" and "Ativan 1 mgm PO X 1 now for aggressive agitation." There were also orders on the " Documentation for Use of Behavioral Medications" forms on 7/23/11 at 1640 (4:40p.m.) for "5 mgm Zyprexa PO X 1 now for [increased] agitation" and on 7/23/11 at 2350 (11:30pm) for "Haldol 5 mgm IM X 1 now for agitation/combativeness" and "Ativan 1 mgm IM X 1 now for agitation/combativeness." No other interventions or debriefing were noted.

V. The facility failed to assure that there were policies to support the provision of care for patients with suicidal ideation does not provide for adequate assessment and monitoring.

Findings include:

A. Suicide Policy 2NS.5.4 dated 11/4/2004 requires that items that the patient might use for self-harm are removed, that the patient sign a suicide contract, and that the patient be checked every 15 minutes unless the physician specifically orders 1 to 1 precautions.

B. In order to review the facility's care of suicidal patients, active Patient A8 was observed and his/her records were reviewed. The patient was admitted with active suicidal thinking and was placed on suicide precautions. The treatment plan included preprinted sheets with a Nursing Plan of Care for each of a list of problems. The Nursing Plan of Care for Suicide, which is a generic plan used for any suicidal patient, included interventions such as: "Provide safe environment"; "Provide close patient supervision by maintaining observation or awareness of patient at all times"; "As able, develop verbal or written contract stating that he/she will not act on impulses to harm herself. Review/update contract prn."; "Assure that individual counseling is ordered for patient."

There was no documentation in patient A8's medical record of nursing documentation of compliance with safety/suicide prevention checks, with safety contracts, or of re-assessment of suicidal ideation by either nursing or medical staff after the initial assessment at admission.

During the survey, patient A8 was observed to have shoelaces and other objects with which could be used to inflict self harm while on suicide precautions.

There was no evidence of the provision of 1:1 counseling for patient A8 in the record.

C. In an interview on 9/28/11 at around 9:45a.m. regarding suicide precautions, LPN2 stated that she re-assesses the need for continuing the suicide treatment plan weekly. She stated that she was not aware of any other assessment for suicidality or dangerousness done by staff. She stated that staff is aware of patients on suicide precautions because this information is on the daily log sheet and they "know to watch out for the patient."

D. In an interview on 9/27/11 at approximately 1:45p.m., the Director of Nursing and the Associate Director of Nursing acknowledged that nursing staff does not do shift or daily suicide risk assessments, and that the Treatment Planning LPN does treatment plan updates on a weekly basis.

VI. The facility failed to document active psychiatric treatment for all patients. In the published unit schedule, only 4 hours of active treatment programming for psychiatric issues was listed for each week (Track II).

Findings include:

A. The September 2011 Program Calendar listed all of the groups and activities for the month. Recreation groups are listed according to the schedule for the day. A typical day included: Devotion Group; Coffee/Tea and Snacks; Arts & Crafts; Exercise; Room visits; Visits, hydration/snacks; Music Therapy; Trivia; Movie. At the top of the schedule is the following: "Track II Group Therapy will be offered on Monday-Wednesday-Friday-11a.m. in the Lower Dining Room" and "Individual Therapy is offered during the week to anyone that needs it."

B. These groups were not offered during the survey because there were no patients on Track II.

C. RN 1 was interviewed on 9/26/11. She stated that patients went to therapy when they were on Track II. She confirmed that there were no Track II patients that day.

D. In an interview on 9/27/11 at approximately 1p.m., regarding active treatment, the Director of Social Work Services stated that social work runs the Group Therapy groups and does a weekly mini mental status evaluation on patients. She said the group notes would be in the patient's chart if groups were done. She stated that Level II Groups and the Individual Psychotherapy groups are voluntary and it is up to the patient to participate.

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

I. Provide Master Treatment Plans for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) that addressed the problems identified by the admitting physician at admission. The treatment plans were not individualized, lacked measurable goals and clearly defined treatment modalities, and did not assist the team in identifying those patients who might not be able to benefit from treatment. The absence of interdisciplinary psychiatric Master Treatment Plans results in lack of focus for treatment for psychiatric problems, and potentially delays patient's recovery. (Refer to B118)

II. Provide an active treatment program except for medication prescription and management for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Patients were enrolled in treatment regardless of their cognitive capacity to benefit from the assigned modalities. Groups that were provided were social and physical skill related and were not related to specific, measurable goals on treatment plans. Groups were optional and fewer than 50% of the observed patients on the unit attended. (Refer to B125-I). In addition, the facility failed to provide necessary adaptive measures and suitable treatment modalities for 1 active sample patient (A6) who was blind. (Refer to B125-I.8). Lack of an active psychiatric treatment program results in patients being hospitalized without determination of suitability for treatment and without appropriate treatment modalities for recovery. Failure to provide adequate accommodations for blind patients compromises these patients' ability to participate in treatment.

IV. Follow acceptable standards of practice and facility policy for manual holds and chemical restraint for 1 active sample patient (A5) and 4 additional patients chosen for review of restraint procedures (R1, R2, R3, R4,). Failure to clearly define the parameters of chemical restraint and follow through with complete documentation is a violation of patients' rights to be free from unnecessary restraint. (Refer to B125-II)

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets in a descriptive fashion for 4 of 8 active sample patients (A3, A4, A6 and A8). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapy.

Findings include:

A. Record Review:

1. Patient A3. In the Psychiatric Evaluation dated 8/31/11, assets only included "survival capacity." This is not a descriptor of patient specific characteristics that may be used to inform treatment planning.

2. Patient A4. In the Psychiatric Evaluation dated 8/19/11, assets only included "survival capacity." This is not a descriptor of patient specific characteristics that may be used to inform treatment planning.

3. Patient A6. In the Psychiatric Evaluation dated 7/13/11, assets only included "survival capacity." This is not a descriptor of patient specific characteristics that may be used to inform treatment planning.

4. Patient A8. In the Psychiatric Evaluation dated 9/20/11, assets only included "supportive family." This is not a descriptor of patient specific characteristics that may be used to inform treatment planning.

B. Interview

In an interview on 9/27/11, the Medical Director stated that it was hard with cognitively impaired patients to identify personal assets useful in their treatment.

Based on record review and interview, the facility failed to develop interdisciplinary Master Treatment Plans which included specific patient problems; specific, individualized patient goals; and psychiatric treatment interventions for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The recreational therapy, social services, and various nursing diagnoses forms were created separately with goals and interventions on preprinted plans. The goals were not specific, measurable, behavioral changes expected for the patient. The interventions were generic staff functions not directed to individual needs of the patient. There was a separate form for the psychiatrist to complete at the time of the admission assessment which included diagnoses and goals and interventions for medical staff. These were not found on any of the interdisciplinary treatment plan documents. The absence of interdisciplinary psychiatric Master Treatment Plans results in lack of focus for treatment for psychiatric problems, potentially delaying patients' recovery.

Findings include:

A. Record Review (date range of the various documents of the treatment plan in parentheses).

1. Social Services Goals, Objectives, and Interventions.

a. The goals on the "Social Services" plan were identical for patients A1 (dated 9/23-25/11), A2 (9/16-19/11), A3 (dated 8/31-9/5/11), A4 (dated8/23-9/18/11), A5 (dated 9/21-23/11), A6 (dated 7/19-23/11), A7 (9/14-19/11), and A8 (dated 9/20/11): "Short-term Goal: Patient's rights will be upheld throughout inpatient hospitalization. Family issues will be identified, addressed and/or resolved while patient is hospitalized." "Long-term Goal: Patient will be discharged to a safe and appropriate environment."

b. The objectives and interventions were identical on all 8 treatment plans, A1, A2, A3, A4, A5,A6, A7, and A8): 1- "Objective, Patient Will: Patient's rights will be upheld throughout inpatient hospitalization." Interventions: "A psycho-social assessment will be completed within 72 hours of admission." "A MMSE [mini mental status examination] will be administered..." "Social services will identify any issues regarding patient rights..." "Any problems with patient rights...will be addressed ..." "Social Services will work with the family..." 2 "Objective, "Patient Will: Patient will be discharged to a safe and appropriate environment:" Interventions: "Social Services will facilitate discharge." 3. "Objective, Patient Will: Patient's family issues will be addressed and/or resolved while patient is hospitalized." Interventions: "...assess family dynamics..." "Family will be invited to attend treatment team..." "Complimentary family counseling will be offered..."

2. Recreational Therapy, Goals, Objectives, and Interventions

a. The goals on the "Recreational Therapy" plan were identical for patients A1, A2, A3, A4, A5, A6, A7, and A8: "Short-term Goal: Patient will participate in small or large group programs 4 to 5 times per week." "Long-term Goal: Patient will be able to maintain social skills as evidenced by participation in recommended recreation therapy programs." "Patient will have a decrease in problem behaviors in order to be able to transfer to a less restrictive setting."

b. The objectives were identical on all 8 treatment plans: "Objectives, Patient Will: 1 "Patient will participate in small or large group programs 4-5 X's per week [note: this is identical to the short term goal];" 2 "Patient is recommended for Track 1 [groups for more cognitively impaired patients] [or] Track 2 [patients with more cognitive ability to participate].

c. Interventions were: "Staff will facilitate patient s participation in activity programs as evidenced by accompanying patient to group room. Activity Staff will facilitate the patient's participation in Track 1 activities: One on one activities; Small groups [men or women];Special events; Book group; Board games; Reminiscence Group; Relaxation Group; Pet therapy; Gardening; Exercise; Arts and Crafts; Spirituality; Music Therapy; Independent Activities. [these items may be checked for each patient];" "The following activities in addition will be offered to Track 2 patients: 1.Individual Therapy, 2. Nursing edu [education], 3. Nutritional edu, 4. Pharmacy education." These last 4 interventions were not appropriately listed under the RT interventions.

3. Nursing Goals and Interventions

Nursing goals and interventions were listed on preprinted forms for various nursing diagnoses the nursing diagnosis was not always listed.

Examples include:

a. Patient A1 Goals and Interventions:
"Short-term Goal: Patient will maintain adequate nutritional status while hospitalized." Interventions: "Patient will be assessed by dietary for difficulty chewing or swallowing. Refer to speech therapy as indicated. Refer to dietician as indicated. Weight [sic] patient on admission, the day after admission and weekly or per MD order. Weight loss or gain of + or - 3lbs. will be referred to the Nutritional Risk Committee. Provide supplements as ordered."
"Short-term Goal "Patient's behaviors [sic] will decrease or stop within 10 days of admission." Interventions: "Monitoring Q 15 min [or] 1:1. Medications as ordered. Rule out medical causes of behavior. Maintain secure environment [written in]. Provide quiet area for patient to de-escalate. [Written in]. Redirect in a calm manner [written in]. Med review prn [written in]."
"Nursing Diagnosis: Alteration in Comfort: Pain" "Short-term Goal: The patient will experience relief of pain as evidenced by: [blanks not filled in]." Interventions: "Assess characteristics of Pain; location, severity on 1-10 or faces scale, type, frequency, precipitating factors, relief factors. Frequency of assessment: [blank]. Eliminate factors that precipitate pain. Offer analgesics per MD order"
"Nursing Diagnosis: At Risk for Complications of Hypertension" "Short-term Goal; Patient's blood pressure will remain within normal limits..." Intervention: "Orthostatic vital signs for 3 days upon admission and as otherwise ordered."
"Nursing Diagnosis: At Risk for Falls" "Short-term Goal:
"Patient will be free from falls with injury..." "Nursing Interventions were: PT/OT screen for patients whose Morse fall risk score is greater than 45. Bed alarm while in bed. Tag alarm. Chair alarm as needed."

b. Patient A2 Goals:
"Patient will maintain adequate nutritional status while hospitalized."
"Patient's behaviors [sic] will decrease or stop within 10 days of admission."
"The patient will demonstrate a decrease in anxiety as evidenced by a reduction in presenting physiological, emotional, and cognitive manifestations of anxiety. The patient will verbalize a relief of anxiety while at [hospital name]."
"Patient will be able to maintain blood glucose levels within a target range by use of medications, diet, and activity level while inpatient at [name of hospital]."
The nursing interventions were all generic nursing tasks. Refer to Patient A1 for examples.

c. Patient A3 Goals: (Patient A3 in on Comfort Care)

"Patient's skin integrity will be restored and maintained through proper interventions..."
"The "Nursing Plan of Care for Comfort Measures" included:
Goal: "Fear related to the dying process Pt and/or family will identify the source of fear related to the dying process."
"The patient will experience relief of pain as evidenced by: Verbal reports of relief of pain [or] Less autonomic responses to pain..."
The nursing interventions were all generic nursing tasks. Refer to Patient A1 for examples.

d. Patient A4 Goals:
"Nursing Diagnosis: Anxiety" "The patient will demonstrate a decrease in anxiety as evidenced by a reduction in presenting physiological, emotional, and cognitive manifestations of anxiety. The patient will verbalize a relief of anxiety while at [hospital]."
"The patient will experience control of behavior with the assistance of nursing staff."
The nursing interventions were all generic nursing tasks. Refer to Patient A1 for examples.

e. Patient A5Goals:
"Patient's skin will remain clean and intact with the use of prevention measures during inpatient stay..."
"Patient will be able to maintain blood glucose levels within a target range by use of medications, diet, and activity level while inpatient at..."
"Patient's behaviors will decrease or stop within 10 days of admission."
The nursing interventions were all generic nursing tasks. Refer to Patient A1 for examples.

f. Patient A6 Goals: (Patient A6 is blind.)
Goal: "Patient's behaviors [sic] will decrease or stop within 10 days of admission."
For this goal Interventions included: "Keep blinds open during waking hours. Orient to facility. Place pt by window for sense of sunshine." [There was no mention that the patient was blind. The only reference on the treatment plan document that she was blind was on the pre printed list of Recreational Therapy interventions: "Pt is blind. Adaptive Equipment [written in]."
Goal: "Patient will be free from falls with injury while an inpatient..."
Nursing interventions included: PT/OT screen for patients whose Morse fall risk score is greater than 45, Bed in low position for at risk patients while in bed, Bed alarm while in bed. Chair alarm as needed, Monitor and report changes in gait to MD/NP/PA"

g. Patient A7 Goals:
"Patient's behaviors will decrease or stop within 10 days of admission."
"Assess patient's potential for violence and past history of violence."
The nursing interventions were all generic nursing tasks. Refer to Patient A1 for examples.

h. Patient A8 Goals:
"The patient will demonstrate a decrease in anxiety as evidenced by a reduction in presenting physiological, emotional, and cognitive manifestations of anxiety."
The nursing interventions were all generic nursing tasks. Refer to Patient A1 for examples.

4. The "Physician Plan of Treatment" was a one page document completed at admission.
An example of the form for Patient A7 includes the following:
"Reason for Admission: aggression."
"DSM-IV Diagnosis; Axis I: Dementia, likely vascular. Mood NOS;" "Axis II: Defer;" "Axis III: See H&P; " Axis IV: Conflicts with Environment ;" "Axis V: GAF= 20."
"Short-term Goal:" "Decreased Aggression," "Long-term Goal:" "Decreased Aggression. "
There were no interventions for medical staff on any of the treatment plan documents for 8 of 8 sample patients A1, A2, A3, A4, A5, A6, A7, and A8.

C. Interview

In an interview on 9/28/11 at approximately 10a.m., the Director of Nursing agreed that the treatment plans were more like nursing care plans and did not include much about psychiatric care and treatment.

I. Based on record review and interview the facility failed to provide an active treatment program except for medication prescription and management for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Patients were enrolled in treatment regardless of their cognitive capacity to benefit. Patients with both psychiatric diagnoses and severe cognitive impairment were admitted for treatment. Groups that were provided were social and physical skill related and were not related to specific, measurable goals on treatment plans. Groups were optional and fewer than 50% of the observed patients on the unit attended. Lack of active psychiatric treatment resulted in patients being hospitalized without determination of suitability for treatment and without the necessary treatment modalities for recovery, potentially delaying their improvement.

Findings include:

A. Record Review

1. In the September 2011 Program Calendar, only 4 hours of active treatment programming for psychiatric issues was listed for a each week. These groups were not offered during the survey.

2. In the September 2011 Program Calendar, the activities and structured groups were typical recreational and memory preservation and socialization groups, not psychiatrically oriented treatment.

3. Patient A1, "Dementia, Vascular Type with Behavioral Dyscontrol. History of Bipolar disorder. Must consider fronto-temporal dementia as well." Patient A1 had a Mini-Mental Status Examination Score of 15/30 consistent with Moderate Dementia. Patient A1 received only Recreational Therapy groups and medication management. The Patient Activity Participation Record in the chart showed only limited attendance at the scheduled activities. No other groups or therapies were documented in the chart.

4. Patient A2, "Dementia, Alzheimer's type with vascular component, with anxiety, paranoia, depressive disorder NOS." Patient A2 had a Mini-Mental Status Examination Score of 15 of 28, consistent with Moderate Dementia. Patient A2 received only Recreational Therapy Groups and medication management. The Patient Activity Participation Record showed only limited attendance at the scheduled activities.

5. Patient A3 "Severe Alzheimer's Dementia with aggression". Patient A3 had a Mini-Mental Status Examination Score of 10/30 consistent with Moderate to Severe Dementia. Patient A3 initially showed limited attendance at groups as documented on the Patient Activity Participation Record. After 9/21/11 he was receiving comfort care measures only.

6. Patient A4, "Dementia, considered mixed in origin. Mood Disorder NOS. Anxiety Disorder NOS." Patient A4 had a Mini-Mental Status Examination score of 4/30 consistent with Severe Dementia. Patient A4 received only Recreational Therapy Groups and medication management. Patient Activity Participation Record shows only limited attendance at the scheduled activities.

7. A. Patient A5 had a diagnosis of "Paranoid Schizophrenia complicated by hypoxic encephalopathy, chronic for several years with resultant mild dementia." His Mini-Mental Status score was 13/20. Patient A5 was assigned to Treatment Track 1. Only patients on Track 2 received group psychotherapy and individual therapy. Patient A5 received only psychiatric medications. He was re-admitted for his fourth admission on 9/20/11. He had failed placement 10 days after discharge. The only other activities noted in his record were Games and Trivia, Reminisce/Spirit, Short Stories/Poems, Cooking and Hydration, News and Discuss, Movie Matinee/TV, Stations/patio/out. [Sic]. These activities were provided by RT2.

Patient A5 was interviewed on 9/26/11 after Trivia Games. He said he was not as "stupid" as the other patients and the activities were not helping him with his goal which was to return to living in his apartment. He stated he like RT2 because she was the only one "who did things with them."

MD1 was interviewed regarding this patient. She stated he had a progressive dementia due to recurrent hypoxia. She stated he was more impaired than he realized. I asked why he was not in Track 2. She said he did not benefit from therapy at his last admission.

8. Patient A6 had a diagnosis of "Mood disorder NOS, rule out bipolar affective disorder, depressed, consider early dementia" and was blind. Her initial Mini-Mental Status score was 14/25 with poor effort due to her symptoms. She was assigned to Treatment Track 1. Record review revealed that she participated in the same type of diversional groups as patient A5 (above). She received medication management. She did not receive group or individual psychiatric treatment. She did not receive materials appropriate for a blind patient, such as taped patient education materials.

Patient A6 was interviewed on 9/26/11 in the day area. She said she enjoyed the activities but wasn't attending any groups for depression. She explained that RT2 helped her with activities because she is blind. She said "they are trying to find a home for me near my husband".

9. Patient A7, "Dementia, likely vascular type, mood disorder NOS." Patient A7 had a Mini-Mental Status Examination score of 4/30. Patient A7 received only medication management and Recreational Therapy Groups. The Patient Activity Participation Record showed limited attendance at the scheduled activities.

10. Patient A8 received a diagnosis of "Bipolar affective disorder, depressed by history, dementia seems likely at this point, mild to moderate." Her Mini-Mental Status Examination score was 27/30 consistent with a normal examination. She was admitted with stated suicidal ideation and was placed on suicide precautions. Record review revealed she received medication management and attended groups similar to patients A5 and A6. She did not receive group or individual psychotherapy. She did not receive any other documented assessment of her suicidal ideation while remaining on suicide precautions.

Patient A8 was interviewed on 9/28/11. She said she would be leaving soon. She said she had help from the social worker with her family but did not have individual or group therapy.

B. Additional Interviews

1. In an interview at 2:45 p.m. on 9/27/11, the Director of Recreation Therapy and the Recreation Therapist acknowledged that RT's provides most of the programming for the patients. The RT Director noted this was "more of a dementia hospital" and stated that groups were geared to this level except for those groups provided by Social Work to the Track II patients. Both staff stated that the patients' attendance was voluntary and that typically about half of the patients were active attendees in their activities.

2. In an interview on 9/27/11 at approximately 1p.m., the Director of Social Work Services stated that the role of Social Work in active treatment was to "monitor patient rights, do discharge planning and coordinate care with the family." She noted that Social Work provides the Group Therapy groups and does a weekly mini mental status evaluation on patients. She said the group notes would be in the patient's chart if groups were done. There was no specific family therapy offered. She stated that Level II Groups and the Individual Psychotherapy groups were voluntary and it was up to the patient to participate. She stated that there was no Social Work coverage on weekends.

II. Based on record review, policy review and interview, the facility failed to ensure that chemical restraints and physical holds were adequately documented in the medical record and that patients' rights to be free of restrictive procedures were protected.

A. There were 16 incidents of chemical restraint and 2 physical restraints reported for a total of 12 patients during the 3 months prior to the survey. The chemical restraint and physical hold records of one active sample patient (A5) and 4 discharged non sample patients (R1, R2, R3, and R4) were reviewed. Medications used for chemical restraint included Haldol, Ativan, and Zyprexa. Two of 5 records reviewed included a physician order which did not note the route of administration (A5 and R2). There was no order found on the chart for the physical hold for Patient A5.

B. There was a special form for "Documentation for Use of Behavioral Medications;" this form was used for medication to be given one time and there was a lack of clarity as to when the use of the medication was considered a chemical restraint and when it was not.

C. The "One Hour Seclusion and Restraint Evaluation" forms were not found on 2 of 5 charts (A5 and R4); on 3 of the 5 charts (R1, R2, and R3) the forms were signed by RNs who had only brief training to do a face-to-face evaluation. A prn order may have been given as a chemical restraint plus a physical hold with no order for Patient A5. A later stat (now) order for chemical restraint was thought to be the written order for the medication at 1:30p.m., if so, the dose of the order was twice the dose given.

The failure to clearly define the parameters of chemical restraint and follow through with complete documentation including proper physician orders results in a potential violation of patients' right to be free from restraint; the failure to document the route of administration of the chemical restraint results in physicians, via inappropriately written orders, giving nurses prescriptive authority for antipsychotic medication being used as a means of chemical restraint; and the failure to document a face to face evaluation of the physical and mental status of the patient within one hour of a restraint procedure results in potential failure to detect physical or emotional injury from the procedure.

Findings include:

A. Document Review

1. A handwritten list was obtained from the Director of Nursing for all restraints for June,
July and August, 2011. For June, 7 patients were listed with a total of 10 incidents of
chemical restraint and one physical restraint; for July, 3 patients were listed for a total of 4 incidents of chemical restraint and 1 incident of physical hold; for August, a total of 2 patients were listed with a total of 2 incidents of chemical restraint.

2. Patient A5 was placed in a physical hold to walk to his room and given Haldol 5 mgm Ativan 1 mgm IM [intramuscular] on 7/23/11 at 1330 [1:30pm]. The nursing note read: "Pt [patient] came out of room yelling threatening, slamming counter with fist, pt unable to stop talking to listen. CPI [Crisis Prevention and Interventions] hold to walk pt to his room & administer Haldol 5 mgm/Ativan 1 mgm IM per new prn [as needed] orders. Pt remained in his room for 45 min." This medication may have been a prn order in the chart (see nursing note). PRN orders are not to be used for chemical restraint. A medication order for a chemical restraint, dated 7/23/11 at1805 [6:05pm] on the "Documentation for Use of Behavioral Medications" form read: "Haldol 10 mgm and Ativan 2 mgm" without designating whether the medications were to be administered PO [by mouth] or IM; if this order was for the medication given at 1:30pm, there is a discrepancy in the dose; it is twice the dose actually given. There was no order for the physical hold found on the chart. There was no "One Hour Seclusion and Restraint Evaluation" form in the chart.

3. Patient R1 was given Haldol 5 mg/Ativan 1 mg IM At 1015 on 7/5/11 as a chemical restraint for "Agitation - combative - unable to redirect - kicking - danger to self/others;" according to the "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation" form. No physician order for these medications was documented. Patient R1 also had physician orders on 7/13/11 at 1800 (6pm) on the "Physician's Orders" form for "Haldol 5 mgm PO X [times] 1 now for aggressive agitation" and "Ativan 1 mgm PO X 1 now for aggressive agitation." There were also orders on "Documentation for Use of Behavioral Medications" forms on 7/23/11 at 1640 (4:40pm) for "5 mgm Zyprexa PO X 1 now for [increased] agitation" and on 7/23/11 at 2350 (11:30pm) for " Haldol 5 mgm IM X 1 now for agitation/combativeness" and "Ativan 1 mgm IM X 1 now for agitation/combativeness." It was not clear from these orders whether or not any of these medications were considered chemical restraints. The One Hour Evaluation form was signed by an RN with only brief training to do the one hour assessment.

4. Patient R2 was given Haldol 5 mgm/Ativan 1 mgm IM as a chemical restraint on 7/20/11 at11:30am for "[increased] anxiety/pacing/escalating/exit seeking/unable to redirect, according to the "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation" form. The physician order was on a "Documentationfor use of Behavioral Medications" form; the order was "Haldol 5mg (PO/IM circled) X 1now for [increased] anxiety" and "Ativan 1 mg (PO/IM circled) X 1 now for [increased] anxiety." The One Hour Evaluation form was signed by an RN with only brief training to do the one hour assessment.

5. Patient R3 was given a chemical restraint (no medication or dose noted given) on 6/27/11 at 1645 (4:45pm) for "pt attempting to choke staff, hitting & kicking;" according to the "One Hour Seclusion and Restraint Evaluation" form. The nursing note on 6/27/11 at 2045(8:45pm) stated: "Pt. bowel tones present and active. Pt. incontinent in adult briefs, pt.unsteady on his feet. Pt became extremely agitated at 1630, Dr. [name] notified. HS [before sleep] Haldol given earlier [than usual] with no results. Pt attempted to choke staff member and continued to hit and kick. Dr notified 1mg of Ativan then given. New order received for Nicotine patch...Will continue with current POC [plan of care]..." The One Hour Evaluation form was signed by an RN with only brief training to do the one hour assessment.

6. Patient R4 was given 10 mg of IM Zyprexa on 8/24/11. The "Documentation for Use of Behavioral Medications" form on 8/24/11 at 2130 [9:30pm] listed reasons for use of behavioral medications on a check list as "anxiety, agitated, danger to others, disoriented confused, violent, hitting, kicking, biting, throwing, unable to follow instructions, and threatening roommate." The order was for "Zyprexa 10mg IM X 1 now for aggressive agitation." A physician note on 8/25/11 stated..." The patient has been having some concerns about agitation, threatening people, and doing some grabbing and things like that on the unit. She ended up getting 10mg of IM Zyprexa last night around 9:30pm..." There was no "One Hour Seclusion and Restraint Evaluation" form on the chart.

7. The Seclusion and Restraint Policy, N.S.5.5, updated May 20, 2009, included the following: Page 1 "RESTRAINT:...a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition...(CFR482.13)" "CHEMICAL RESTRAINT: The administration of a medication used for rapid control of psychiatric symptoms or behaviors that represent a high potential for danger to the patient or others."
Page 3 "5. One Hour Face to Face Evaluation Assessment" "A physician, LIP [licensed independent practitioner], or Qualified RN [QRN] must see and evaluate the need for restraint or seclusion within 1 hour after the initiation of this intervention" "The QRN has gone through specialized training in order to perform the One Hour Face to Face Evaluation Assessment" "a. The QRN must have at least 2 years of nursing experience in an acute care setting or psychiatric facility." "b. The QRN must be CPI (Crisis Prevention and Interventions) trained" "c. The QRN will attend training in Seclusion and Restraints and Performing the One Hour Face to Face Evaluation Assessment prior to being able to complete the assessment."

B. Interviews

1. In an interview on 9/27/11 at approximately 3p.m., the Director of Nursing stated, "I do the training to be a QRN [qualified registered nurse] immediately after the nurse's CPI training. I go over the forms and how to fill them out as well as how to do the evaluation. There is no other special training for RNs to do face to face evaluations." The training does not include physical and mental assessment of the patient.

2. In an interview on 9/28/11 at 10:15a.m., the Director of Nursing was asked about how the decision is made about whether a 'behavioral medication' is a chemical restraint or not. She stated "I make that decision." She stated that she does not have written criteria, but makes a judgment about "which medication is for chemical restraint and which is not."

3. In an interview on 9/27/11 at approximately 3p.m., when asked whether physical holds are always documented as a restraint, the DON stated, "My nurses are not very good at that."

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

I. Ensure that all nursing staff had adequate experience and education in psychiatric nursing in order to create a therapeutic environment for psychiatric patients; provide necessary adaptive measures and suitable treatment modalities for patients who were blind; provide interpersonal care and supervision for suicidal patients; provide psychiatric nursing interventions for patients who are disruptive; and accurately document all aspects of patient care, including those who are a fall risk. Lack of experience and education compromises care for patients with psychiatric problems or other special needs. (Refer to B148-I)

II. Employ psychiatric technicians to assist with active psychiatric treatment. Auxiliary nursing staff was all CNAs (certified nursing assistants) with training and experience to provide personal care with activities of daily living for patients with physical problems; they were not trained and experienced to provide care for psychiatric patients. This failure deprives patients of psychiatric care by trained and experienced mental health workers/psychiatric technicians. (Refer to B150).

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

I. Provide adequate numbers of qualified nursing staff to provide active psychiatric treatment. There were not enough registered nurses to provide coverage for vacation, illness, and increased patient acuity. When additional staff were needed, nurses were asked to work overtime hours. This failure results in potentially depriving patients of nursing staff who are well rested and alert to their care and treatment needs. (Refer to B150)

II. Employ psychiatric technicians to assist with active psychiatric treatment. Auxiliary nursing staff were all CNAs (certified nursing assistants) with training and experience to provide personal care with activities of daily living for patients with physical problems; they were not trained and experienced to provide care for psychiatric patients. This failure deprives patients of care for activities of daily living and assistance with implementation of psychiatric treatment plans by trained and experienced mental health workers. (Refer to B150)

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

I. Ensure that 5 of 5 active sample patients (A1, A2, A3, A4 and A7) who were admitted for behavior problems related to dementia with secondary psychiatric diagnoses had the cognitive capacity to benefit from psychiatric care. This failure prevents patients from receiving services at the appropriate level of care. (Refer to B099-I)

II. Ensure that 3 of 3 active sample patients with documented dementia, but with a primary diagnosis of a psychiatric problem (A5, A6 and A8), received active psychiatric treatment. There was no documented treatment for these patients except medication prescription and medication management. Failure to provide psychiatric treatment modalities for patients with psychiatric diagnoses results in patients with psychiatric problems not receiving active treatment for their primary psychiatric problems. (Refer to B099-II)

III. Ensure that 17 of 17 patients whose death records were reviewed (E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, E15, E16, E17) and 1 of 8 active sample patients (A3) whose physical conditions did not permit active psychiatric treatment were transitioned to appropriate levels of care. This resulted in palliative care being provided at an acute care level for these patients. (Refer to B099-III)

IV. Ensure that interdisciplinary Master Treatment Plans included specific, individualized, patient goals and psychiatric treatment interventions for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This failure prevents those patients who could benefit from psychiatric treatment from receiving all of the therapeutic modalities that might reduce their length of stay and prevents the team from identifying those patients who might not benefit from treatment. (Refer to B118)

V. Provide an active treatment program except for medication prescription and management for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Patients were enrolled in treatment regardless of their cognitive capacity to benefit. Patients with both psychiatric diagnoses and severe cognitive impairment were admitted for treatment. Groups that were provided were social and physical skill related and were not related to specific, measurable goals on treatment plans. Groups were optional and fewer than 50% of the observed patients on the unit attended. In addition, the facility failed to provide appropriate accommodations for patient A6 who was blind, appropriate safety measures for patient A8 who had suicidal ideation.
(Refer to B125-I)

VI. Ensure that chemical restraints and physical holds were adequately documented in the
medical record and that patients' rights to be free of restrictive procedures were protected
for 4 restraint sample patients (R1, R2, R3, R4) and 1 active sample patient (A5). (Refer to B125-II)

VII. Ensure that all nursing staff had adequate experience and education in psychiatric nursing in order to create a safe therapeutic environment for psychiatric patients. Lack of nursing staff's psychiatric experience and education compromises care for patients with psychiatric problems or other special needs other than physical problems. (Refer to B148)

VIII. Ensure that there were adequate numbers of qualified Registered Nurses, Licensed Practical Nurses, and Mental Health Workers to provide a safe and therapeutic environment for psychiatric patients. Lack of psychiatric nursing staff deprives patients of care for psychiatric and emotional problems. (Refer to B150)

Based on document review and interview, the Director of Nursing failed to:

I. Ensure that all direct care nursing staff had adequate experience and education in psychiatric nursing in order to create a therapeutic environment for psychiatric patients; provide necessary adaptive measures and suitable treatment modalities for patients who were blind; provide interpersonal care and supervision for suicidal patients; provide psychiatric nursing interventions for patients who are disruptive; and accurately document needed care for patients with high "fall risk" scores. Lack of nursing staff's psychiatric experience and education compromises care for patients with psychiatric problems or other special needs other than physical problems.

Findings include:

A. Failure to provide a therapeutic environment and nursing care for psychiatric patients:

1. The list of the 5 Registered Nurses on the staff provided by the DON, with their education and experience noted by the DON, reads: One nurse who "has worked here over a year. Is a QRN [qualified RN], working on BSN [bachelor of science in nursing] Prior psych experience in a Veteran's Home on the Psych Wing as an LPN;" One nurse who "has worked here 3 years. Is a QRN Associates Degree in Nursing Worked in Neuro Critical Care for many years;" One who "started here in August 2011 Associates Degree in Nursing Working on BSN Worked for a year and a half in the Emergency Room;" One who "Has worked here for over one year. Is a QRN Associates Degree in Nursing. Bachelors Degree in Nursing 6/2/11. Working on MSN. Worked on an Alzheimer's Unit prior to working here;" One nurse who "Has worked here 2 years. Is a QRN Associates Degree in Nursing worked at the State School & Hospital for many years. Worked in long term care." 2. The list of "CNA Competencies" provided by the DON includes only physical care of patients

2. A document provided by the DON, "C.N.A. Competencies" includes:
"The following needs to be completed by 6 weeks of hire and annually therafter [sic] the month prior to your annual evaluation. You need to be observed by a charge nurse or a nurse administrator to be signed off." The "ADL's Tasks" are: "Oral Care, Shaving, Denture care, Peri Care/changing attends, and bathing" The "Transfers etc. Tasks" are "Transfers [from bed to chair], Turning, Use of Gait Belts, Hoyer Lift," "Meals Tasks" are: "Tray set up, Thickening liquids, Feeding patients, I&O, Recording Intake" "Miscellaneous Tasks" are "Making beds, Vital Signs, Admit a patient, Discharge a patient, Belongings, Observations. Documentation-all blanks are filled in with appropriate information shower, meal percent Etc. all noted behaviors are marked and documented on using appropriate verbiage"

3. In an interview on 9/27/11 at 10:00am, LPN1 stated that she is a PRN (as needed) employee. She was formerly full time. She stated that her orientation to the hospital was that she was "given some verbal information and followed somebody around for a couple of shifts."

4. In an interview with the Director of Nursing and the Associate Director of Nursing on 9/27/11 at approximately 1:45p.m., the DON stated that the nursing staff was not trained psychiatric nurses, but were generally medical/surgical nurses. She acknowledged that the nursing staff and CNA's do no counseling or psychiatric treatment. Nurses are trained to do mental status examinations when the patients were admitted, which were followed by a social work MMSE [Mini Mental Status Examination]. Follow-up MMSEs are done by Social Work and not nursing. RNs do not do medication education; the Treatment Planning LPN may run a medication group for Track II patients.

5. In an interview on 9/27/11 at approximately 3p.m., the DON stated that there is no schedule of inservice education; "I do the CPI training and have pharmacy students or others come into the nursing meetings for educating the nurses."

B. Failure to provide for a blind patient [

1. Patient A6 is blind. On the nursing care plan, one goal was: "Patient's behaviors [sic] will decrease or stop within 10 days of admission." For this goal one nursing interventions included: "Keep blinds open during waking hours. Orient to facility. Place pt by window for sense of sunshine." There was no mention that the patient was blind. The only reference on the treatment plan document that she was blind was on the pre printed list of Recreational Therapy interventions: "Pt is blind. Adaptive Equipment" was written in. Another nursing goal was "Patient will be free from falls with injury while an inpatient..." The nursing interventions included: PT/OT screen for patients whose Morse fall risk score is greater than 45, Bed in low position for at risk patients while in bed, Bed alarm while in bed. Chair alarm as needed, Monitor and report changes in gait to MD/NP/PA" Here again, there was no mention that the patient is blind.

2. In an interview on 9/27/11 at approximately 2:00pm the DON stated that there were no specific nursing plans or interventions available for patients who are blind or who have other disabilities.

C. Failure to provide interpersonal care and supervision for suicidal patients

1. In an interview on 9/27/11 at approximately 2p.m., the quality improvement director/assistant director of nursing stated that "Nursing does not do a shift or daily suicide assessment, that is up to the psychiatrist;"

2. In order to review the facility's care of suicidal patients, active Patient A8 was reviewed. The patient was admitted with active suicidal thinking and was placed on suicide precautions.
The treatment plan includes preprinted sheets with a Nursing Plan of Care for each of a list of problems. The Nursing Plan of Care for Suicide, which is a generic plan used for any suicidal patient, includes such interventions as: "Provide safe environment"; "Provide close patient supervision by maintaining observation or awareness of patient at all times"; "As able, develop verbal or written contract stating that he/she will not act on impulses to harm herself. Review/update contract prn."; "Assure that individual counseling is ordered for patient."

D. Failure to provide psychiatric nursing interventions for patients who are disruptive

1. Patient A5 was placed in a physical hold to walk to his room and given Haldol 5 mgm Ativan 1 mgm IM [intramuscular] on 7/23/11 at 1330 [1:30pm]., A nursing note read: "Pt [patient] came out of room yelling threatening, slamming counter with fist, pt unable to stop talking to listen. CPI [Crisis Prevention and Interventions] hold to walk pt to his room & administer Haldol 5 mgm/Ativan 1 mgm IM per new prn [as needed] orders. Pt remained in his room for 45 min."

2. Patient R1 was given Haldol 5 mg/Ativan 1 mg IM At 1015 on 7/5/11 as a chemical restraint for "Agitation - combative - unable to redirect - kicking - danger to self/others;" according to the "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation" form. Patient R1 also had physician orders on 7/13/11 at 1800 (6pm) on the "Physician's Orders" form for "Haldol 5 mgm PO X [times] 1 now for aggressive agitation" and "Ativan 1 mgm PO X 1 now for aggressive agitation." There were also orders on "Documentation for Use of Behavioral Medications" forms on 7/23/11 at 1640 (4:40pm) for "5 mgm Zyprexa PO X 1 now for [increased] agitation" and on 7/23/11 at 2350 (11:30pm) for "Haldol 5 mgm IM X 1 now for agitation/combativeness" and "Ativan 1 mgm IM X 1 now for agitation/combativeness." It was not clear from these orders whether or not any of these medications were considered chemical restraints.

E. Failure to accurately document needed patient care for patients with high "fall risk" scores:

1. On 9/27 at approximately 11:45a.m., RN1 was asked about Patient A10, who had a fall risk rating of 110 (high) but was not on the fall risk alert (a special star by the names of fall risk patients on the daily census). She stated that Patient A10 "is unsteady, but actually gets around well; 20 points was added to his fall risk scale because of a [indwelling] catheter" (on admission 5 days prior).

2. The Nursing Diagnosis treatment plan for fall risk states that a fall risk of 45 or above is high enough to need an OT/AT consultation. The daily patient roster included the fall risk of each patient according to the Morse Fall Risk Scale. A special 'star' denoted a "High Fall Risk."
Patients A1 (score=55), A2 (score=55), A6 (score=65), and A7 (score=55) all had a high fall risk score, but no star by their name. Patient A4 (score=23) had a low fall risk score, but had a star by her name.

II. Ensure the proper use and documentation of restraint for 5 of 5 patients reviewed (active sample patient A5 and discharge sample patients R1, R2, R3, and R4). The chemical restraint and physical hold records of one active sample patient (A5) and 4 discharged restraint sample patients (R1, R2, R3, and R4) were reviewed. Medications used for chemical restraint include Haldol, Ativan, and Zyprexa. Two of 5 records reviewed included a physician order which did not note the route of administration (A5 and R2). There was no order found on the chart for the physical hold for Patient A5. There was a special form for "Documentation for Use of Behavioral Medications;" this form was used for medication to be given one time and there was a lack of clarity as to when the use of the medication was considered a chemical restraint and when it was not. A prn order may have been given as a chemical restraint for Patient A5. A later stat (now) order at 6:05pm for chemical restraint was thought to be the written order for the medication at 1:30pm, if so, the dose or the order was twice the dose given. The "One Hour Seclusion and Restraint Evaluation " forms were not found on 2 of 5 charts (A5 and R4); on the other 3 of the 5 charts (R1, R2, and R3) the forms were signed by RNs who had only brief training to do a face to face evaluation; the training did not include physical and mental assessment. The failure to clearly define a chemical restraint and follow through with complete documentation including proper physician orders results in a potential violation of patients ' right to be free from restraint; the failure to insist that the route of administration of the chemical restraint is documented in the physician order results in nurses acting beyond their scope of practice, and the failure to provide and document a face to face evaluation by a qualified professional, including the mental and physical status of the patient, within one hour of the restraint results in potential failure to detect physical or emotional injury from the procedure. (Refer to B125-II)

II. Ensure that RNs were able to participate in developing treatment plans for psychiatric care. The nursing part of the treatment plans were based on nursing diagnoses for physical problems. The absence of individualized patient goals and nursing interventions for care of psychiatric patients results in lack of focus for treatment of any psychiatric problems and potential delay of response and recovery.

Findings include:

A. Record Review

Nursing goals and interventions were listed on preprinted forms for various nursing diagnoses The nursing diagnosis was not always listed.

Examples include:

a. Patient A1 Goals and Interventions:
"Short-term Goal: Patient will maintain adequate nutritional status while hospitalized." Interventions: "Patient will be assessed by dietary for difficulty chewing or swallowing. Refer to speech therapy as indicated. Refer to dietician as indicated. Weight [sic] patient on admission, the day after admission and weekly or per MD order. Weight loss or gain of + or - 3lbs. will be referred to the Nutritional Risk Committee. Provide supplements as ordered."
"Short-term Goal "Patient's behaviors [sic] will decrease or stop within 10 days of admission." Interventions: "Monitoring Q 15 min [or] 1:1. Medications as ordered. Rule out medical causes of behavior. Maintain secure environment [written in]. Provide quiet area for patient to de-escalate. [Written in]. Redirect in a calm manner [written in]. Med review prn [written in]."
"Nursing Diagnosis: Alteration in Comfort: Pain" "Short-term Goal: The patient will experience relief of pain as evidenced by: [blanks not filled in]." Interventions: "Assess characteristics of Pain; location, severity on 1-10 or faces scale, type, frequency, precipitating factors, relief factors. Frequency of assessment: [blank]. Eliminate factors that precipitate pain. Offer analgesics per MD order"
"Nursing Diagnosis: At Risk for Complications of Hypertension" "Short-term Goal; Patient's blood pressure will remain within normal limits..." Intervention: "Orthostatic vital signs for 3 days upon admission and as otherwise ordered."
"Nursing Diagnosis: At Risk for Falls" "Short-term Goal:
"Patient will be free from falls with injury..." "Nursing Interventions were: PT/OT screen for patients whose Morse fall risk score is greater than 45. Bed alarm while in bed. Tag alarm. Chair alarm as needed."

b. Patient A2 Goals:
"Patient will maintain adequate nutritional status while hospitalized."
"Patient's behaviors [sic] will decrease or stop within 10 days of admission."
"The patient will demonstrate a decrease in anxiety as evidenced by a reduction in presenting physiological, emotional, and cognitive manifestations of anxiety. The patient will verbalize a relief of anxiety while at [hospital name]."
"Patient will be able to maintain blood glucose levels within a target range by use of medications, diet, and activity level while inpatient at [name of hospital]."
The nursing interventions were all generic nursing tasks. Refer to Patient A1 for examples.

c. Patient A3 Goals: (Patient A3 in on Comfort Care)

"Patient's skin integrity will be restored and maintained through proper interventions..."
"The "Nursing Plan of Care for Comfort Measures" included:
Goal: "Fear related to the dying process Pt and/or family will identify the source of fear related to the dying process."
"The patient will experience relief of pain as evidenced by: Verbal reports of relief of pain [or] Less autonomic responses to pain..."
The nursing interventions were all generic nursing tasks. Refer to Patient A1 for examples.

d. Patient A4 Goals:

"Nursing Diagnosis: Anxiety" "The patient will demonstrate a decrease in anxiety as evidenced by a reduction in presenting physiological, emotional, and cognitive manifestations of anxiety. The patient will verbalize a relief of anxiety while at [hospital]."
"The patient will experience control of behavior with the assistance of nursing staff."
The nursing interventions were all generic nursing tasks. Refer to Patient A1 for examples.

e. Patient A5Goals:

"Patient's skin will remain clean and intact with the use of prevention measures during inpatient stay..."
"Patient will be able to maintain blood glucose levels within a target range by use of medications, diet, and activity level while inpatient at..."
"Patient's behaviors will decrease or stop within 10 days of admission."
The nursing interventions were all generic nursing tasks. Refer to Patient A1 for examples.

f. Patient A6 Goals: (Patient A6 is blind.)
Goal: "Patient's behaviors [sic] will decrease or stop within 10 days of admission."
For this goal Interventions included: "Keep blinds open during waking hours. Orient to facility. Place pt by window for sense of sunshine." [There was no mention that the patient was blind. The only reference on the treatment plan document that she was blind was on the pre printed list of Recreational Therapy interventions: "Pt is blind. Adaptive Equipment [written in]."
Goal: "Patient will be free from falls with injury while an inpatient..."
Nursing interventions included: PT/OT screen for patients whose Morse fall risk score is greater than 45, Bed in low position for at risk patients while in bed, Bed alarm while in bed. Chair alarm as needed, Monitor and report changes in gait to MD/NP/PA"

g. Patient A7 Goals:

"Patient's behaviors will decrease or stop within 10 days of admission."
"Assess patient's potential for violence and past history of violence."
The nursing interventions were all generic nursing tasks. Refer to Patient A1 for examples.

h. Patient A8 Goals:

"The patient will demonstrate a decrease in anxiety as evidenced by a reduction in presenting physiological, emotional, and cognitive manifestations of anxiety."
The nursing interventions were all generic nursing tasks. Refer to Patient A1 for examples.

4. The "Physician Plan of Treatment" was a one page document completed at admission.
An example of the form for Patient A7 includes the following:
"Reason for Admission: aggression."
"DSM-IV Diagnosis; Axis I: Dementia, likely vascular. Mood NOS;" "Axis II: Defer;" "Axis III: See H&P; "Axis IV: Conflicts with Environment ;" "Axis V: GAF= 20."
"Short-term Goal:" "Decreased Aggression," "Long-term Goal:" "Decreased Aggression. "
There were no interventions for medical staff on any of the treatment plan documents for 8 of 8 sample patients A1, A2, A3, A4, A5, A6, A7, and A8.

B. Interview

In an interview on 9/28/11 at approximately 10a.m., the Director of Nursing agreed that the treatment plans were more like nursing care plans and did not include much about psychiatric care and treatment.

III. Ensure that there were adequate numbers of qualified Registered Nurses, Licensed Practical Nurses, and Mental Health Workers to provide a safe and therapeutic environment for psychiatric patients. Lack of psychiatric nursing staff deprives patients of care for psychiatric and emotional problems. (Refer to B150)

Based on document review and interview, the facility failed to provide adequate numbers of qualified nursing staff to provide active psychiatric treatment. There were not enough staff to provide coverage for vacation, illness, and increased patient acuity. When additional staff were needed, nursing staff volunteered to work overtime hours; there was no list of on-call staff; overtime was by current staff. There were no psychiatric technicians to assist with active psychiatric treatment. Auxiliary nursing staff was all CNAs (certified nursing assistants) with training and experience to provide personal care with activities of daily living for patients with physical problems; they were not trained and experienced to provide care for psychiatric patients. These failures deprive patients of psychiatric care by trained and experienced ,mental health workers/psychiatric technicians and result in potentially depriving patients of nursing staff who are well rested and alert to their care and treatment needs.

A. Document Review

1. The nursing needs assessment for the ward, completed by the DON on the first day of the survey, showed that 13 patients required partial assistance and 7 required total assistance by the staff with Self Care; 11 patients required partial assistance with mobility and one was bedfast; 7 patients required diabetic checks and 1 required catheter care; 7 patients were potentially assaultive; 3 patients were low risk suicidal; 4 patients took medications reluctantly and 1 had medication problems (forced, non voluntary or parental meds); 1 was admitted in the prior 48 hours; 16 were on assault precautions; 17 were on elopement precautions; 9 were on fall precautions; 2 were under 1:1 supervision; 19 were on 15-30 minute checks, and 20 attended activities on the ward, with 1 unable to participate in activities.

2. A document listing nursing staff overtime hours from 7/18/11 to 9/26/11 was provided by the DON. The total hours of overtime by direct care nursing staff was 744.5 hours; divided by 8 hours, this equals 93 8-hour shifts of a total of 210 shifts with at least one staff member working overtime during the 9 weeks recorded.

B. Interview

1. In an interview on 9/27/11 at approximately 1:30p.m., the DON stated that the nursing staff includes 5 RNs, 9 LPNs, and CNAs; there were no psych techs [psychiatric technicians], one RN was new and none of the staff (RNs, LPNs, and CNAs) had psychiatric experience in a hospital setting

2. In an interview on 9/27/11 at 2:20p.m., the DON stated that they "have no additional list of staff who are on call thus, our staff do work quite a lot of overtime."