HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that 1 of 1 patient's closed record for restraint had the restraint documentation related to the patient's restraint procedure. (Closed Record - Patient 8)


The findings are:


On 08/03/16 at 12:00 p.m., review of the closed chart for Patient 8 revealed the patient was admitted on 05/19/16. Review of the patient's chart revealed there was no documentation of the 15 minute observations for the patient during the restraint period dated 05/23/16 for over 25 minutes and no documentation of the type of restraint or technique used. On 08/03/16 at 12:13 p.m., the Director of Quality Performance revealed, "We don't have the 15 minute observation form in the file."

Based on review of the hospital's quality data, interview, and review of the hospital's policies and procedures, the hospital failed to ensure medical errors and adverse patient events were analyzed, causes identified, preventive actions taken, and mechanisms that included feedback and learning throughout the hospital were implemented for 2 of 59 medication variances.


The findings are:


On 8/3/2016 at 10:50 a.m., review of a documented medication variance dated 11/20/2015 revealed "Type: Wrong Patient", but there was no documentation that showed the hospital analyzed the cause(s) and implemented preventive actions to prevent a reoccurrence. On 8/3/2016 at 11:10 a.m., the Director of Performance Improvement, stated, "The only information I have is these papers. I don't remember the investigation since it was in November."

On 8/3/2016 at 11:00 a.m. review of a medication variance dated 4/2/2016 revealed, "Type: Wrong Medication", but there was no documentation the hospital analyzed the cause(s) and implemented preventive actions to prevent a reoccurrence. On 8/3/2016 at 11:15 a.m., the Director of Performance Improvement stated, "The only information I have are these papers."

On 8/3/2016 at 12:10 p.m., review of the hospital's policy, titled, "Incident/Serious occurrence Reporting Risk Management", states "...The Risk Manager or designee will investigate, collect, and maintain this data for reporting ...to...the Quality Management Committee...".

Based on record reviews, interviews, and review of the hospital's policy and procedure, the hospital failed to ensure 4 of 35 open patient charts contained re-assessments post pain medication administration (Patient 2, 24, 25, and 28) and failed to ensure documentation of the patient's vital signs for 1 of 35 open patient charts (Patient 28)


The findings are:


On 08/01/16 at 1:52 p.m., review of Patient 2's chart revealed the patient was admitted on 07/25/2016. Review of the "Medication Education Documentation" form revealed, "Tylenol 650 mg (milligrams) po (by mouth) prn (as needed) q (every) 6 h (six hours) for back pain" was administered on 08/01/16 on a pain scale of 7/10 (seven out of ten) with no post evaluation of the patient's pain documented. On 08/01/16 at 2:00 p.m., the findings were verified by Nursing Supervisor 1. On 08/02/16 at 10:28 a.m., the Director of Admissions revealed, "There is no pain re-assessment policy at present."

On 08/02/16 at 8:50 a.m., review of Patient 24's chart revealed the patient
was admitted on 07/26/16. Review of the patient's "Medication Education Documentation" form revealed, "Tylenol 650 mg po q 6 h prn pain" was administered on 08/01/16 for a pain scale of 7/10 with no evaluation of the patient's documented, and again, on 08/02/16 on a pain scale of 8/10 with no post evaluation of the patient's pain documented. On 08/02/16 at 9:20 a.m., the findings were verified by Nursing Supervisor 1.

On 08/02/16 at 9:25 a.m., review of Patient 25's chart revealed the patient was admitted on 07/23/16. Review of the patient's "Medication Education Documentation" form revealed, "Motrin 600 mg q 6 h prn pain" was administered on 07/27/16 on a pain scale of 7/10 with no post evaluation of the patient's pain documented. On 08/02/16 at 9:45 a.m., the findings were verified by Nursing Supervisor 1.

On 08/02/16 at 10:55 a.m., review of Patient 28's chart revealed the patient was admitted on 07/22/16. Review of the patient's "Medication Education Documentation" form revealed, "Tylenol 650 mg po q 6 h prn pain" with no identified initial pain level. On 08/02/16 at 11:15 a.m., the findings were verified by Nursing Supervisor 1. On 08/02/16 at 10:55 a.m., review of Patient 28 revealed the patient was admitted on 07/22/2016. Review of the patient's admission orders dated 07/22/16 revealed, "Vital signs daily". Review of the "data flow sheet" revealed there was no documentation of the patient's vital signs on 07/30/16. On 08/02/16 at 11:10 a.m., the findings were verified by Nursing Supervisor 1.

Based on observations and interview, the hospital failed to ensure expired patient supplies were removed from patient stock and opened potentially used patient supplies were properly disposed of.(Yankeur)


The findings are:


On 08/01/16 at 11:25 a.m., random observations in the laboratory area revealed the following expired items:
(9) Para-Pak Zn- PVA Formalin expired 07/16
(49) BD Vacutainer push button expired 04/16
On 08/01/16 at 11:26 a.m., the findings were verified by the Chief Executive Officer.





36397

On 8/1/16 at 1:41 p.m., random observations of the crash cart located on Unit 6 revealed an out of package opened Yankeur suction tip (used for removal of excessive secretions) was not covered, and it was connected to the suction machine. On 8/1/16 at 1:42 p.m., Charge Nurse 1 verified the findings.

Based on record review, interview, and review of the hospital's policy and procedures, the hospital failed to ensure a Medical History and Physical was completed within 24 hours after admission for 1 of 35 active patients charts reviewed for care and services. (Patient 9)


The findings are:


On 8/1/16 at 11:30 a.m., review of Patient 9's chart revealed the patient was admitted on 7/26/16 with Bipolar and Depression. Review of the documentation of the patient's history and physical examination in the chart revealed the history and physical examination was completed on 7/28/16. The hospital failed to complete the patient's history and physical within 24 hours. On 8/1/16 at 3:34 p.m., the Director of Admission verified the findings.

Hospital policy and procedure, titled, "Minimum Documentation Requirements", reads, ".....Medical Staff (Physicians): Within the first 24 hours of admission the attending physician shall complete the Initial Psychiatric Evaluation. Within the first 24 hours of admission, the physician or nurse practitioner will complete a History and Physical Examination.....".

Based on record reviews, interviews, and review of the hospital's laboratory and diagnostic policy and procedures, the hospital failed to ensure 1 of 35 active patient charts reviewed for care and services contained available information (laboratory reports) for the physician. (Patient 10)


The findings are:


On 8/1/16 at 12:15 p.m., review of Patient 10's chart revealed the patient was admitted on 7/30/16 with initial laboratory orders. However, there was no evidence of laboratory results for the initial physician laboratory orders dated 7/30/16 on the patient's chart for physician review. On 8/1/16 at 3:30 p.m., the Director of Admission verified the findings. On 8/3/16 at 9 a.m., the laboratory results were still absent.

Hospital policy and procedures, titled, "Laboratory and Diagnostic values and results", reads, "When routine laboratory or diagnostic reports are provided to nursing staff, they should be reviewed as soon as reasonably possible. When routine values or results are received and contain non-critical values or results the nurse will determine if immediate reporting to the physician is appropriate or if any other actions are necessary. The report is placed in the medical record for review and signature by the physician.....".

Based on observations, record reviews, interview, and review of the hospital's policies and procedures, the hospital failed to ensure its drugs and biologicals were secured. (Hospital Unit 2)

The findings are:

On 08/02/16 at 8:50 a.m., random observations of Hospital Unit 2's work area revealed the unit's medDispense system's door was open from 8:50 a.m. to 9:20 a.m., and a sign on the front of the medDispense system's door read,"Never leave door open". On 08/02/16 at 10:00 a.m., Licensed Practical Nurse(LPN) 1 verified the finding. LPN 1 reported that the procedure for administering medications begins with hand hygiene and involves ensuring the door of the medDispense system is closed.

Hospital policy, titled, "medDispense user Instructions for Nurses", reads, "The medDispense machine and a limited number of other patient items ....Remember to close the drawer and log off the medDispense system."

Based on record review and interview, the hospital failed to ensure the person with responsibility for the hospital's dietary department was a full time employee with the responsibility for oversight and monitoring the hospital's dietary department.


The findings are:


During an interview on 8-3-16 at 10:30 a.m., the Director of Plant Operations with the responsibility for the operations for the hospital's dietary department, housekeeping department, and maintenance department, stated, "I work in all three areas as the Director, with 30%(percent) of my time spent in each department with 10% variance. I have a dietician that works two days a week for the clinical side of dietary. I have worked in several restaurants. My hours vary from 6:00 a.m. to 7:00 p.m. each day and on-call each day.

During record review on 8-2-16 at 4:45 p.m. with the Director of Plant Operations, he/she stated, "I was hired six years ago as the Director of Dietary Services. As the years have gone by, I have added responsibility for housekeeping and maintenance. The job description is all we have here that shows each area with my limited areas of responsibility. The technical position with specific functions for dietary include the following: purchasing of food and non-food items including outside services, receipt of and proper storage of food and non-food items, production of daily menu, catering, and special functions; salad bar production, and dishroom operations, identification and completion of processes improvement in food quality, cost control, area improvements, and staffing issues.

During record review on 8-2-16 at 4:30 p.m., review of the Director of Plant Operation's credential file revealed the employee had manager experience at two restaurants and was a food specialist with training as a ServSafe with a 3-18-16 date of expiration.

During an interview on 8-2-16 4:15 p.m., the Chief Executive Officer revealed the employee was hired for the Director of Dietary Services six years ago and then acquired the responsibility for housekeeping and maintenance. Review of the job description revealed the Plan of Operations Manager was responsible for the dietary department, the housekeeping department, and the maintenance department. The job description revealed the Director of Plant Operations is a full time role with the role divided as: Dietary: 1/3 of the job responsibility which is 30% of the Plant Operations Manager's job. Human Resources verified there was no full-time Director for the hospital.

Based on personnel record review and interview, the hospital failed to ensure the infection control officer had formal educational training in infection control from an accredited organization.


The findings are:


On 08/02/16 at 3:00 p.m., personnel review of the infection control officer's file revealed the Infection Control Officer position description was signed on 05/15/16. Review of the infection control educational transcript revealed the Infection Control Officer's file had no evidence that the Infection Control Officer attended any educational training in infection control from an accredited organization. On 08/02/16 at 4:15 p.m., the Infection Control Officer revealed a corporate infection control and prevention training on 08/29/16 to 09/01/16.

Based on observations, interview, and review of the hospital's hand hygiene policy, the hospital failed to ensure 1 of 4 Registered Nurses (RN 1) and 1 of 1 Licensed Practical Nurse (LPN 1) followed acceptable principles for infection control to minimize the potential transmission of infectious agents in the hospital setting.


The findings are:


On 8/2/16 at 8:56 a.m., random observations during medication pass revealed Registered Nurse(RN) 1 retrieve the patient's medication from the Pixis machine, properly prepare the medication, and called Patient 9 to the window for administration after proper identification of the patient: Zoloft 50 milligrams (mg) daily. The patient took his/her medication and returned the small plastic water cup and the medication cup to RN 1. RN 1 placed the cups and the medication packaging into the trash and repeated the process to retrieve medication for another patient (Patient 11). RN 1 failed to perform hand hygiene after providing direct patient care and failed to perform hand hygiene before entering the Pixis machine.

On 8/2/16 at 8:59 a.m., random observations during medication pass revealed RN 1 retrieved the patient's medication from the Pixis machine, properly prepared the medication, and called Patient 10 to the window for administration after proper identification of patient: Protonix 40 milligrams (mg) daily, Lasix 20 mg daily, Wellbutrin XL 300 mg daily, Wellbutrin XL 150 mg daily, and K-Dur 10 milliequivalent (meq) daily. The patient took the medication, returned the small plastic water cup and the medication cup to RN 1, RN 1 placed the cups and the medication packaging into the trash container, performed hand hygiene using hand sanitizer, shook his/her hands dry and repeated the process to retrieve medication for another patient (Patient 12). The RN 1 failed to rub hands until dry after direct care and before entering the pix's machine. On 8/2/16 at 9:04 a.m., RN 1 verified the findings, stating, "I caught myself with the hand hygiene."

Hospital policy and procedure, titled, "Hand Hygiene", reads, ".....Waterless Handwashing products - If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations other than those listed under "Brainwashing" above. (The Behavioral Health setting may not be able to mount alcohol hand rubs accessible to patients but they can be made available to staff. Other non-alcohol based products may be considered). When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry."

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

I. Ensure that Psychiatric Evaluations included an inventory of specific patient assets that could be used in treatment planning for seven (7) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16 and F4). The failure to identify patient assets can impair the treatment team's ability to develop treatment interventions utilizing the individual strengths and personal attributes of each patient. (Refer to B117)

II. Provide comprehensive Master Treatment Plans (MTPs) that included treatment interventions by all members of the interdisciplinary team for seven (7) for eight (8) active sample patients (A2, A11, B4, C4, D3, D14 and E2). The seven (7) patients listed above did not consistently have physician interventions for psychiatric and/or medical problems identified on the plans. Failure to chart specific interventions by all members of the interdisciplinary team on the MTP hampers staff's ability to provide coordinated treatment and potentially results in patients not receiving all needed treatment to address their problems. (Refer to B118)

III. Determine that psychiatric Problem identification was expressed behaviorally for three (3) of eight (8) active sample patients (D3, D16, and E2)...This failure results in no patient specific behaviors being described that would support the stated Problem and that would be the focus of treatment. (Refer to B120)

IV. Consistently formulate treatment goals that were relevant to the patient's condition for eight (8) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16, E3 and F9). Many of the goals on the pre-printed treatment plan forms were either staff goals (what staff wanted the patient to accomplish) or consisted of adherence to routine hospital treatment (such as "will take medication as prescribed"), rather than outline a mental status or functional status level to be attained. Without a set of defined goals against which to measure progress, it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in cases of lack of progress. (Refer to B121)

V. Determine that for eight (8) of eight (8) active sample patients (Patients A2, A11, B4, C4, D3, D16, E2 and F9) their Master Treatment Plans listed interventions on the preprinted form that were generic, routine discipline functions. This failure results in no information about how treatment will be, or not be individualized. (Refer to B122)

VI. Clearly identify the first and last name of staff responsible for each specific intervention on the Master Treatment plans for eight (8) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16, E2 and F9). The responsible staff column primarily contained the initials and discipline of one or more responsible staff for each intervention. Each treatment plan had a page where staff involved in developing the treatment plans signed either first and last name or first initial and last name, but put no discipline identification next to the name. In many cases, the initials next to the interventions and/or the staff signatures were illegible, making it difficult to connect initials with staff signatures. In addition some initials did not match any staff signatures. This practice makes it difficult to determine who is responsible for each intervention and results in inability to clearly monitor staff accountability for seeing that specific interventions are carried out. (Refer to B123)

VII. Provide active treatment, including alternative interventions for two (2) of eight (8) active sample patients (A2 and A11) on the Adult Crisis Unit. Both patients were not motivated to attend all groups on the unit activity schedule. Although the treatment plan for these patients listed multiple generic groups (such as social work group and activity therapy groups), these patients regularly and repeatedly did not consistently attend group therapies. Both patients spent many hours in their rooms without much structured activities. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patient's treatment goals and objectives, potentially delaying the patient's improvement. (Refer to B125I)

VIII. Ensure a therapeutic milieu for 1 non-sample patient (F1) who was a 10 year old and the sole child on the Child/Adolescent Unit where eight (8) adolescents ranging in age from 13 to 17 years old were present. Psychiatric issues being processed by teenagers are not the material appropriate for a child. Contra-wise, a child's behaviors may potentially influence the milieu established for the adolescent patients. (Refer to B125II)

IX. Determine that for eight (8) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16, E2 and F9) physician progress notes did not include statements of progress or lack thereof. This failure results in no documented evidence of patient response to selected treatment modalities. (Refer to B126.)

X. Ensure that registered nurses consistently documented patients' progress or lack of progress toward nursing interventions on the Master Treatment Plans for seven (7) of eight (8) active sample patients (A2, A11, B4, C4, D16, E2 and F9). This failure results in absence of information regarding patient ' s progress and level of functioning being available to the treatment team member, thereby resulting in the potential for delayed discharge. (Refer to B127)



XI. Determine that for six (6) of eight (8 )active sample patients ( A2, A11, B4, C4, E2 and F9) the social service staff failed to disclose in progress notes the patient's progress or lack thereof. This failure results in no documentation of patient response either positive or negative to the selected treatment modalities. (Refer to B128)

Based on record review and staff interview it was determined that for eight(8) of eight(8) patients ( A2, A11, B4, C4, E2, D3, D16, and F9) the psychosocial assessments failed to describe what the role of the social service staff would be in treatment and discharge planning. This failure results in neither the patient nor members of the treatment team knowing what specific interventions were anticipated as necessary.

Findings include:

A. Record Review:

1. Patient A2: The psychosocial assessment, dated 7/25/16, did not describe what efforts the social service staff anticipated as appropriate specifically for this patient.

2. Patient A11: The psychosocial assessment, dated 6/21/16, did not describe what efforts the social service staff anticipated as appropriate for this patient.

3. Patient B4: The psychosocial assessment, dated 7/28/16, did not describe what efforts the social service staff anticipated as appropriate specifically for this patient.

4. Patient C4: The psychosocial assessment, dated 8/01/16, did not disclose what efforts the social service staff anticipated as appropriate for this patient.

5. Patient D3: T Five patient D3 the psychosocial assessment, dated 8/01/16, did not describe what efforts the social service staff anticipated as appropriate for this patient.

6. Patient E2: The psychosocial assessment, dated 6/13/16, did not describe what efforts the social service staff anticipated as appropriate specifically for this patient.

7. Patient D 16: The psychosocial assessment, dated 7/20/16, did not describe what efforts the social service staff anticipated as appropriate specifically for this patient.

8. Patient F9: The psychosocial assessment, which was not dated, did not have an anticipated role for social services for this patient.


B. Staff Interview:

On 8/2/16 at 8:45 a.m. the facility's Risk Manager, who also supervises the Social Work Director, was told of the findings described in Section I, above. She examined the psychosocial assessments for Patients C4, D3, D16 and F9. She agreed with the findings and the not dated incomplete psychosocial assessment for patient F9. She agreed that patient F9 had been present more than 72 hours which is defined as the time limit for completion of psychosocial assessments at the facility.

Based on record review and interview, the facility failed to ensure that Psychiatric Evaluations include an inventory of specific patient assets that could be used in treatment planning for seven (7) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16 and F4). The failure to identify patient assets can impair the treatment team's ability to develop treatment interventions utilizing the individual strengths and personal attributes of each patient.

Findings include:

A. Record Review

The Admission Psychiatric Evaluations (dates in parentheses) for the following patients did not contain assets using the individual strengths and personal attributes of each patient:

1. Active sample patient A2. The Psychiatric Evaluation (7/28/16) listed the non-specific personal assets as "stable housing" and "supportive family/friends."

2. Active sample patient A11. The Psychiatric Evaluation (7/28/16) listed the non-specific personal assets as "financial stability" and "stable housing."

3. Active sample patient B4. The Psychiatric Evaluation (7/25/16) listed the non-specific personal assets as "stable housing" and "supportive family/friends."

4. Active sample patient C4. The Psychiatric Evaluation (7/30/16) listed the non-specific personal assets as "stable housing" and "supportive family/friends."

5. Active sample patient D3. The Psychiatric Evaluation (7/5/16) listed the non-specific personal assets as "self-rated" and "stable housing."

6. Active sample patient D16. The Psychiatric Evaluation (7/20/16) listed the non-specific personal asset as "youth."

7. Active sample patient F9. The Psychiatric Evaluation (7/30/16) listed the non-specific personal assets as "stable housing" and "supportive family/friends."


B. Interview

On 8/2/16 at 2:00 p.m., the Clinical Director was shown the assessments as described above. He agreed that these were not patient specific attributes expressed descriptively and not interpretively. He, also, acknowledged that the assets did not describe patient specific attributes potentially useful in therapeutic endeavors.

Based on record review and interview, the facility failed to provide comprehensive Master Treatment plans (MTPs) that included treatment interventions by all members of the interdisciplinary team for seven (7) for eight (8) active sample patients (A2, A11, B4, C4, D3, D14 and E2). The seven (7) patients listed above did not consistently have physician interventions for psychiatric and/or medical problems identified on the plans. Failure to include specific interventions by all members of the interdisciplinary team on the MTP hampers staff's ability to provide coordinated treatment and potentially results in patients not receiving all needed treatment to address their problems.

Findings include:

A. Records Review

1. MTP for active sample patient A2 did not have physician interventions for the following medical problems (dates of MTPs in parenthesis)): "seizures (7/21/16)", "fall risk (unsteady gait) (7/28/16)", and "wound impaired-skin integrity - staples in scalp (7/28/16)."

2. MTP for active sample patient A11 did not have physician interventions for psychiatric problems of "anxiety evidenced by anxious mood, panic attacks, repetitive behaviors, inappropriate emotional depression" and "irrational statements (7/29/16)."
There were no physician interventions for the medical problem of hypothyroidism (7/29/16).

3. MTP for active sample patient B4 did not have a physician intervention for the medical problem of "ineffective airway clearance evidenced by congestion (7/29/16)."

4. MTP for active sample patient C4 did not have a physician intervention for the psychiatric problem of "depression evidenced by depressed mood, suicidal ideation, poor sleep, crying spells, hx of suicide attempts, recent attempts" and "substance abuse (7/29/16)."

5. Active sample patient D3 did not have a physician intervention for the psychiatric problem of "anxiety evidenced by:" (Nothing was checked on choices offered on the pre-printed treatment plan form) (8/1/16).

6. Active sample patient D16 did not have a physician intervention for the psychiatric problem of "depression evidenced by:" (Nothing was checked on the choices offed on the pre-printed treatment plan form (7/19/16).

7. Active sample patient E2 did not have a physician intervention for the psychiatric problem of "depression evidenced by depressed mood" and "poor sleep (7/26/16)."


B. Interview

In an interview on 8/2/16 at 2:00 p.m, the lack of physician interventions on many of the Master Treatment plans was discussed with the Medical Director. He did not dispute the findings.

Based on record review and staff interview it was determined that psychiatric Problem identification was not expressed behaviorally for three (3) of eight (8) active sample patients (D3, D16, and E2). This failure results in no patient specific behaviors being described that would support the stated Problem and that would be the focus of treatment.

Findings include:

A. Record Review:

1. Patient D3: The Master Treatment Plan, dated 8/1/16, had no description of Problem 1 "Depression" as to how this patient specifically manifested behaviorally this conclusion.

2. Patient D16: The Master Treatment Plan, dated 7/19/16, had no description of Problem "Alteration of Mood/Depression" as to how this patient specifically manifested behaviorally this conclusion.

3. Patient E2: The Master Treatment Plan, dated 7/26/16, had for Problem "Depression" stated as the behavioral substantiation for this diagnosis "Depressed Mood" and "Poor sleep".


II. Staff Interview:

On 8/2/16 at 9:30 a.m. the facility's Risk Manager was interviewed. She agreed that Psychiatric Master Treatment Plans need to describe psychiatric Problems in behavioral terms. She agreed when this did not occur it was a matter requiring treatment team members to do so, and did not contest the findings described in Section I, above.

Based on record review and interview, the facility failed to consistently formulate treatment goals that were relevant to the patient's condition for eight (8) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16, E3 and F9). Many of the goals on the pre-printed treatment plan forms were either staff goals (what staff wanted the patient to accomplish) or consisted of adherence to routine hospital treatment (such as "will take medication as prescribed"), rather than outline a mental status or functional status level to be attained. Without a set of defined goals against which to measure progress, it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress.

Findings include:

1. In patient A2's treatment plan, dated 7/21/16, the treatment goals for the identified problem "psychotic behaviors" included staff goals of "patient will report any self-harm thoughts or impulses to staff prior to acting on them" and "patient will develop a crisis safety plan." An example of adherence to routine hospital treatment was "patient will take [antipsychotic medication] and other prescribed medication willingly."

2. In patient A11's treatment plan, dated 7/29/16, the treatment goals for the identified problem "aggressive/violent behaviors evidenced by bullying, intimidation, defiance, hostility to authority, attack of staff, attack of peers" and "damage to property" included staff goals of "patient will report any self-harm thoughts/impulses to staff prior to acting on them." An example of adherence to routine hospital treatment was "patient will develop a crisis safety plan and identify and demonstrate 2 new coping skills to manage triggers and [angry or other] feelings related to aggressive behavior."

3. In patient B4's treatment plan, dated 7/27/16, the treatment goals for the identified problem of "depression evidenced by depressed mood, suicidal ideation of poor sleep" included the staff goal of "patient will report any self-harm thoughts/impulses to staff prior to acting on them." An example of adherence to routine hospital treatment was "patient will identify pattern of ineffective coping skills that lead to suicidal/self-harm thinking and hospitalization; patient will develop crisis safety plan."

4. In patient C4's treatment plan, dated 7/29/16, the treatment goals for identified problem of "depression evidenced by depressed mood, suicidal ideation, poor sleep, crying spells" included the staff goal of "patient will report any self-harm thoughts/impulses to staff prior to acting on them." An example of adherence to routine hospital treatment was "patient will identify pattern of ineffective coping skills that lead to suicidal/self-harm thinking and hospitalization; patient will develop crisis safety plan."

5. In patient D3's treatment plan, dated 8/1/16, the treatment goals for the identified problem of "anxiety" included the staff goal of "patient will report any self-harm thoughts/impulse to staff prior to acting on them." An example of adherence to routine hospital treatment was "patient will identify pattern of anxiety that led to hospitalization and develop crisis safety plan."

6. In patient D16 treatment plan, dated 7/19/16, the treatment goals for the identified problem of "depression" included the staff goal of "patient will report any self-harm thoughts/impulses to staff prior to acting on them." An example of adherence to routine hospital treatment was "patient will identify pattern of ineffective coping skills that lead to suicidal/self-harm thinking and hospitalization; patient will develop crisis safety plan."

7. In patient E2's treatment plan, dated 7/26/16, the treatment goal for the identified problem of "depression evidenced by depressed mood to poor sleep" include the staff goal of "patient will report any self-harm thoughts/impulses to staff prior to acting on them." An example of adherence to routine hospital treatment was "patient will identify pattern of ineffective coping skills that lead to suicidal/self-harm thinking and hospitalization; patient will develop crisis safety plan."

8. In patient F9's treatment plan, dated 8/1/16, the treatment goals for the identified problem of "aggressive/violent behaviors evidenced by defiance, hostility to authority, attack of staff and attack of peers" included the staff goal of "patient will report any self-harm thoughts/impulses to staff prior to acting on them." An example of adherence to routine hospital treatment was "patient will develop a crisis safety plan and identify and demonstrate 3 new coping skills to manage triggers [angry or other] feelings related to aggressive behavior."


B. Interview

In an interview on 8/2/16 at 8:46 a.m. and 1:00 p.m., the routine staff and patient adherence to routine hospital treatment goals were discussed with the Director of Nursing who assisted surveyor with chart review. She did not dispute the findings.

Based on record review and staff interview it was determined that for eight (8) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16, E2 and F9) their Master Treatment Plans listed interventions on the preprinted form that were generic, routine discipline functions. This failure results in no information about how treatment will be, or not be individualized.

Findings include:

A. Record Review:

1. Patient A2: The Master Treatment Plan, dated 7/21/16, had as nursing staff interventions for the following three psychiatric problems (1) Problem #1 "Alteration of Mood/Anxiety "-----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to anxiety" and "Conduct self-harm reassessments." (2)Problem#2 "Psychotic behaviors "----"Provide check-ins with patient regarding mood, negative thoughts/behaviors and significant changes in condition" and "Conduct suicidal assessments" and (3) Problem# 3 "Mania"----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to anxiety" and "Conduct self-harm reassessments."

2. Patient A11: The Master Treatment Plan treatment, dated 7/29/16, had as nursing staff interventions for the following three psychiatric problems (1) Problem #1 "Alteration of Mood/Depression"-----"----- "Provide check-ins with patient regarding mood, negative thoughts/behaviors related to anxiety" and "Conduct self-harm reassessments." (2) Problem #2 "Aggressive/Violent Behavior"----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to depression" and "Conduct self-harm assessments." and (3) Problem# 3 "Alteration of Mood/Anxiety"----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to anxiety" and "Conduct suicidal reassessments."

3. Patient B4: The Master Treatment Plan ,dated 7/27/16, had as nursing staff interventions for the one psychiatric problem (1) Problem #1 "Alteration of Mood/Anxiety"-----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to anxiety" and "Conduct self-harm reassessments."

4. Patient C4: The Master Treatment Plan, dated 7/29/16, had as nursing staff interventions for the following two psychiatric problems (1) Problem #1 "Alteration of Mood/Depression "-----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to anxiety" and "Conduct self-harm reassessments." (2) Problem#2 "Substance Use/Abuse"---- "Provide check-ins with patient regarding mood, negative thoughts/behaviors related to substance abuse/detox" and "Conduct self-harm reassessments." Also, for Problem# B "Seizure" - there were no physician interventions.

5. Patient D3: The Master Treatment Plan, dated 8/1/16, had as Problem "Alteration of Mood/Depression" no interventions by either the nursing or medical staff.

6. Patient D16: The Master Treatment Plan, dated 7/19/16, had as nursing staff interventions for the psychiatric Problem "Alteration of Mood/Depression"-----"Provide check-ins with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition" and "Conduct suicidal reassessments."

7. Patient E2: The Master Treatment Plan, dated 7/26/16, had as nursing staff interventions for the psychiatric Problem "Alteration of Mood/Depression"-----"Provide check-ins with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition" and "Conduct suicidal reassessments." Also, there were no interventions by the psychiatrist.

8. Patient F9: The Master Treatment Plan, dated 8/1/16, had as nursing staff interventions for the psychiatric Problem "Hyperactivity Impulsivity" "-----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to depression" and "Conduct self-harm assessments." Problem#3 "Aggressive/Violent Behavior"----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to depression" and "Conduct self-harm assessments."


II. Staff Interview:

On 8/2/16 at 1:30 p.m. the facility's Risk Manager was interviewed. She agreed that the interventions listed in Section I, above were generic and were not individualized.

Based on record review and interview, the facility failed to clearly identify the first and last name of staff responsible for each specific intervention on the Master Treatment plans of eight (8) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16, E2 and F9). The responsible staff column primarily contained the initials and discipline of one or more responsible staff for each intervention. Each treatment plan had a page where staff involved in developing the treatment plans signed either first and last name or first initial and last name, but put no discipline identification next to the names. In many cases, the initials next to the interventions and/or the staff signatures were illegible, making it difficult to connect initials with staff signatures. In addition some initials did not match staff signatures. This practice makes it difficult to determine who is responsible for each intervention and inability to clearly monitor staff accountability for seeing that specific interventions are carried out.

Findings include:

A. Medical Records

1. Facility policy, titled "Interdisciplinary Treatment Plans", last revised 7/15/14, stated under "Treatment Plan Components:" "Signature/Initial/Date:" "Signature of staff responsible for contributing to the development of the treatment plan, the initials utilized on the treatment plan, and the date the component was added or revised." The policy did not clarify whether the initials next to the intervention and signatures under staff involved in the development of the plans should be the same or not.

2. All of the following treatment plans of the eight (8) active sample patients (dates of treatment plans in parenthesis) had many initials and/or staff signatures that were illegible making it difficult or impossible to consistently identify staff by first and last name responsible for seeing that each intervention is carried out: A2 (7/21/16), A11 (7/29/16), B4 (7/27/16), C4 (7/29/16), D3 (8/1/16), D16 (7/19/16), E2 (7/26/16), and F9 (8/1/16).


B. Interview

In an interview with the Director of Nursing on 8/2/16 at 1:00 p.m., the many illegible initials and responsible staff signatures on the Master Treatment plans was discussed. She agreed with the findings.

Based on record review, observation and interview, the facility failed to provide active treatment, including alternative interventions for two (2) of eight (8) active sample patients (A2 and A11) on the Adult Crisis Unit. Both patients were not motivated to attend all groups on the unit activity schedule. Although the treatment plan for these patients listed multiple generic groups (such as social work group and activity therapy groups), these patients regularly and repeatedly did not consistently attend group therapies. Both patients spent many hours in their rooms without much structured activities. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patient's treatment goals and objectives, potentially delaying the patient's improvement.


Findings include:

I. Lack of Active Treatment

Patient A2

1. Patient A2 was admitted on 7/20/16. According to the Psychiatric Evaluation, dated 7/21/16, "Pt [patient] presents [with] paranoid, bizarre delusions & [and] agitated. Reports ciber [sic] [illegible word] is real and then goes on a tangent of paranoid thinking. Pressured and disorganized thought process. No AVH [audio visual hallucinations] reported. Mood irritable, labile. May need commitment. Denies SI [suicidal ideations]."

2. During an interview on 8/1/16 at 10:41 a.m., RN1 was asked about an individual activity schedule for A2 and told surveyor that there was only a unit schedule and all patients on the unit were expected and encouraged to attend the groups offered on the schedule. When asked about any patients who do not routinely attend the groups offered, patient A2 was identified. RN1 stated: "[S/he] spends most of [his/her] time in bed."

3. A MHT [Mental Health Technician] group was being held in the dayroom at 11:06 a.m. Patient A2 was observed on 8/1/16 at 11:06 a.m. in bed with covers up to and covering his/her head. When asked why s/he was in bed, patient A2 stated that s/he was not feeling good.

4. A "Nursing Group" was held in the dayroom of the unit at 11:28 a.m. Patient A2 was observed as still in his/her room in bed at this time.

5. The generic groups listed on patient A2's Master Treatment plan, dated 7/29/16, were: "SW [social work] group, med/mgmt. [medication management], RN [registered nurse] group, family therapy and activity therapy groups" and "MHT group activities."

6. Group attendance by patient A2 between 7/25/16 and 7/30/16 were as follows:

- 7/25/16 - "MHT Group" from 9:00 a.m. and 9:30 a.m. - "Patient attended: No. Pt. refused." "Pt slept, did not attend group."

"MHT Group" from 7:00 p.m. and 7:30 p.m. - "Goals Group" "Patient attended: No. Pt never got out of bed."

- 7/26/16 - "Group Therapy Progress Notes" - "Group topic: The Hole." "Attended: No. Pt stayed in room. Alternative provided: pt was offered the handout to read. Patient declined due to: [Space blank]."

- 7/27/16 - "Nursing Group" - "Group from 11:30 a.m. to 12:30 p.m." "Patient attended: No. Pt. refused. Patient response to alternative provided pt. confused & delusional."

- "MHT Group" - Group from 8:00 p.m. to 8:20 p.m. "Group topic: Educational." "Patient attended: No. Patient medicated."

- 7/29/16 - "Group Therapy Progress Note": "Group topic: Coping skills." "Attended: No. Pt. stayed in the room. Pt was offered the handout to read. Patient declined due to: [Space blank]." "Pt refused to attend group."

- 7/30/16 - "Nursing Group Notes": Group from 11:30 a.m. to 12:30 a.m. "Group topic: Educational" "Patient attended: No. Pt refused." "Patient response to alternative provided: Pt asleep."

7. A nursing update on A2's Master Treatment plan, dated 7/29/16, did not address patient's lack of participation in groups and what alternative treatment programming was initiated. This section of the update was blank.

Patient A11

1. Patient A11 was admitted on 7/28/16. According to the Psychiatric Evaluation, dated 7/29/16, "19 y.o [year old] [male/female] presents with severe disorganization, suicidal behavior - attempts to harm self, agitated - biting/spitting at officers who came to help - intoxicated with cocaine and [illegible words] labile, irritable and uncooperative. Currently lying in bed refusing to participate in interview"---"estimated length of inpatient treatment 7 - 10 days. Initial discharge plans: Home placement." "Initial treatment plan: may need rehab [rehabilitation]. Will start Prolixin/Benadryl/tegretal for mood stability/aggression. Monitor response and provide safe environment."

2. During a discussion with RN1 on 8/1/16 at 10:41 a.m., on patients who were not attending groups, patient A11 was mentioned as a patient, with multiple previous admissions to the facility and one who spent a lot of time in his/her room.

3. Patient A11 was observed in room sleeping on 8/1/16 at 11:15 a.m. during a MHT Group being held on the unit in the dayroom at that time.

4. Some of the generic groups listed on patient A11's Master Treatment plan dated 7/29/16, were "SW Group, family therapy, med education, nursing group" and "activity group."

5. Group attendance by patient A11 between 7/29/16 and 8/1/16 were as follows:

- 7/29/16 - "Group Therapy Progress Note": "Group topic: Coping skills. Attended: No. Pt stayed in the room. Alternative provided: Pt was offered the handout to read. Patient declined due to: [no reason given]." "Patient refused to attend group."

- 7/29/16 - "MHT Group" from 8:00 p.m. and 8:24 p.m. "Group topic: Educational. Patient attend: No." No reason given. "Patient response to alternative provided: Pt medicated resulting in therapeutic sleep."

- 7/30/16 - "Nursing Group Notes". "Group topic: educational." "Pt attended: No. Pt refused."

- 7/31/16 - "Group Therapy Progress Notes": "Group topic: Positive" 10:30 a.m. to 11:30a.m." "Attended: No. Alternative provided: Group work available. A11did not attend group. "

- "MHT Group": "Group topic: Educational from 8:00 p.m. to 8:25 p.m. Patient attended: No. Pt refused. Alternative provided: journaling. No response provided to alternative."

- 8/1/16 - "MHT Group" - from 8:00 a.m. to 8:30 a.m. "Group topic: Educational." "Pt attended: No." "Patient response to alternative provided: Pt refused."

- "Group Therapy Progress Notes": "Group topic: Compliance" - from 9:15 a.m. to 10:15 a.m." "Attended: No." "Pt stayed in the room. Alternative provided: Pt asked to journal about what their discharge plans were. Patient declined due to: [No reason given]." "Patient refused to attend group."

- "MHT Group" - from 8:00 p.m to 8:15 p.m. "Group topic: Educational." "Patient attended: No. Pt response to alternative provided: Pt medicated resulting in therapeutic sleep."

6. During a discussion with the Nursing Director on 8/2/16 around 9:00 a.m., the problems of patients not attending groups provided on their units was discussed. She stated that patient A11 was well known by most staff because of his/her multiple admission to the facility. "I know that just offering journaling or handouts is not sufficient. I'm working on some written instructions for staff [nursing] on ways to address this problem."


II. Based on observation and staff interview, it was observed that the facility failed to ensure a therapeutic milieu for 1 non-sample patient (F1). On 8/2/16 at 10:15 a.m., the Risk Manager and the charge nurse of unit, RN2, were interviewed. They were asked about the treatment modalities provided non-sample patient F1. This is a 10 year old and the sole child on the Child/Adolescent Unit where 8 adolescents ranging in age from 13 to 17 years old are present. They acknowledged that the unit had only one child at present. Weekly treatment intervention schedule disclosed that group therapies, activity therapies etc. would be provided. They agreed when patient F1 was behaving appropriately, s/he would be included in all the scheduled modalities. Psychiatric issues being processed by teenagers are not the material appropriate for a child.

Contra-wise, a child's behaviors may potentially influence the milieu established for the adolescent patients. Surveyor observed on 8/2/16 at 12:30 p.m. patient F1 having a temper tantrum in the unit common area. S/he was yelling, kicking and inappropriate. At that time the adolescent patients were off the unit at lunch, but had they been present this episode would have effected their milieu negatively.

On 8/2/16 at 2:00 p.m. the Clinical Director was interviewed. The issue of patient F1 was discussed. He acknowledged that there does not exist a separate treatment program for children versus adolescents presently.

Based on record review and staff interview it was determined that for eight (8) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16, E2 and F9) physician progress notes did not include statements of progress or lack thereof. This failure results in no documented evidence of patient response to selected treatment modalities.

Findings include:

A. Record Review:

The physician progress notes of the patients listed were reviewed for a one week period i.e. 7 days prior to 8/02/16 if the patient had been present that long or for whatever shorter period they had been present. None of the patient's progress notes by physicians for the eight (8) active sample patients disclosed the patient's progress or lack thereof in meeting treatment goals or response to the selected interventions.


II. Staff Interview:

On 8/2/16 at 12:45 p.m. the surveyor and the facility's Risk Manager together looked at the physician progress notes for Patients C4, D3, D16 and F9. The Risk Manager agreed that there were no statements regarding progress or lack thereof for these patients.

Based on record review and staff interview the facility failed to ensure that registered nurses consistently documented patients' progress or lack of progress toward nursing interventions on the Master Treatment Plans for seven (7) of eight (8) active sample patients (A2, A11, B4, C4, D16, E2 and F9). This failure results in absence of information regarding patient's progress and level of functioning being available to the treatment team member, thereby resulting in the potential for delayed discharge.

Findings include:

A. Record Review

A review of the medical records listed above revealed that there were no progress notes completed by registered nurses for all of the following identified nursing interventions on the Master Treatment plans as of 8/2/16:

1. Active sample patient A2, MTP dated 7/21/16, had as a nursing intervention: "Educate patient on the benefits of taking [antipsychotic medication] and other prescribed medications, their side effects, and the importance of medication compliance."

2. Active sample patient A11, MTP dated 7/29/16, had as a nursing intervention: "Educate patient on the purpose of taking medications Tegretal, their actions, side effect, and risk. Discuss importance of compliance."

3. Active sample patient B4, MTP dated 7/27/16, had as a nursing intervention: "Help patient identify coping strategies and triggers that will help manage suicidal/ self-harm thoughts and record these strategies in the crisis safety plan. Patient will practice these coping skills during groups and 1:1s."

4. Active sample patient C4, MTP dated 7/29/16, had as a nursing intervention: "Help the patient to identify stressors & [and] circumstances that trigger suicidal thoughts."

5. Active sample patient D16, MTP dated 7/19/16, had as a nursing intervention: "Help the patient to identify stressors & circumstances that triggers suicidal thoughts."

6. Active sample patient E2, MTP dated 7/26/16, had as a nursing intervention: "Help the patient to identify stressors & circumstances that triggers suicidal thoughts."

7. Active sample patient F9, MTP dated 8/1/16, had as a nursing intervention: "Educate patient on the purpose of taking medication Tenex, actions, side effects, and risk. Discuss importance of compliance."


B. Interview/Discussion

1. The Nursing Director reviewed nursing progress notes for patients A2, A11, B4 and E2 with the surveyor. She acknowledged that there were no nursing progress notes for the sample of nursing interventions mentioned above.

Based on record review and staff interview it was determined that for six (6) of eight (8) active sample patients ( A2, A11, B4, C4, E2 and F9) the social service staff failed to disclose in progress notes the patient's progress or lack thereof. This failure results in no documentation of patient response either positive or negative to the selected treatment modalities.

Findings include:

A. Record Review:

The progress notes by social service staff for the six (6) patients listed above were reviewed for the week up to 8/2/16 or for whatever lesser time the patient had been present. There were no comments about patient progress either positively or negatively to the treatment interventions the staff was pursuing.


B. Staff Interview:

On 8/2/16 at 12:45 p.m. the facility's Risk Manager and the surveyor looked at the progress for Patients C4 and F9 together. She agreed that the content of the progress notes failed to describe patient response or lack thereof to the treatment modalities selected.

Based on record review and interview, the facility failed to provide sufficient numbers of trained activity therapy staff. There were only two recreational therapy staff for the 100 bed facility with six patient units. Therefore recreational activities were not available every day, seven (7) days per week for all patients. This failure precludes the ability to provide activity groups based on assessed needs on each of the six units on a daily basis. The absence of any trained staff 7 days per week precludes the development of a professional program that meets patients' needs. (Refer to B158)

Based on record review and interview, the Medical Director failed to monitor and evaluate the quality of care provided by the clinical staff. Specifically the Medical Director failed to:

1. Ensure that Psychiatric Evaluations included an inventory of specific patient assets that could be used in treatment planning for seven (7) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16 and F4). The failure to identify patient assets can impair the treatment team's ability to develop treatment interventions utilizing the individual strengths and personal attributes of each patient. (Refer to B117)

2. Provide comprehensive Master Treatment plans (MTPs) that included treatment interventions by all members of the interdisciplinary team for seven (7) for eight (8) active sample patients (A2, A11, B4, C4, D3, D14 and E2). The seven (7) patients listed above did not consistently have physician interventions for psychiatric and/or medical problems identified on the plans. Failure to include specific interventions by all members of the interdisciplinary team on the MTP hampers staff's ability to provide coordinated treatment and potentially results in patients not receiving all needed treatment to address their problems. (Refer to B118)

3. Determine that psychiatric Problem identification was expressed behaviorally for three (3) of eight (8) active sample patients (D3, D16, and E2). This failure results in no patient specific behaviors being described that would support the stated Problem and that would be the focus of treatment. (Refer to B120)

4. Consistently formulate treatment goals that were relevant to the patient's condition for eight (8) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16, E3 and F9). Many of the goals on the pre-printed treatment plan forms were either staff goals (what staff wanted the patient to accomplish) or consisted of adherence to routine hospital treatment (such as "will take medication as prescribed"), rather than outline a mental status or functional status level to be attained. Without a set of defined goals against which to measure progress, it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress. (Refer to B121)

5. Determine that for eight (8) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16, E2 and F9) their Master Treatment Plan listed interventions on the preprinted form that were generic, routine discipline functions. This failure results in no information about how treatment will be, or not be individualized. (Refer to B122)

6. Clearly identify the first and last name of staff responsible for each specific intervention on the Master Treatment plans of eight (8) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16, E2 and F9). The responsible staff column primarily contained the initials and discipline of one or more responsible staff for each intervention. Each treatment plan had a page where staff involved in developing the treatment plans signed either first and last name or first initial and last name, but put no discipline identification next to the name. In many cases, the initials next to the interventions and/or the staff signatures were illegible, making it difficult to connect initials with staff signatures. In addition some initials did not match staff signatures. This practice makes it difficult to determine who is responsible for each intervention and inability to clearly monitor staff accountability for seeing that specific interventions are carried out. (Refer to B123)

7. Provide active treatment, including alternative interventions for two (2) of eight (8) active sample patients (A2 and A11) on the Adult Crisis Unit. Both patients were not motivated to attend all groups on the unit activity schedule. Although the treatment plan for these patients listed multiple generic groups (such as social work group and activity therapy groups), these patients regularly and repeatedly did not consistently attend group therapies. Both patients spent many hours in their rooms without much structured activities. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patient's treatment goals and objectives, potentially delaying the patient's improvement. (Refer to B125I)

8. Ensure a therapeutic milieu for 1 non-sample patient (F1). This is a 10 year old and the sole child on the Child/Adolescent Unit where 8 adolescents ranging in age from 13 to 17 years old. Psychiatric issues being processed by teenagers are not the material appropriate for a child. Contra-wise, a child's behaviors may potentially influence the milieu established for the adolescent patients. (Refer to B125II)

9. Determine that for eight (8) of eight (8) active sample patients (A2, A11, B4, C4, D3, D16, E2 and F9) physician progress notes did not include statements of progress or lack thereof. This failure results in no documented evidence of patient response to selected treatment modalities. (Refer to B126)

10. Determine that for six (6) of eight (8) active sample (A2, A11, B4, C4, E2 and F9) the social service staff failed to disclose in progress notes the patient's progress or lack thereof. This failure results in no documentation of patient response either positive or negative to the selected treatment modalities. (Refer to B128)

Based on record review and staff interview it was determined that for eight(8) of eight (8)active sample patients ( A2, A11, B4, C4, D3, D16, E2 and F9) there was a failure by the Nursing Director to monitor the quality and appropriateness of nursing interventions on the Master Treatment Plans. This failure results in neither the patient nor members of the treatment team knowing what specific interventions were anticipated as necessary.

Findings include:

a. Record Review:

1. Patient A2: The Master Treatment Plan dated 7/21/16 had as nursing staff interventions for the following three psychiatric problems (1) Problem #1 "Alteration of Mood/Anxiety "-----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to anxiety" and "Conduct self-harm reassessments." (2) Problem#2 "Psychotic behaviors"----"Provide check-ins with patient regarding mood, negative thoughts/behaviors and significant changes in condition" and "Conduct suicidal assessments" and (3) Problem # 3 "Mania"----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to anxiety" and "Conduct self-harm reassessments."

2. Patient A11: The Master Treatment Plan treatment dated 7/29/16 had as nursing staff interventions for the following three psychiatric problems (1) Problem #1 "Alteration of Mood/Depression"-----"----- "Provide check-ins with patient regarding mood, negative thoughts/behaviors related to anxiety" and "Conduct self-harm reassessments." (2) Problem #2 "Aggressive/Violent Behavior"----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to depression" and "Conduct self-harm assessments." and (3) Problem # 3 "Alteration of Mood/Anxiety"----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to anxiety" and "Conduct suicidal reassessments."

3. Patient B4: The Master Treatment Plan dated 7/27/16 had as nursing staff interventions for the one psychiatric problem (1) Problem #1 "Alteration of Mood/Anxiety"-----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to anxiety" and "Conduct self-harm reassessments."

4. Patient C4: The Master Treatment Plan dated 7/29/16 had as nursing staff interventions for the following two psychiatric problems (1) Problem #1 "Alteration of Mood/Depression"-----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to anxiety" and "Conduct self-harm reassessments." (2) Problem #2 "Substance Use/Abuse"----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to substance abuse/detox" and "Conduct self-harm reassessments." Also, for Problem #B "Seizure" - there were no physician interventions.

5. Patient D3: The Master Treatment Plan dated 8/1/16 had as Problem "Alteration of Mood/Depression" no interventions by either the nursing or medical staff.

6. Patient D16: The Master Treatment Plan dated 7/19/16 had as nursing staff interventions for the psychiatric Problem "Alteration of Mood/Depression"-----"Provide check-ins with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition" and "Conduct suicidal reassessments."

7. Patient E2: The Master Treatment Plan dated 7/26/16 had as nursing staff interventions for the psychiatric Problem "Alteration of Mood/Depression"-----"Provide check-ins with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition" and "Conduct suicidal reassessments." Also, there were no interventions by the psychiatrist.

8. Patient F9: The Master Treatment Plan dated 8/1/16 had as nursing staff interventions for the psychiatric Problem "Hyperactivity Impulsivity" "-----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to depression" and "Conduct self-harm assessments." Problem#3 "Aggressive/Violent Behavior"----"Provide check-ins with patient regarding mood, negative thoughts/behaviors related to depression" and "Conduct self-harm assessments."


B. Interview

In an interview on 8/4/16 at 1:00 p.m., the generic nursing interventions on the Master Treatment plans was discussed with the Nursing Director. She agreed with the findings.

Based on record review and staff interview it was determined that for eight(8) of eight (8) active patients A2, A11, B4, C4, D3, D16, E2 and F9) there was a failure by the Director of Social Work to monitor the quality and appropriateness of responsibilities of social service staff. Specifically, the Social Work Director failed to:

I. Provide psychosocial assessments that described what the role of the social service staff would be in treatment and discharge planning. This failure results in neither the patient nor members of the treatment team knowing what specific interventions were anticipated as necessary.

Findings include:

A. Record Review:

1. Patient A2: The psychosocial assessment, dated 7/25/16, did not describe what efforts the social service staff anticipated as appropriate specifically for this patient.

2. Patient A11: The psychosocial assessment, dated 6/21/16 did not describe what efforts the social service staff anticipated as appropriate for this patient.

3. Patient B4: The psychosocial assessment dated 7/28/16, did not describe what efforts the social service staff anticipated as appropriate specifically for this patient.

4. Patient C4: The psychosocial assessment, dated 8/1/16, did not disclose what efforts the social service staff anticipated as appropriate for this patient.

5. Patient D3: T Five patient D3 the psychosocial assessment dated 8/1/16 did not describe what efforts the social service staff anticipated as appropriate for this patient.

6. Patient E2: The psychosocial assessment, dated 6/13/16, did not describe what efforts the social service staff anticipated as appropriate specifically for this patient.

7. Patient D 16: The psychosocial assessment, dated 7/20/16, did not describe what efforts the social service staff anticipated as appropriate specifically for this patient.

8. Patient F9: The psychosocial assessment, which was not dated, did not have an anticipated role for social services for this patient.


B. Staff Interview:

On 8/2/16 at 8:45 a.m. the facility's Risk Manager was told of the findings described in Section I, above. She examined the psychosocial assessments for Patients C4, D3, D16 and F9. She agreed with the findings and the undated incomplete psychosocial assessment for patient F9. She agreed that patient F9 had been present more than 72 hours which is defined as the time limit for completion of psychosocial assessments at the facility.


II Disclose in progress notes the patient ' s progress or lack thereof to the treatment modalities selected: This failure results in no documentation of patient response either positive or negative to the selected treatment modalities.

Findings include:

A. Record Review:

The progress notes by social service staff for the six (6) patients listed above were reviewed for the week up to 8/2/16 or for whatever lesser time the patient had been present. There were no comments about patient progress either positively or negatively to the treatment interventions the staff was pursuing.

B. Staff Interview:

On 8/2/16 at 12:45 p.m. the facility's Risk Manager, who supervises the Social Work Director, and the surveyor looked at Patients C4 and F9 together. She agreed that the content of the progress notes failed to describe patient response or lack thereof to the treatment modalities selected.

Based on record review and interview, the facility failed to provide sufficient numbers of trained activity therapy staff. There were two recreational therapy staff for the 100 bed facility with six patient units. Therefore recreational activities were not available every day, seven (7) days per week for all patients. This failure precludes the ability to provide an activity group, based on assessed needs on each of the six units on a daily basis. The absence of any trained staff precludes the development of a professional program that meets patients' needs.

Findings include:

A. Record Review

A review of the activity schedule for the 6 patient units: 2 (Adult Crisis), 3 (Geriatric), 4 (Substance Abuse), 5 (Adult General), 6 (Women's) and 7 (Child/Adolescent) showed that activity therapy groups were offered 4 days per week for 5 of the six patient units. Unit 5 (Adult General) had 5 activity therapy groups per week.


B. Interview

In an interview on 8/2/16 at 12:12 p.m., the activity therapy scheduled was discussed with RT1. He stated that there were two (2) FTE s (full time equivalents) in this area- himself who is a CTRS (certified therapeutic recreational specialist) and one other staff member who had a bachelor's degree in recreation, but was not certified. RT1 stated that the two take turns working on the weekends. The person who works on a weekend has the Friday before and the Monday after the weekend off. This results in one recreational therapist working alone on those days for the entire hospital and also in situations when one of them is on vacation or absent for other reasons (i.e. illness. Conferences, etc.). These two people also do RT assessments on all admission within 72 hours of admission. When told that 2 people for 100 patients were not sufficient to meet the needs of all patients, RT1 stated "I know. I do the best I can with what I have."