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Based on medical record reviews, review of facility policies and interviews for 1 of 3 patients reviewed for patient rights, (Patient #301), the facility failed to ensure that the patient's dignity/privacy was maintained while implementing safe treatment interventions. The finding includes:


Patient #301 was admitted the hospital on 3/6/13 with significant harm to self and/others. Patient #301's diagnoses included Diabetes, Bipolar Disorder and Obesity. Patient #301 had a history of serious aggressive/self-injurious behaviors and ingesting items. Review of the integrated treatment plan dated 9/6/7 identified that Patient #301 was restarted on his/her behavior plan on 1/23/17 which included finger foods, no utensils, three strong blankets and large towels for toileting with no underwear. In addition, monitoring of the patient in the bathroom included 3 staff inside bathroom and 1 staff at the door. Further review of the medical record failed to identify that Patient #301's behavior plan was reviewed to include interventions to promote an increase in the patient's dignity and/or privacy. Patient ##301 continued to have no underwear, utilized towels for toileting and had no feminine hygiene products. Interview with the Nursing Director #3 on 9/15/17 identified that in the past, the patient put some of these items into his/her body and it would be a safety risk, however, had not seen this behavior in the last few months. Review of the facility policy identified that the patient has the right to personal dignity, privacy and confidentiality.

1. Based on clinical record reviews, review of facility policies and procedures and interviews for 1 of 3 patient's reviewed that were on constant observation, (Patient #301), the facility failed to ensure that a patient on constant observation was monitored to prevent injury to self. The findings include:


Patient #301 was admitted the hospital on 3/6/13 with significant harm to self and/others. Patient #301's diagnoses included Diabetes, Bipolar Disorder and Obesity. Patient #301 has a history of serious aggressive/self-injurious behaviors and ingesting items. Review of the physician orders dated 7/2017 identified that Patient #301 was on constant (continuous) observation with one staff member for the protection of self/others. MHW #2 was assigned to perform a constant observation on Patient #301. On 7/8/17, Patient #301 was in a group room with Mental Health Worker #2 (MHW) listening to music on headphones. Patient #301 asked MHW #2 to listen to a song on his/her headphones. MHW #2 bent down and immediately the patient snatched his/her pen from their folder and swallowed a pen. Further review identified that multiple staff were called and attempted to get the pen from Patient #301 without success, therefore, the patient was sent to the hospital for removal of a foreign body.
Interview with MHW #2 on 9/14/17 identified that the patient grabbed a pen out of folder that he/she was holding when he/she was asked by the patient to listen a song the patient was listening to on his/her headphones.
Review of facility policy identified that continuous observation is which the patient requires ongoing monitoring to ensure his/her safety and/or the safety of others. The nursing staff assigned provides that by having a clear view and unimpeded access to the patient at all times. Further review of facility policy identified that a one to one observation is considered the highest level of observation and are reserved for those patients whose needs require that the assigned staff member monitors only one patient, and that the staff member remains within arm's length of the patient at all times. In addition, the patient's hands, face and neck must be in clear view at all times unless otherwise ordered by a prescriber as a result of a documented assessment of risk.


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2. Based on observation, review of clinical records, hospital incident report, policies and procedures, and interviews for one patient allegedly identified with smoking materials, Patient #106, the hospital failed to ensure that smoking materials were secured and/or that a smoke free environment was maintained in accordance with hospital policy. The findings include:


Patient #106 was admitted to the hospital on 6/14/2017 with diagnoses that included schizoaffective disorder and nicotine dependence. Review of the clinical record lacked documentation of a smoking risk assessment and/or guidance regarding smoking management.

A physician order dated 8/15/17 directed that Patient #106 may go on pass with the unit social worker. Review of an Integrated Treatment Plan (ITP) dated 7/28/17 identified that the patient's preference for method of de-escalation was smoking a cigarette.

A progress note dated 8/15/17 at 2:30 PM by Social Worker #2 identified that he/she accompanied Patient #106 into town for a community reinforcement activity and returned to the hospital. At 10:00 PM RN #46 documented that he/she put Patient #106's cigarettes and lighter in the treatment room. An incident report dated 8/15/17 at 9:30 PM by RN #46 identified a smoking violation was committed by Patient #106 and/or Patient #111. The violation was identified when staff smelled an odor consistent with cigarettes in the comfort room. Both Patient's #106 and #111 had returned cigarettes and lighters that day and the staff had returned them to the patient's personal bins (secured in the nursing station). One lighter was located in the comfort room. The staff determined that only Patient #106's bedroom had an odor consistent with a cigarette smell. Patient #106 denied smoking in the comfort room. The staff searched both patient rooms and found two partially smoked cigarettes on top of the wardrobe in Patient #106's room. No contraband was discovered in Patient #111's room.

Interview with SW #2 on 8/23/17 at 1:34 PM identified for patients who smoked and did not have a smoking restriction documented on their treatment plan, smoking materials were stored in an individual plastic box with each patient's personal items that required supervision for use. The patient was not allowed to hold the materials. The SW would retrieve smoking material from the patient's box, carry them to the car, and keep them in his/her possession until the patient and the SW arrived at their destination. At that point, the SW would present the pack (s) of cigarettes and lighter (s) to the patient unless the physician order was more restrictive. When the community activity was over and the patient and SW returned to the car, the SW would take possession of the smoking materials and keep them until the patient and SW returned to the hospital. Upon return, the SW would direct the patient to the nursing station to check in. SW #2 identified that Patient #106 was always within eyesight during an off grounds activity, however, there was no mechanism in place to track the number of cigarettes smoked and/or number of lighters issued and returned and/or assessments of a patient's ability to smoke safely and independently. Interview with MD #8 and Program Manager #2 on 8/21/17 at 1:26 PM identified that Patient #106 had admitted to having smoked (in the comfort room) and he/she had turned in his/her smoking materials. They presumed that Patient #106 had other smoking materials in his/her room. As follow up to the incident, a community meeting was held and the dangers of smoking on the unit was discussed and a fire drill was conducted.

A policy for Tobacco and E-Cigarette Free Environment identified that the hospital is a tobacco free environment. As part of each patient's individual assessment by his/her attending Psychiatrist, the various options for managing tobacco addiction will be addressed. Smoking is prohibited anywhere on the hospital grounds. The sale of tobacco products is prohibited. The possession of tobacco or smoking materials in any form by patients is not permitted. The policies of the tobacco free campus extends to include hospital supervised or escorted trips and activities.





3. Based on observation and review of hospital policies and procedures, the hospital failed to ensure that a patient utilizing locked seclusion could be clearly visualized while on continuous observation (CO). The findings include:


Tour of the seclusion room on B2S (room 235) on 9/11/17 at 9:30 AM with Program Manager #2 identified a rectangular, padded room with a reflective (mirror like) devise mounted in the upper left corner of the room diagonally across from the entrance door. The door opened into the seclusion room. The upper part of the door contained a rectangular window to facilitate staff observation of a patient in seclusion.

At surveyor request, a staff member entered the seclusion and stood to the right of the seclusion room door. The door was closed. View through the window from outside the seclusion room identified that a person was standing next to the door, but could only be visualized by looking at the reflection in the reflective device. Although a person's presence could be identified, the image was unclear and distorted. Program Manager #2 identified that the room lacked any other mechanism for visually monitoring a patient in seclusion.

A hospital policy for seclusion use identified that a patient who is in seclusion is monitored on continuous observation by competently trained nursing staff. A policy for special observation identified that continuous observation is an observation in which the patient requires ongoing monitoring to ensure his/her safety and/or the safety of others. The nursing staff assigned provides that by having a clear view and unimpeded access to the patient at all times.

Based on clinical record review, interview and policy review the facility failed to ensure that the physician's orders identified the type of mechanical restraints to be utilized for 1 of 3 patients placed in restraints (P # 107). The findings include the following:


Patient #107 was admitted to the facility on 11/30/16 with a history of traumatic brain injury, intermittent explosive disorder and seizures. The clinical record indicated that on 7/22/17 the patient was seen in his/her roommates drawer, at that time the patient was redirected by staff and became angry, threw a garbage can, and a laundry bin. The patient became aggressive towards staff and peers. Review of the physicians orders dated 7/22/17 at 4:45 PM directed physical restraint not to exceed 20 minutes and a mechanical restraint not to exceed 2 hours, (specify type). The restraint type was identified as "physical hold with secure guide escort". The restraint and seclusion flow sheet indicated that the patient was placed in four point restraints at 4:45 PM. Although the physician note dated 7/22/17 at 5:30 PM indicated that the patient was agitated, throwing items and was subsequently placed in four point restraints for protection of others the physician order failed to identify the specific type of restraints to be utilized.

Review of the policy indicated that the order for restraints must include the date, time, time limit and the type of restraint to be used. Interview with the Director of Regulatory on 8/24/17 at 10:20 AM confirmed that the order lacked the identification of the type of restraint. The Director of Regulatory indicated that the physician documented the type in his/her note completed on 7/22/17 at 5:30 PM, (thirty five minutes after the application of the four point restraints).

Based on medical record reviews, review of facility policies and interviews for 1 of 3 patients reviewed for privilege level (Patient #319), the facility failed to ensure that a physician's order was in place to direct variations in the patient's activity level. The finding includes:


Patient #319's diagnoses included paranoid schizophrenia and post-traumatic stress disorder (PTSD). Physician orders dated 8/29/17 directed level 2 activity. The integrated treatment plan (ITP) dated 8/29/17 identified a behavioral guideline that a dedicated staff member accompany the Patient when eating on the dining room so that the Patient may return to the unit early upon his/her request. Physician orders dated 8/30/17 directed level 3A privilege level. Review of the Patient's record and interview with Unit Director #1 on 9/11/17 at 2:37 PM noted that Patient #319 also required a one to one accompaniment when the patient goes to the courtyard. Further interview identified that there should be a physician's order for the one to one and an order had not been written. The facility policy for patient privileges identified that increase or decrease in any patients' freedom of movement must be documented by the Attending Psychiatrist on the Physician's Order Sheet. The facility policy for special observation policy indicated that special observation to include one to one requires a written order by the examining provider.

1. Based on medical record reviews, review of facility policies and interviews for 1 of 3 patient who required one to one engagement (Patient #319), the facility failed to ensure that the nursing engagement activity for each shift included documentation of the Patient's preferred activity. The finding includes:


Patient #319's diagnoses included paranoid schizophrenia and post-traumatic stress disorder (PTSD). The integrated treatment plan (ITP) dated 8/29/17 identified a nursing intervention for individual nursing engagement twice a day and to offer preferred plan activities as identified in the patient's list of personal preferences. A review of the engagement progress notes dated 9/7/17 to 9/10/17 indicated that although the patient participated in an engagement activity twice daily from 9/7/17 to 9/10/19, the documentation lacked the actual activity that the patient participated in for each shift. Interview with Supervisor #1 on 9/11/17 at 2:30 PM noted that he/she was unaware that the preprinted engagement progress note did not have a section to document the actual activity and that this would be important to know.
Although the facility memorandum dated 12/14/12 identified that the MHA (mental health assistant) documentation on the treatment specialist engagement note include, in part, the patient's response to the activity, the memorandum lacked direction for documentation of the preferred activity the patient participated in.




2. Based on medical record reviews, review of facility policies and interviews for 2 of 6 patients reviewed for restraint use (Patients #301 and #319), the facility failed to ensure that safety treatment interventions were identified in the patient's treatment plan. The finding includes:


a. Patient #301 was admitted the hospital on 3/6/13 with significant harm to self and/others. Patient #301's diagnoses included Diabetes, Bipolar Disorder and Obesity. Patient #301 has a history of serious aggressive/self-injurious behaviors and ingesting items. Review of the physician orders dated 7/2017 identified that Patient #301 was on constant (continuous) observation with one staff member for the protection of self/others. On 7/8/17, Patient #301 was in a group room with Mental Health Worker #2 listen to music on headphones. Patient #301 asked MHW #2 to listen to a song on his/her headphones. MHW #2 bent down and immediately the patient snatched his/her pen from their folder and swallowed a pen. Further review identified that multiple staff were called and attempted to get the pen from Patient #301, however, the patient was sent to the hospital for removal of a foreign body.

Interview and review of the clinical record with Nursing Director #3 on 9/15/17 identified that a treatment plan is usually updated with a significant change in the patient's condition, however, the treatment plan was not updated after Patient #301 ingested a pen.
Review of the integrated treatment plan dated 7/12/2017 and 8/4/17 identified that although the incident regarding the ingestion of a pen was noted on 7/8/17, the treatment plan failed to identify additional interventions to ensure the patient's safety after the incident.
Review of facility policy identified that the treatment plan is reviewed on a regular basis to ensure that it effectively addresses the wishes, concerns and needs of the individual receiving care. Any new risk, the team reviews the treatment plan, achievement of goals and objectives, and progress toward discharge. The integrated treatment plan is also reviewed whenever the individual in recovery experiences a significant change in their psychiatric/behavioral condition and/or physical heath.

Review of the integrated treatment plan dated 8/9/17 identified that after two assaultive episodes with staff, Patient #301 had been able to go on fresh air breaks and had set a new goal for treatment compliancy and engagement in recovery. Further review lacked documentation in the treatment plan that identified additional groups that Patient #301 had been attending since being compliant with treatment goals. Review of the group log sheet dated 7/30/17 to 9/2/17 identified that although the patient had excused absences documented, the log failed to identify any groups the patient had attended and/or including any other alternatives for treatment.

Observation of two group therapies on 9/12/17 (Green Street and Leisure Group) failed to identify that Patient #301 attended the groups or documentation was lacking as to why the patient did not attend these groups.
Interview with the Therapeutic Recreation Specialist on 9/15/17 identified that Patient #301 is not restricted to attend groups but is based on his/her behaviors. Further interview identified that Patient #301 was assigned certain things like fresh air privileges twice a day and music two times a day.

Review of the integrated treatment plan dated 9/6/7 identified that Patient #301 was restarted on his/her behavior plan on 1/23/17 which included finger foods, no utensils, three strong blankets and large towels for toileting with no underwear. In addition, monitoring of the patient in the bathroom includes 3 staff inside bathroom and 1 staff at the door. Further review failed to identify that Patient #301's behavior plan was reviewed with interventions to promote an increase in the patient's dignity and/or privacy. Patient #301 continued to have no underwear, utilized towels for toileting and had no feminine hygiene products Interview with the Nursing Director #3 on 9/15/17 identified that the patient has in the past put some of these items into his/her body and it would be a safety risk, however, has not seen this behavior in the last few months.
Review of facility policy identified that the treatment plan is reviewed on a regular basis to ensure that it effectively addresses the wishes, concerns and needs of the individual receiving care. Any new risk, the team reviews the treatment plan, achievement of goals and objectives, and progress toward discharge. The integrated treatment plan is also reviewed whenever the individual in recovery experiences a significant change in their psychiatric/behavioral condition and/or physical heath.




b. Patient #319's diagnoses included paranoid schizophrenia and post-traumatic stress disorder (PTSD). Physician orders dated 6/6/17 directed to administer Prolixin, Benadryl and Ativan if the patient refused oral Prolixin, Valproic Acid, Topamax and Trileptal. The treatment plan dated 6/7/17 identified a behavioral guideline indicating that the Patient will follow his/her recommended medication regime. Restraint documentation dated 6/12/17 indicated that Patient #319 refused his/her oral medication, attempted to attack the nurse and was restrained in 4- point restraints per MD order from 10:38 AM to 11:40 AM and intramuscular (IM) medications were administered (Prolixin, Benadryl and Ativan). Interview with Supervisor #1 on 9/11/17 at 2:30 PM identified that Patient #319 can be given medications against his/her will per the Probate Court and Patient #319 had an aversion to needles. Supervisor #1 further indicated that Patient #319 was a safety risk to his/her self and others for the IM medication administration and Person #1 (Conservator) gave permission for Patient #319 to be restrained for the IM medication administration. Review of the Patient's record and interview with Supervisor#1 on 9/11/17 at 2:30 PM identified that although an order would be obtained for each restraint episode, the treatment plan lacked documentation for the Patient's aversion to needles and/or the agreed upon safety intervention for the use of restraints for IM medication administration. The facility ITP identified that the plan should integrate and coordinate all selected services, supports and treatments provided to the individual while they reside at the hospital in a manner to meet the individual's treatment and rehabilitation goals. The plan consists of, in part, specific interventions that should consider, in part, risk/safety issues.


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3. Based on review of clinical records, incident reports, hospital policies and procedures, and interviews for one patient with a history of being physically victimized by peers (Patient #103) and for one patient with a history of physical aggression towards peers (Patient #105), the hospital failed to develop comprehensive Integrated Treatment Plans (ITP) that included interventions to prevent further victimization and/or aggression towards peers. The findings include:

a. Patient #103 was admitted to the hospital on 7/29/16. Diagnoses included dementia with behavior disturbance with a history of Traumatic Brain Injury (TBI) and adult physical and sexual abuse. The patient spoke a limited amount of English and required an interpreter, exhibited difficulties maintaining personal boundaries, and had a history of making inappropriate, sexualized comments. Review of the clinical record identified Patient #103 was assaulted by peers on 2/17/17, 3/17/17 and 4/4/17. Following another assault by a peer on 7/21/17, Patient #103 was to another unit. Review of Patient #103's ITP dated 7/31/17 failed to identify the patient's risk of being a victim of acts of physical aggression and assault by peers.

b. Patient #105 was admitted to the hospital on 7/20/16 with a diagnoses of schizoaffective disorder, bipolar type. An annual psychiatric progress note dated 7/21/2017 identified that Patient #105 had a personal history of physical trauma while incarcerated and initially exhibited inappropriate behaviors with patients of the opposite gender and was grandiose and delusional. Patient #105 assaulted peers on 9/16/16, 9/22/16 and in December of 2016. Although Patient #105 was transferred to another unit, Patient #105 continued to be verbally aggressive with grandiose delusions, was inappropriate with peers of the opposite gender and assaulted peers on 4/7/17. Patient #105 was transferred to a same gender unit on 5/2/17 where he/she continued to be psychotic with grandiose delusions despite multiple adjustments of psychotropic medications. Review of an ITP dated 7/20/17 identified predisposing risk factors of aggression that include chronic mental illness, substance abuse, lack of insight, and a condoning environment. Precipitating factors include issues related to food, medication non-adherence, and exacerbation of psychiatric symptoms. Although the coping skills of watching TV, walking away from conflict, exercise, music, and medication adherence were identified as strategies to utilize to mitigate the psychiatric symptom of aggression, the ITP failed to provide specific interventions for managing Patient #105's acts of aggression towards peers.

c. An incident report dated 7/21/17 at 5:10 PM identified that Patient #105 was in the dining room when Patient #103 entered the dining room. According to hospital documentation including an incident report, and documentation by RN #46 and MD #10, Patient #105 pushed Patient #103 against a wall causing Patient #103 to fall to the floor and Patient #105 proceeded to repeatedly punch Patient #103 in the face. Interview with RN #40 on 8/23/17 at 2:00 PM identified that he/she arrived in the dining room to find Patient #105 on top of Patient #103 punching Patient #103 in the face. RN #40 assisted in separating the patients. Patient #105 required seclusion and Patient #103 required medical treatment. MD #10 identified that Patient #103 was hit in the nose and fell to the floor sustaining abrasions. Patient #105 hit Patient #103 in the nose, and continued to punch Patient #103 while he/she was on the floor. Patient #103's nose bleed was controlled by the application of ice and the patient was evaluated at an acute care hospital with no nasal fractures identified. Patient #105 received intramuscular injections of antipsychotic medication and was placed in locked seclusion. Subsequent to the incident, Patient #103 was transferred to another unit.

A policy for ITP identified that the purpose of the ITP is to develop and maintain a plan of recovery with each individual in the hospital's care. The hospital addresses the needs of individual's over time. The plan consists of a series of goals, objectives, and interventions designed to address the needs identified by the person in recovery. Interventions should consider (in part) risk/safety issues. The treatment plan should be revised to reflect the individual's current status and should by reflected in the goals, objectives, and interventions.

Based on clinical record review and interview with staff for 1 of 3 patient records (Patient #302), the hospital failed to ensure that the clinical record contained only information pertinent to Patient #302. The findings include:

Review of Patient #302's clinical record on 9/11/17 identified observation sheets belonging to another patient, Patient #307. Patient #307's observation sheets dated 9/8/17, 9/9/17 and 9/10/17 identified target positive behaviors, interventions, and the patient's response to the interventions. Interview with the Director of Nursing (RN #49) on 9/11/17 at 12:05 PM identified that Patient #307's clinical record information should not have been in Patient #302's clinical record.

Based on review of hospital documentation and observations, the hospital failed to ensure that proper radiation safety precautions were maintained. The findings include:


On October 3, 2017 as part of the Connecticut Valley Hospital (CVH) Full Certification Survey, the Radiology Department of CVH was inspected for compliance with federal regulations.

The inspection consisted of a review of records, procedures, equipment and facilities, including the following: (a) in-house physics reports and follow-up corrective actions; (b) personnel dosimetry records; (c) shielding surveys; (d) records of calibration of x-ray equipment; (e).

In the Radiology Department, the following item of non-compliance was identified within the scope of the inspection.

R.C.S.A 19-24-8 (5)(C) requires in part that each area or room in which sources of ionizing radiation other than radioactive materials are used shall be conspicuously posted with the sign or signs bearing the radiation caution symbol and appropriate wording to designate the nature of the source.

Contrary to the above, CVH did not have the proper conspicuously posted radiation sign for dental operatories in the Merritt Building.

Based on review of hospital documentation and observations, the hospital failed to ensure that proper radiation safety precautions were maintained. The findings include:


On October 3, 2017 as part of the Connecticut Valley Hospital (CVH) Full Certification Survey, the Radiology Department of CVH was inspected for compliance with federal regulations.

The inspection consisted of a review of records, procedures, equipment and facilities, including the following: (a) in-house physics reports and follow-up corrective actions; (b) personnel dosimetry records; (c) shielding surveys; (d) records of calibration of x-ray equipment; (e).

In the Radiology Department, the following item of non-compliance was identified within the scope of the inspection.


RCSA Sec. 19-24-6(a)(1) requires in part each owner will provide personnel monitoring or be able to produce surveys necessary to comply with Sec. 19-24-1 through Sec. 19-24-14.

Contrary to the above, CVH did not provide dosimetry to their occupationally exposed radiation workers in a manner that properly recorded their occupational radiation dose.

Based on review of hospital documentation and observations, the hospital failed to ensure that staff who were subjected to radiation exposure were properly monitored. The findings include:

On October 3, 2017 as part of the Connecticut Valley Hospital (CVH) Full Certification Survey, the Radiology Department of CVH was inspected for compliance with federal regulations.

The inspection consisted of a review of records, procedures, equipment and facilities, including the following: (a) in-house physics reports and follow-up corrective actions; (b) personnel dosimetry records; (c) shielding surveys; (d) records of calibration of x-ray equipment; (e).

In the Radiology Department, the following item of non-compliance was identified within the scope of the inspection.

RCSA Sec. 19-24-6(a)(1) requires in part each owner will provide personnel monitoring or be able to produce surveys necessary to comply with Sec. 19-24-1 through Sec. 19-24-14.

Contrary to the above, CVH did not provide dosimetry to their occupationally exposed radiation workers in a manner that properly recorded their occupational radiation dose.

The Condition of Participation for Physical Environment has not been met.

Based on observations, review of hospital documentation, and interviews with staff, multiple points of ligature were identified throughout the five patient care buildings resulting in a finding of Immediate Jeopardy.

Please see A701

Based on observations, review of hospital documentation, and interviews with staff, multiple points of ligature were identified throughout the five patient care buildings resulting in a finding of Immediate Jeopardy. The findings include:


1. a. A tour of the Dutcher 3N unit (census 26) was conducted on 9/11/17 with RN #49 (Director of Nursing). Observation of Patient #302's bedroom (Room #305) and other patient rooms throughout the unit from 10:43 AM to 11:10 AM identified that each room was equipped with two night lights that had oblong shaped, domed plastic covers. At least one bed in each room was positioned so that the nightlight was on the side of the bed, approximately 2 to 3 feet above the bed and secured to the wall. A gap behind each nightlight was also observed as a possible ligature point. Interview with RN #49 (DNS) on 9/11/17 at 11:00 AM indicated that she believed that the plastic nightlights were present in all patient rooms in the Dutcher building. Subsequent observations of the Dutcher 3S unit (census 23) on 9/11/17 at 1:30 PM and Dutcher 2N (census 24) and 2S (census 22) units on 9/12/17 from 9:32 AM to 12:00 PM verified that the same nightlights existed in all observed bedrooms. Review of the Environmental Safety Risk Assessment of D3N room #350 dated 1/4/17 failed to identify the night lights as a safety risk. Review of the risk assessments for the remaining rooms on D3N and units D2N, D2S and D3S units also failed to identify the night lights as a safety risk.


b. A tour by the Life Safety Code (LSC) surveyor of the Dutcher Building on 09/12/17 at 9:00 AM and times throughout the day with the facility Plant Facility Engineer 1 along with a Building Skilled Trades Worker observed that the building television rooms throughout the building had cables and padlocks securing patient refrigerator doors that were unsupervised and could be utilized as a ligature point. These ligature points were not identified as a risk to patient safety on the most recent facility's risk based analysis of the Dutcher Building. Subsequent to these observations, the refrigerators were removed to a staff secured area.


c. A tour by the Life Safety Code (LSC) surveyor of the Dutcher Building on 09/12/17 at 9:00 AM and times throughout the day, the surveyor and the facility Plant Facility Engineer 1 along with a Building Skilled Trades Worker observed that fire alarm notification appliances and night lights utilized throughout the building patient room corridors that were not under direct staff observation could be utilized as a ligature point. These ligature points were not identified as a risk to patient safety on the facility's most recent risk based analysis of the Dutcher Building.


2. a. Tour and observation of the Battell B3N unit on 9/11/17 at 3:10 PM with Program Manager #2 identified a black box located on the interior of a bathroom door. The box was associated with components of a self-closing door which created a ligature risk. In addition, in this bathroom there was a plastic garbage/linen container able to hold the weight of a patient that could be used to stand on to gain access to the black box. Review of the unit's Environmental Safety Risk Assessment dated 8/7/17 failed to identify that the black box was a point of ligature and failed to identify that the garbage/linen container could be used to gain access to the black box.


b. Tour and observation of the (Battell) B2S unit on 9/11/17 at 10:00 AM with Program Manager #2 identified a medical bed in use in bedroom #2280. Observation identified that when the head of the bed was raised, there were exposed bed springs on the decking that created a ligature risk. Review of the unit's Environmental Safety Risk Assessment dated 8/22/17 failed to identify that the medical bed had exposed springs that could be used as a point of ligature.


c. A tour by the Life Safety Code (LSC) surveyor of the Battell Building on 09/13/17 at 2:00 PM with Facility Plant Facility Engineer 1 along with a Building Skilled Trades Worker observed that the 2nd floor center core building patient infectious disease Isolation Room was not designed to a behavioral health institutional standard i.e. bath controls and faucets that posed a ligature hazard, non-tamper resistant and/or hospital grade electrical outlets and building maintenance/skilled trade workers lacked keys to the room. The room was not identified as a risk to patient safety on the facility's most recent risk based analysis of the Battell Building.


d. A tour by the Life Safety Code (LSC) surveyor of the Battell Building on 09/13/17 at 9:30 AM and times throughout the day with Facility Plant Facility Engineer 1 along with a Building Skilled Trades Worker observed that the East and West Dorms on the second, third, and forth floors had wire mold conduit raceway that had 2 X 4 junction boxes containing the wiring for the pressure alarms for the cubicle room dividers that posed a ligature hazard. The boxes were not identified as a risk to patient safety on the most recent facility's risk based analysis of the Battell Building.


e. A tour by the Life Safety Code (LSC) surveyor of the Battell Building on 09/13/17 at 9:30 AM and times throughout the day with Facility Plant Facility Engineer 1 along with a Building Skilled Trades Worker observed that the East and West Dorms on the second, third, and forth floors had connection openings in the walls of the cubicle room dividers that posed a ligature hazard. The holes in the cubicle room divider walls were not identified as a risk to patient safety on the facility's most recent risk based analysis of the Battell Building.


3. a. During a tour with the Woodward building Program Manager on 9 /11/17 and 9/12/17 it was identified the Woodward building shower rooms contained plastic, empty glove boxes secured by non-breakaway screws. Upon examination the empty glove boxes were loose and/or allowed for a gap between the glove box and wall allowing a potential ligature point. Involved hospital units included: Woodward North first and second floor and Woodward South first floor, both male and female shower rooms. Upon surveyor inquiry the plastic glove boxes were removed from all male and female shower rooms.


b. A tour by the Life Safety Code (LSC) surveyor of the Woodward Building on 09/12/17 at 8:30 AM with Facility Plant Facility Engineers 1 & 2 with a Building Skilled Trades Worker observed that the over bed night lights throughout the building patient rooms were a ligature point hazard. A representative sample of the lights, when tested with a lanyard, held an adult male placing body weight with a downward motion. The lights were not identified as a risk to patient safety on the facility's most recent risk based analysis of the Woodward Building. Subsequent to these observations the skilled trade workers started removing the lights.


4. a. A tour by the Life Safety Code (LSC) surveyor of the Merritt building on 09/11/17 at 10:00 AM and times throughout the day with Plant Facility Engineer 1 and the Building Skilled Trades Worker observed that water fountains throughout the building day rooms were not under direct staff observation and were equipped with goose neck bottle fillers and/or slanted water outlets that could be utilized as a ligature point.. These ligature points were not identified as a risk to patient safety on the most recent facility's risk based analysis of the Merritt Building. Subsequent to these observations, the water fountains that were not under direct staff observation were removed by facility engineering staff until the fountain water outlets could be replaced by institutionally designed parts.


b. A tour by the Life Safety Code (LSC) surveyor of the Merritt building on 09/11/17 at 10:00 AM and times throughout the day with Plant Facility Engineer 1 and the building Skilled Trades Worker observed that privacy curtains tracks between patient beds throughout the second, third and fourth floors had non security/tamper resistant hardware throughout the building.


5. A tour by the Life Safety Code (LSC) surveyor of the entire facility on 09/13/17 through 09/14/17 the surveyor with Facility Plant Facility Engineer 1 along with a Building Skilled Trades Workers observed that the patient corridors and common areas throughout the facility had handrails that were not designed to a behavioral health institutional standard that posed a ligature hazard. The handrails were not identified as a risk to patient safety on the facility's most recent risk based analysis for the patient care environment.

Interview with Facility Plant Facility Engineer 1 on 9/13/17 and 9/14/17 identified that the risk based analysis of each building is conducted annually.



6. Based on observation, review of manufacturer instructions, hospital documentation and interviews, the hospital failed to ensure that beds utilized for application of mechanical restraints were assessed as safe for patient use. The findings included:


Tour and observation of the Battell building with Program Manager #2 on 9/11/17 at 9:55 AM identified 4 rooms used exclusively for patients who required mechanical restraints. Each room had a bed designated as a restraint bed. The design and age of the beds (old thin metal framed hospital bed with little structural stability) created a potential hazard for use as a restraint bed if used for an agitated, struggling or aggressive patient. The beds had non-locking wheels that would not prevent the bed from moving and/or tipping, metal edging on the decking that could contribute to injury, gaps in the decking allowing a patient to grab and/or grip the deck increasing the potential for tipping or sustaining an injury and a head and foot board that could be used for self-harm.

Interview with the Accreditation Manager on 9/14/17 at 1:00 PM identified that he/she had worked at the hospital for greater than twenty years and believed that the restraint beds were recycled, original psychiatric patient beds that had been stored in a hospital warehouse.

Interview with the Director of Nursing Quality and Patient Safety on 9/14/17 at 12:15 PM identified that the hospital has used the restraint beds for many years and they had been previously cited by their accreditation agency for issues related to the use of the beds. The hospital's plan was to replace all of the old restraint beds throughout the hospital. However, as of 9/14/17 only one of the four buildings (Dutcher) received new restraint beds with appropriately fitting restraints. The three other patient care buildings continued to utilize the old beds.



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Based on an observation during tour of an in-patient psychiatric unit, the hospital failed to ensure that supplies such as patient bed pillows were maintained to ensure an acceptable level of safety and quality. The findings include:

A tour of patient room # 2276 on B2S was conducted with Program Manager #2 on 9/12/17 at 3:30 PM. The patient bed pillow was noted without a pillow case. The pillow had a plastic-like surface that was cracked with many loose pieces of the surface material. The surface was breached, exposing interior filler. The deteriorated surface presented a portal for bacteria and moisture, inhibiting thorough, effective cleaning and the cracked pillow an acceptable level of quality and comfort for the patient.

Based on document review, staff interview, and hospital policy review, the facility failed to ensure that the Psychosocial Assessment for six (6) of 15 active sample patients (A2, A3, A4, A5, A6 and A11) included a description of the anticipated Social Work roles in treatment. This failure results in critical patient psychosocial information necessary for treatment and discharge planning decisions not being available to the other members of the treatment team.

Findings include:

A. Record Review:

1. Patient A2 was admitted for "increased psychosis and agitation resulting in hitting a staff member" on 7/17/17. The Psychosocial Assessment completed on 7/21/17 did not identify specific roles for social work in this patient's treatment and discharge planning.

2. Patient A3 was admitted for "delusional thinking" on 6/8/16. The annual updated Psychosocial Assessment completed on 6/2/17 did not identify specific roles for social services in this patient's treatment.

3. Patient A4 was admitted for "Occasional emotional dysregulation, verbal aggression and physical assaults" on 3/17/14. The annual updated Psychosocial Assessment completed on 3/16/17 did not identify specific roles for social work services in this patient's treatment.

4. Patient A5 was admitted for "aggression/assaultiveness, self-harming behaviors, medication non-adherence" on 3/30/17. The Psychosocial Assessment completed on 3/31/17 did not identify specific roles for social work services in this patient's treatment.

5. Patient A6 was admitted for "Alcohol Dependence issues" on 8/2/17. The Psychosocial Assessment completed on 8/7/17 did not identify specific roles for social work services in this patient's treatment.

6. Patient A11 was admitted for "continues to present with serious thought disorder and Sx (symptoms) of psychosis" on 1/27/17. The Psychosocial Assessment completed on 1/31/17 did not identify specific roles for social work services in this patient's treatment.


B. Policy Review:

The hospital's "Operational Procedure Manual" Section III, Chapter 12, Procedure 12.a.16: "Psychosocial History and Assessment" made no mention of conclusions and recommendations including anticipated social work role in treatment and discharge planning.

C. Staff Interview:

In a meeting with the Social Work Director and her senior social work staff on 9/6/17 at 1:45 p.m., they did not dispute the above findings and further stated, "It is an easy fix."

Based on medical record review and interview it was determined that the facility failed to provide psychiatric evaluations that included an assessment of patient assets in descriptive, not interpretive fashion for seven (7) of 15 active sample patients (A3, A5, A7, A9, A10, A11 and A14). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that might utilize the patient's positive attributes in therapy.

Findings include:

A. Record Review

1. Patient A3: The Psychiatric Evaluation, dated 6/8/16, noted under the section titled "Patient Strengths/Assets And Resources": "Patient has a good relationship with CVH (Connecticut Valley Hospital) staff. S/he is verbal and expressive about his/her needs."

2. Patient A5: The Psychiatric Evaluation, dated 3/30/17, noted under the section titled "Patient Strengths/Assets And Resources": "Resilient and good sense of humor, good rapport with outpatient team."

3. Patient A7: The Psychiatric Evaluation, dated 7/28/17, noted under the section titled "Patient Strengths/Assets And Resources": "Attached to mental health providers. On psychotropic, including injectable. Adequate current response to psychotropic."

4. Patient A9: The Psychiatric Evaluation, dated 8/4/17, noted under the section titled "Patient Strengths/Assets And Resources": "Patient has supportive mother, has medical provider, [Physician names] at a facility in Arizona. Patient has health issues."

5. Patient A10: The Psychiatric Evaluation, dated 5/16/17, noted under the section titled "Patient Strengths/Assets And Resources": "I'm smart, I'm strong, and I care a lot."

6. Patient A11: The Psychiatric Evaluation, dated 1/27/17, noted under the section titled "Patient Strengths/Assets And Resources": "Unknown-limited social support and resources (homeless)."

7. Patient A14: The Psychiatric Evaluation, dated 10/22/16, noted under the section titled "Patient Strengths/Assets And Resources": "Calm, cooperative."

B. Policy Review:

The Health Information Management Policy and Procedure Chapter 2, Procedure 2.3a "Admission Psychiatric Evaluation" approved on August 26, 2015, under XI stated: "Patient Strengths/Assets and Resources documents the patient's personal attributes as well as other resources available to him/her that might be employed to promote recovery."

C. Interview:

In an interview on 9/6/17 at 1:05 p.m., the Medical Director did not dispute the findings that Psychiatric Evaluations failed to include personal attributes (skills, talent, or special interests) of the patients that could be used in their treatment during hospitalization.

Based on record review and interview, the facility failed to ensure the Master Treatment Plans (MTPs) for 12 of 15 active sample patients (A1, A2, A3, A4, A5, A7, A9, A11, A12, A13, A14 and A15) clearly delineated whether nursing and social work active treatment interventions would be delivered in individual or group sessions. In addition, the listed treatment interventions were generic monitoring and discipline functions that were required for all patients regardless of the reason for admission, assessed needs, and continued hospitalization. This failure results in treatment plans that lack consistency and fail to guide staff regarding the use of specific treatment modalities. Such failure potentially results in treatment that is inconsistent, disorganized, and ineffective.

Findings include:

A. Record review:

1. Patient A1: Master Treatment Plan, dated 8/10/17, identified the following problem (called "Barriers to Achieving Goals" by the facility): "Partial response to treatment in spite of many medication trials. Has remote history of assaultiveness and medication non-adherence."Deficient intervention statements included the following.

a. Nursing: (Nursing staff will offer [patient] a variety of games (including word, board, and card) or other cognitive stimulation activity while giving verbal reinforcement when [s/he] displays pro-social interactions." (2) RN will review with [patient] the prescribed medications and explain, to the best of [her/his] ability to comprehend, their purpose and utility for his health." (3) "The nurse will review [patient] components of a healthy lifestyle, on a weekly basis, including the benefit of physical activity and healthy eating, with information adjusted to suit [patient's] level of comprehension." It was not stated if interventions listed would be provided in individual or group sessions and some were routine nursing functions.

b. Social work: "Social worker will meet with [patient] to encourage engagement in various treatment activities including meeting with the social worker." It was not stated if meetings will occur in individual or group sessions. The intervention of encouraging the patient was a routine social work task.

2. Patient A2: Master Treatment Plan, dated 8/31/17, identified the following problem: "Psychosis." Deficient intervention statements included the following.

a. Nursing: "RN (Registered Nurse)/MHA (Mental Health Assistant) will provide reality orientation and assist patient with [her/his] daily activities." It was not stated if interventions listed would be provided in individual or group sessions and some were routine nursing functions.

b. Social work: "Social worker will meet with [patient] weekly for 30 minutes or as needed to address prosocial interactions with peers and staff. [Patient] will be able to verbalize [her/his] understanding of how [her/his] positive behavior will help [her/him] in the community. Social worker will work with [patient] and find out from [her/him], what [her/his] individual needs will be for [her/him] to have a successful discharge." It was not stated if meetings would occur in individual or group sessions. The interventions were routine social work functions. The intervention statement included a patient outcome reflecting what the patient would be doing rather than how the social worker would assist the patient to achieve the outcome.

3. Patient A3: Master Treatment Plan, dated 8/9/17, identified the following problem: "Long history of chronic persistent mental illness. [S/he] has a pattern of not adhering to [her/his] medication regime which causes rapid decompensation and increased paranoia and delusions." Deficient intervention statements included the following.

a. Nursing: "MHA to provide prompting and cueing to [patient] throughout the day regarding attending ADL's [activities of Daily living] and hygiene. And will assist with completion of these tasks as indicated. MHA's will encourage [patient] to attend daily programing as prescribed. The goal is to assist [patient] in maintaining and supplementing both [her/his] cognitive and physical abilities." (2) "RN will provide 2x/daily assessments to [patient] to monitor for [her/his] individual psychiatric symptoms, which include paranoia, mood instability, and delusional thinking. The RN will provide [patient] feedback from [her/his] assessments and education to help [her/his] recognize and modulate [her/his] symptoms. The RN will encourage adherence to treatment, including compliance with Olanzapine and Depakote. The goal is to help prepare [patient] for a successful discharge to a lower level of care."It was not stated if interventions listed would be provided in individual or group sessions and the intervention statements regarding encouraging, monitoring, assessing the patient were routine nursing functions.

4. Patient A4: Master Treatment Plan, dated 8/22/17, identified the following problem: "Aggression, mood lability." Deficient intervention statements included the following:

Nursing: "Due to [patient's] weakness in attention, when possible the nursing staff will make sure they have [her/his] full attention and that distractions are minimized. Door to room may have to be closed. T.V. or radio may have to be turned off. Intrusive peers may have to be redirected away. [Patient] may have to be relocated away from noise and distractions to have a particular discussion. (2) Due to [Patient's name] slow processing speed, important information should be given in small amounts, possibly over multiple visits, with repletion and reinforcement. This will allow [patient] to process information and help facilitate later recall. Staff should be prepared to repeat things and slow down the pace of the interaction. People providing information should ask her/him at points during the conversation if [s/he] understands the information, encourage [her/him] to ask questions, and ask [her/him] to repeat or summarize what was discussed with [her/him]. (3) As hypoxia can cause/exacerbate cognitive limitations, [patient] should be encouraged to wear [her/his] BiPAP[Bilevel Positive Airway Pressure] device when resting/sleeping in bed to help maintain adequate oxygenation. (4) [Patient] should be encouraged to engage in independent problem solving, to increase [her/his] level of empowerment. Offering [her/his] choices to choose from is helpful in this regard. (5) [Patient] tends to engage in perseverative thinking, and redirecting [her/his] attention may help alleviate that. Distracting [her/his] with pleasurable conversation of an enjoyable activity can be helpful. (6) [Patient] will at times need and benefit from prompting and cues with basic activities allowed to take a timeout and temporarily as activities relating to ADL's. (7) If [patient] becomes anxious [s/he] should be allowed to take a timeout and temporarily remove [her/himself] from the situation or discussion. (8) [Patient] is likely to be better in small groups or one on one interactions as opposed to large groups of people, especially if several people are talking at a time." These statements were instructions for providing safe nursing care not active treatment interventions to assist the patient to achieve the identified patient outcomes.It was not stated if interventions listed would be provided in individual or group sessions and some were routine nursing functions.

5. Patient A5: Master Treatment Plan, dated 8/28/17, identified the following problem: "History of assaultive and self-injurious behavior, psychotic symptoms, impulsivity, and intrusiveness." Deficient intervention statements included the following:

a. Nursing: "Encourage [patient] to express how [s/he] is feeling that day and if [s/he] is having any feeling of harm to self/others. Prompt patient to utilize coping skills if s/he is experiencing emotional difficulties." (2) "RN will facilitate self-care abilities and [her/his] sense of responsibility by developing a clearer understanding of the medications [s/he] is taking. It is also felt that a greater patient and staff report [sic] increases the therapeutic alliance enabling the patients to maximize the likelihood of compliance." It was not stated if interventions listed would be provided in individual or group sessions and some were routine nursing functions.

6. Patient A7: Master Treatment Plan, dated 8/30/17, identified the problem "Impulsivity and poor self-care abilities and [her/his] decision making leading to frequent relapse and re-hospitalization." Deficient intervention statements included the following:

a. Nursing: "RN will review with [patient] how [s/he] plans to use [her/his] leisure time, and suggest an activity that will promote physical activity and health (walking, deep breathing). RN will review any present symptoms of psychosis with [patient] discuss olanzapine, Haldol, and benztropine with [patient] and review intended effect of medications. RN will discuss with [patient] [her/his] perception of how taking these medications assist [her/him] in [her/his] recovery from substance abuse." It was not stated if interventions listed would be provided in individual or group sessions.

b. Social work: "Will meet on Mondays (x1 week for 45 minutes) from admission to discharge with clients on the B-side of Unit AB. Method utilized will be topic focused discussion and handouts to augment the learning experience." It was not stated if meetings will occur in individual or group sessions and the topic of discussion was not specific.

7. Patient A9: Master Treatment Plan, dated 8/21/17, identified the following problem: "History of sexual assault. Not taking medication." Deficient intervention statements included the following:

a. Nursing: "Will meet with patient at least twice a week to review and reinforce skills learned in DBT (Dialectical Behavior Therapy) and recovery groups which will help [her/him] reach [her/his] goal "to get my life straighten out." [sic] Nurse will encourage patient to learn the about the S/S (signs and symptoms) of mental illness (which affects [her/him]) as bipolar, PTSD (post-traumatic stress disorder) and depression and be able to use skills learned in recovery groups to help [her/him] through the moment or utilize prn [as needed] medication as ordered by MD (Doctor of Medicine)." It was not stated if interventions listed would be provided in individual or group sessions and some were routine nursing functions.

8. Patient A11: Master Treatment Plan, dated 8/10/17, identified the problem of "Medication non-adherence and resulting exacerbation of symptoms (delusion, paranoia, agitation)." Deficient intervention statements included the following:

a. Nursing: "Nursing will administer medication as prescribed and provide nursing care. Nursing will assist in management of aggressive behavior. Participants of aggression include substance use, medication non-adherence, increase psychotic symptoms. Staff will assist in management of aggressive behavior through verbal redirection, prn medication, and preferred activities like music and car [sic] playing."It was not stated if interventions listed would be provided in individual or group sessions and some were routine nursing functions such as administering medications.

b. Social work: "Social work will review with team whether [s/he] is clinically stable for group work. Social worker will discuss triggers and strategies for anger management with [patient]." It was not stated if meetings with the patient would occur in individual or group sessions. Review with the team was the routine task of the social worker.

9. Patient A12: Master Treatment Plan, dated 8/17/17, identified the problem of, "Cognitively limited, limited insight." Deficient intervention statements included the following:

a. Nursing: "Nurse will administer medications, notify MD of any refusal or side effects. Staff will continue to encourage [patient] encourage [sic] to attend any prescribed treatment groups. If [patient] presents with delusional thought content, staff will gently attempt to provide reality feedback in non-challenging manner. To manage aggression toward self and others, nursing staff recognize antecedents including jealousy of attention given to peers, changes routine, confusion and manage aggression through use of preferred strategies such as removing from stimulation, maintaining daily routine, talking with staff. If [s/he] appears agitated or angry, staff should redirect [her/him] to [her/him] preferred coping skills (additional medication, calling friend or family, cool drink) and notify MD as warranted." It was not stated if interventions listed would be provided in individual or group sessions and some were routine nursing functions such as administering medications and notifying the MD.

b. Social work: "Social Worker will meet with [patient] for least 20 minutes each week to encourage [her/his] towards meeting [her/his] objective of managing [her/his] symptoms (intrusive behaviors, self-harm, aggressive behaviors) using her/his preferred coping skills (playing video games, listening to music, talking with staff). Social worker will facilitate communication between CVH [Connecticut Valley Hospital], community (CMHA), Conservator and treatment team to identify and implement a plan for [patient] discharge." It was not stated if meetings will occur in individual or group sessions. Some interventions listed were routine social work functions.

10. Patient A13: Master Treatment Plan, dated 7/7/17, identified the problem of "[Patient] is continuing to exhibit significant psychotic symptoms despite [her/his] cooperation with taking antipsychotic medications." Deficient intervention statements included the following:

a. Nursing: "Administer meds as ordered. Explore how [patient] experiences [her/his] hallucinations and share experiences to help give [her/him] as sense of power that [s/he] might be able to manage the hallucinatory voice. Ongoing Help [sic] [patient] to identify times that the hallucinations are most prevalent and frightening. Ongoing Work [sic] with [patient] to find which activities reduce anxiety and distract the client from hallucinatory material and Practice skills with the client..." It was not stated if interventions listed would be provided in individual or group sessions and some were routine nursing functions.

b. Social work: "Intervention will include listening to songs and/or reading lyrics from various musical eras. After listening to music clients will engage in therapeutic discussion of meaning of music, lyrics and sounds they enjoy, and thoughts of feelings the music evokes. Clients will be encouraged to socialize with other peers and connect to others via universality of music." It was not stated if interventions would occur in individual or group sessions.

11. Patient A14: Master Treatment Plan dated 8/30/17 identified the problem "assaultive, impulsive, and aggressive behaviors. Increased paranoia, delusions impulsivity and risk of assault. [S/he] has minimal insight into the destructive behaviors [s/he] becomes involved in. Poor treatment compliance."A deficient intervention statement was as follows:

Nursing: "RN will encourage [patient] to engage in the recommended medical and psychiatric treatments on a daily basis. RN will encourage [patient] to manage any frustrations or irritabilities by 1) attending and participating in groups 2) accepting medical care and adjustments in [her/his] medications 3) utilizing effective coping skills and personal preferences (watching TV, talking with staff or on phone to [her/his] friends). RN to offer medication education as adjustments are made and dosing increase." The intervention statements regarding encouraging the patient were routine nursing functions. The intervention regarding medication education failed to include whether the education would occur in individual or group sessions.

12. Patient A15: Master Treatment Plan, dated 8/16/17, identified the following problem: "[Patient has a lengthy history of mental illness and treatment. [S/he] is cognitively limited and has difficulty engaging with others."A deficient intervention statement was as follows:

Nursing: "RN will provide daily assessment and orientation to [patient]. RN will administer medications as ordered by MD. RN will encourage [patient] to utilize [her/his] preferred coping skills (coloring, prayer) to manage increased frustration and stress." These interventions were routine nursing functions of assessing, administering medication, and encouraging patients instead of specific interventions provided in individual or group sessions to assist the patient to understand his/her medication and to mange stress.

B. Interviews

1. In an interview with Director of Staff Development and Director of Nursing# 2, on 9/7/17 at 9:10 a.m. the method of delivery for treatment interventions and generic nursing interventions on the MTPs were reviewed. They both agreed with the findings. Director of Staff Development stated, "We began training on active treatment interventions, we are not there yet."

2. In an interview with Social Work Director and her senior social work staff on 9/6/17 at 1:45 p.m., the social work interventions on the treatment plan were discussed. They agreed that some interventions did not include the delivery method when the intent was an individual contact was the patients.

3. In an interview on 9/6/17 at 10:00 a.m., SW#6, when reviewing the treatment plan for active sample patient A3, agreed that the social work interventions were not specific and did not include a method of delivery.

4. In an interview on 9/6/17 at 2:58 p.m., active sample patient A5's MTP was discussed.
SW#1 agreed that the delivery method was not included for all of the interventions on the patient's treatment plan.

Based on record review and interview, the facility failed to ensure that treatment notes for seven (7) of 15 active sample patients (A1, A3, A5, A10, A11, A12, and A15) reflected their response to treatment efforts. Specifically, treatment notes regarding the Medication Education and Health and Wellness groups assigned to registered nurses on Master Treatment Plans were not documented to include the specific information. The documentation failed to consistently includethe patients' response to the treatment intervention, including the level of participation, the level of understanding, behaviors exhibited, or specific comments by patients. In addition, patients' non-attendance in groups was not consistently documented. This failure results in information regarding active interventions and the response to these interventions not being available for the treatment team.

Findings include:

A. Record Review:

1. Patient A1's MTP, dated 8/10/17, identified following nursing interventions:

a. "Medication Education - RN will review with [Patient] the prescribed medications and explain, to the best of [his/her] to comprehend, their purposes and utility for [his/her] health." This intervention was planned for "30 minutes, weekly." A review of treatment notes from 8/5/17 through 9/5/17 revealed that the patient's level of participation and understanding was not documented consistently. In addition, the intervention noted was not the specific intervention assigned on the MTP. For the note, dated 8/30/17, it was difficult to discern the relevance of the topic for the medication group. The RN documented, "Group focus was on music, relaxation and self care."

b. "Health and Wellness - The nurse will review with [Patient] components of a healthy lifestyle, on a weekly basis, including the benefit of physical activity and healthy eating ..." This intervention was planned for "50 minutes, weekly."A review of treatment notes from 8/5/17 through 9/5/17 revealed that the patient's level of participation and understanding was not documented consistently. In addition, the intervention noted was not the specific intervention assigned on the MTP. A treatment note dated 8/5/17, reported, "Quietly participated in group activity." There was no other information about this patient's response to the intervention.

2. Patient A3's MTP, dated 8/9/17, identified following nursing interventions:

a. "Medication Education - RN will facilitate [Patient] self care abilities and [his/her] sense of responsibility by developing a clearer understanding of the medication [s/he] is taking ..." This intervention was planned for "30 minutes, weekly." A review of treatment notes from 8/5/17 through 9/5/17 revealed that the patient's level of participation and understanding was not documented consistently. The treatment note dated 8/11/17documented, "[Patient] appeared to listen and understand the material presented. [S/he] had no questions.There was no documented evidence of the patient's level of participation and how his/her understanding was determined.

b. "Health and Wellness - The nurse will provide weekly education to promote an Alcohol, Tobacco, and substance free lifestyle, Healthy eating ... safety and violence prevention." This intervention was planned for "45 minutes, weekly." A review of treatment notes from 8/5/17 through 9/5/17 revealed that the patient's level of participation and understanding was not documented consistently. The treatment notedated 8/5/17 reported, "[Patient] was present and alert and appeared to understand the material presented." There was no documented evidence of the patient's level of participation or how his/her understanding was determined.

3. Patient A5's MTP, dated 8/29/17, identified following nursing intervention:

a. "Medication Education - RN will facilitate [Patient] self care abilities and [his/her] sense of responsibility by developing a clearer understanding of the medication [s/he] is taking ..." This intervention was planned for "30 minutes, weekly." A review of treatment notes from 8/5/17 through 9/5/17 revealed that there only two of four treatment notes documented during this period. The "Individual's Consistency/Attendance of Programming" showed that the patient participated in the medication group 25% of the time. There were one documented attendance and one non-attendance. There were no other documented non-attendance or alternative offered this patient for the medication education group.

b. "Health and Wellness - The nurse will provide education, skills, and insight into achieving and sustaining an alcohol, tobacco, and substance free lifestyle, Healthy eating ... safety and violence prevention." This intervention was planned for "30 minutes, weekly." A review of treatment notes from 8/5/17 through 9/5/17 revealed that there only one of four planned groups documented during this period. The "Individual's Consistency/Attendance of Programming" showed that the patient participated in the Health and Wellness Group 0% during this period. However, there was one documented attendance on 8/5/17 and no documented non-attendance. There were no other documented non-attendance or alternative offered this patient for the health and wellness group.

4. Patient A10's MTP, dated 7/13/17, identified following nursing interventions:

a. "Medication Education - RN will engage [patient] in 1 Medication Education session weekly, for the next 8 weeks, to improve and maintain [her/his] medication knowledge, symptom management and medication compliance ..." This intervention was planned for "45 minutes, weekly." A review of treatment notes from 8/5/17 through 9/5/17 revealed that the patient's level of participation and understanding was not documented consistently. The treatment note dated 8/9/17 documented, "Participated in Group." On 8/16/17, the RN documented,"Patient participated in the group discussion." There was no documented evidence noting the patient response to the interventions that included the level of participation, the level of understanding, any specific comments by the patient, or the patient's behavior during the group session.

b. "Health and Wellness - RN will provide once weekly, for the next 8 weeks, education to [patient] to promote an Alcohol, Tobacco, and other substances free lifestyle, Healthy eating ... safety and violence prevention ..." This intervention was planned for "45 minutes, weekly." A review of treatment notes from 8/5/17 through 9/5/17 revealed that the patient's level of participation and understanding was not documented consistently. The treatment note dated 8/12/17 documented, "Participated in the group discussion." On 8/19/17, the RN documented, "Client participated in Health and Wellness group."There was no documented evidence noting the patient response to the interventions that included the level of participation, the level of understanding, any specific comments by the patient, and the patient's behavior during the group session.

5.Patient A11's MTP, dated 8/10/17, identified following nursing intervention:

"Health and Wellness - The nurse will review health and wellness in the management of aggression. Module concentrates on 4 skills areas: 1 obtaining information, 2. Knowing correct self administration and evaluation of medication, 3. Identifying side effects of medication, 4. Negotiating ..." This intervention was planned for "30 minutes, 2 times per week." A review of treatment notes from 8/5/17 through 9/5/17 revealed that the patient's level of participation and understanding was not documented consistently. The treatment notes dated 8/9/17 reported, "Good participation. "On 8/23/17, the RN documented, "Good participation, patient was off topic most of the group." There was no documented evidence regarding the patient's specific response to the intervention, specify comments the patient made to show good participation, the patient's level of understanding of the content, and any positive or negative behaviors exhibited during the group sessions.

6. Patient A12's MTP, dated 8/17/17, identified following nursing intervention:

"Health and Wellness - RN will provide skill building modules for [Patient]. These modules concentrate on 4 skills: 1. Obtaining information, 2. Knowing correct self administration and evaluation of medication, 3. Identifying side effects of medication, 4. Negotiating ..." This intervention was planned for "30 minutes, weekly." A review of treatment notes from 8/5/17 through 9/5/17 revealed that the patient's level of participation and understanding was not documented consistently. The treatment note, dated 8/9/17 and 8/23/17documented, "Good participation." There was no documented evidence regarding the patient's response to the intervention, specify comments the patient made to show good participation, the patient's level of understanding of the content, and any positive or negative behaviors exhibited during the group sessions.

7. Patient A15's MTP, dated 8/17/17, identified following nursing intervention:

"Medication Education - Group leader will enhance [Patient] knowledge about the psychotropic medications that [s/he] is taking. Teach [Patient's name] to ask physicians ... about [his/her] medications ..." This intervention was planned for "45 minutes, weekly." A review of treatment notes from 8/5/17 through 9/5/17 revealed that the patient's level of participation and understanding was not documented consistently. The "Individual's Consistency/Attendance of Programming" showed that the patient participated in the Medication Education Group 0% of the 5 groupsessions scheduled during this period. There were three of the five groups documented as non-attendance and only one documentation on 8/26/17 showing an alternative was offered this patient for the medication education group.

B. Interview

In an interview with the acting Director of Nursing (DON) and Director of Staff Development on 9/7/17 at 9:10 a.m., RN treatment notes were reviewed for active sample patients. They did not dispute the finding that treatment notes failed to include the patients' response to group interventions consistently. They agreed that there was limited information regarding the level of participation, the level of understanding, any specific comments made by patients, or behaviors exhibited during group sessions.

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

I. Provide sufficient active treatment measures for two (2) of five (5) active sample patients (A2 and A4) housed in the Woodward building. These patients were reported to be too "clinically unstable" to participate in the facility's scheduled group treatment program. Despite these patients repeated and regular non-attendance in the group treatment program, the Master Treatment Plan was not revised to reflect planned individual active treatment measures to engage them.This failure results in patients not receiving active treatment at the level and intensity for recovery, potentially delaying improvement and timely discharge from the hospital.

II. Ensure that a comprehensive face-to-face evaluation of the patient's status was documentedfor three (3) of four (4) non-sample patients (B1, B2, and B3) selected to review episodes of seclusion and restraint (S&R). Specifically, the review of notes during the first hour after S&R revealed that physicians did not document a comprehensive assessment that consistently included: the patient's response to the intervention, an evaluation of the patient's medical condition (a review of systems and medications to determine possible contributing factors); a behavioral assessment; and a statement regarding the need to continue or terminate the seclusion or restraint procedure. The lack of a comprehensive evaluation of a patient during the first hour of seclusion or restraint may potentially fail to identify adverse physical and mental effects of a seclusion or restraint procedure. Also, the Master Treatment Plans(MTPs) were not modified to reflect the use of seclusion or restraint with specific goals/objectives and interventions to prevent further restrictive procedures.This deficient practice could lead to the failure to identify and implement interventions that can prevent and avoid future seclusion or restraint episodes for patients.

Findings include:

I. Failure to provide active treatment

Record Review

1. Patient A2

a. Patient A2 was admitted on 7/17/17. The patient's Psychiatric Evaluation, dated 7/17/17, documented psychiatric diagnoses of "Schizoaffective disorder bipolar type, Major Neurocognitive disorder due to TBI [Traumatic Brain Injury] with behavior disturbance, Alcohol abuse, cocaine abuse." The Psychiatric Evaluation also noted,"[S/he] has had multiple psychiatric hospitalizations for paranoia, auditory hallucinations, manic episodes, and agitation." Throughout the survey, during observations, the patient was either in his/her room or sitting in the day area and not participating in or attending therapeutic groups.

b. During an interview on 9/5/17 at 3:06 p.m., Patient A2 talked to the surveyor for approximately two minutes and then terminated the interview making unclear statements about his concerns.

c. During an observation on 9/5/17 at 1:00 p.m. a group on the unit schedule titled, "Recovery through Art" was being conducted. Active sample patient A2 was in his/her room. This group included 4 of 13 patients on the unit. There was no other group treatment doing this period. During another observation on 9/6/17 at 12:00 p.m., the Mental Health Assistant (MHA) attempted to get Patient A2 to attend his/her assigned "Memory Group" scheduled at 12:00 p.m. The patient was agitated and made nonsensical angry statements.

d. The Master Treatment Plan (MTP), dated 8/31/17 identified one clinical problem, called "Barriers to Achieving Goals" by the facility: "Psychosis." The MTP had the following interventions for the objective of, "[Patient's name] will demonstrate safe and prosocial interactions with peers and staff, despite persistent paranoid delusions for at least 90 days ..."

Psychologist - "Cognitive Rehabilitation group will include various cognitive exercises ..." "Memory Group - Utilizing cognitive remediation techniques, including mnemonic strategies, to improve cognitive functions of group participants ..."

Rehabilitation Therapists -" ... RT2 will encourage [Patient] to initiate and follow along with conversation within the group setting to increase [his/her] ability to interact with staff and peers without interference from [his/her] paranoid delusions."

Registered Nurses - "RN/MHT will provide reality orientation and assist with [his/her] daily activities."

Social Worker - "Social Worker will meet with [Patient] weekly for 30 minutes to address prosocial interactions with peers and staff ..."

e. A review of the "Individual's Consistency/Attendance of Programming" from 8/5/17 through 9/6/17 showed the patient's limited participation in the planned group treatment identified above and revealed that of the 20 hours of group treatment scheduled, the patient participated was "20% of the time."There were no provisions made in the Master Treatment Plan to indicate that the current plan was not appropriate to the reality of the patient's "clinically unstable" condition. The MTP was not revised to reflect the reality of the patient's "clinically unstable" condition and show planned individual treatment to engage the patient daily instead of the scheduled group treatment.

f. In staff interviews, it was confirmed that the patient did not attend groups and that no alternative active treatment measures had been developed to identify appropriate interventions based on the patient's current psychiatric condition and level of functioning.

2. Patient A4

a. Patient A4 was admitted on 3/17/14. The patient's Master Treatment Plan, dated 8/22/17, documented psychiatric diagnoses of "Major depressive disorder - recurrent- in partial remission and Borderline personality disorder ..." The patient's Annual Psychiatric Progress Note dated 3/9/17 noted, "Throughout this past year, [Patient] has been adherent with medications ... For approximately the first six months, the severity, intensity and frequency of [Patient] behaviors of concern fluctuated but s/he was able to get [his/her] level up to Modified 4 [Patient was able to go to off unit groups and activities]. For the next six months, [his/her] behaviors of concerns increased with the addition of aggressive and assaultive behaviors ... At this time, [his/her] level of privilege is 1 [restricted to the unit]."

b. During an interview on 9/5/17 at 2:28 p.m., Patient A4stated, "I like the Coping skills and sensory movement groups, but I don't have the right level to go off the unit." The patient also said, "I enjoyed the Yahtzee game I played today. I haven't played in a long time." This activity was not a part of the facility's "Nursing Engagement" program as reported by MHA1 on 9/6/17 at approximately 3:10 p.m.

c. During an observation on 9/6/17 at 9:20 a.m., the patient was scheduled for a coping skills group but did not attend because the group was held outside of the unit. No other planned active treatment intervention was scheduled for this patient during this period. Throughout the survey, this patient was observed either in the day area or his/her room and was not engaged in planned group treatment interventions.

d. The Master Treatment Plan (MTP), dated 8/22/17 identified the clinical problems, called "Barriers to Achieving Goals" by the facility: "History of aggression, mood lability." The MTP included the following interventions for the objective of, "[Patient's name] will learn how to handle feelings of frustration and anger in constructive ways, as evidenced by having less than two incidents per week of loud, disruptive behavior ..."

Psychologist - " ... will engage in psychotherapy with [Patient] ... will assist [Patient] in modulating [his/her] emotional responses and express feelings in an appropriate manner and venue."This intervention was planned "30 minutes, 2 times per week."

Rehabilitation Therapists - "Leisure in Recovery ... - 1x weekly for 60 minutes ... RT2 will present activities of interest to [Patient] on unit and utilize day hall and smaller areas to encourage [his/her] to explore relationships with others ..." "Coping Skills and Stress Management -3 times weekly for 30 minutes, ... RT#2 will teach [Patient] stress reducing activities (yoga, meditation ... to facilitate calm relaxed behavior ..."

Registered Nurses - There were no specific active treatment interventions to be provided by RN in individual or group sessions identified on the patient's MTP. The MTP contained instructions for providing care and routine nursing duties.

Social Worker - "Discharge Planning - LCSW will meet with [Patient] to offer support, encouragement and education about attaining [his/her] goals and wishes for discharge .... Social Worker will meet with [Patient] weekly for 30 minutes to address prosocial interactions with peers and staff ..." "Reminiscing Group -The LCSW will present [Patient] with materials in a group setting that include music, information about historical events ..." This intervention was planned "30 minutes, weekly."

e. A review of the "Individual's Consistency/Attendance of Programming" from 8/5/17 through 9/5/17 showed limited participation in the planned group treatments identified above and revealed that of the 31 hours of group treatment scheduled, the patient participation was "13% of the time" in group treatment. There were no provisions made in the Master Treatment Plan to indicate that the current plan was not appropriate to the reality of the patient's "clinically unstable" condition. The MTP was not revised to show brief planned contacts with the patient to provide individual instead of group interventions to engage the patient on a daily basis.

B. Interviews

1. In a discussion on 9/5/17 at approximately 2:00 p.m., RN#6 presented the schedule for Patient A2 and stated, "This is all that is scheduled for the patient because [s/he] is clinically unstable at this time."

2. In an interview on 9/6/17 at 11:09 a.m. with RT#2, the documentation of group attendance and alternative active treatment measures was discussed. RT#2 stated, "Patients are excused [from attending groups] for illness or being clinically unstable" and noted that there were no expectations that alternative active treatment measures were to be implemented.

3. SW#1 stated, in an interview on 9/6/17 at 2:58 p.m., that Patient A4 did not attend groups because s/he was "clinically unstable" and spends a lot of time in his/her room. SW#1 noted when the patient refuses to attend group, the patient is seen in his/her room to provide the information presented in the group session. However, SW#1 was only able to locate two notes documenting these alternative active treatment sessions.

4. In an interview on 9/7/17 at approximately 10:00 a.m. with RN#5, RN#6, MD#1, and PsychD#1, active treatment for patient A2 was discussed. They did not dispute the finding that the patient was not attending the group treatment program. They agreed that the patient was not receiving active treatment at a level of intensity for recovery and acknowledged that the treatment plan had not been revised to reflect appropriate planned individual engagements with the patient by each clinical discipline.


II. Failure to document comprehensive face-to-face assessments after initiation of S&R:

A. Record Review

1. Patient B1

a. Patient B1 was admitted 8/31/16 and experienced multiple episodes of seclusion during August 2017. The patient was placed in locked seclusion six (6) times during this period. A review of the seclusion episode that occurred on 8/6/17 from 2:41 p.m. to 4:40 p.m.and the episode that occurred on 8/25/17 from 8:50 p.m. to 10:20 p.m. revealed that a comprehensive face-to-face evaluation was not conducted for these two episodes. The Physician orders and a description of behaviors leading to the use of seclusion were documented but there was no comprehensive one hour face-to-face evaluation documented which included: an evaluation of the patient's physical and psychological condition that included a review of systems and medications to determine if there were any contributory factors to explain the patient's behavior; a notation regarding the patient's response to the intervention; and a rationale for the patient continuing in seclusion.

b. Despite multiple episodes of seclusion, the Master Treatment Plan was not modified to reflect the use of locked seclusion to control this patient's behavior. A review of the Master Treatment Plan (MTP) submitted for this patient, dated 8/31/17,revealed no statement reflecting the use of locked seclusion to control the patient's aggressive behaviors. Also, there was no specific objective aimed at the patient developing non-harmful behaviors to prevent the use of further restrictive procedures. The MTP also failed to include interventions to address specific strategies regarding the prevention of further restrictive procedures with ways the patient could manage his/her aggressive without the use of seclusion. There was no document submitted that contained a "Focused Treatment Plan Review" as per facility policy. The facility policy, titled "Seclusion Use" revised 9/28/15, stated, "The treatment team will convene on the next business day to do a Focused Treatment Plan Review (FTPR), which includes a review of the seclusion episode looking at the predisposing, precipitating and perpetuating factors, any changes in the treatment plan in response to the episode, or the rationale for not making changes."

2. Patient B2

a. Patient B2 was admitted 4/26/17, and experienced multiple episodes of seclusion during August 2017. The patient was placed in restrictive procedures eight (8) times during this period (locked seclusion four (4) times and Posey net four times). A review of the mechanical restraint episode that occurred on 8/2/17 from 4:35 p.m. to 6:50 p.m. and the episode that occurred on 8/25/17 from 8:50 p.m. to 10:20 p.m. revealed that a comprehensive face-to-face evaluation was not documented for these two episodes. The Physician orders and a description of behaviors leading to the use of seclusion were documented but there was no comprehensive one hour face-to-face evaluation which included: an evaluation of the patient's medical condition would include a complete review of systems; a review of medications; a notation regarding the patient's response to the intervention, or a rationale for the patient continuing in seclusion. The "Physician Assessment" for 8/15/17 noted, "Patient was agitated, assaultive, swing at staff. [Illegible] garbage can and threw at staff. Not verbally redirectable." This was the only statement documented by the physician despite the following prompts for documentation requirements on the S& R Form: "Part I - Initial Assessment by RN and MD." This section required the following documentation, "Describe the emergency/imminent risk, direct assessment of the patient and determination regarding the need for continued seclusion/restraint. Include physical/medical assessment and note cautions or special interventions needed."

b. Despite this patient's having multiple episodes of seclusion and restraint, there was only one Focused Treatment Plan Review(FTPR) submitted, dated 8/3/17. This FTPR failed to outline specific strategies to prevent or lessen the use of further restricted procedures with this patient. A review of this plan revealed that there was also no specific objective aimed at the patient developing non-harmful behaviors when feeling angry to prevent further occurrences of restraint or seclusion. The plan contained using "net restraints" instead of only identifying strategies the patient could use to prevent the use of restrictive procedures. There was no behavioral modification plan developed after the patient continued to be restrained or secluded to control aggressive behavior.

3. Patient B3.

a. Patient B3 was admitted 4/20/17, was placed in locked seclusionon 8/20/17 from 5:58 p.m. to 6:45 p.m. A review of the seclusion and restraint form "Part 1 - Initial Assessment by RN and MDrevealed that a comprehensive face-to-face evaluation was not conducted for this episode. The "Physician Assessment" for 8/20/17 noted, "Pt [Patient]became extremely agitated & threatening toward staff after receiving STAT IM[intramuscular] medication. [S/he] became assaultive and did not respond to verbal redirection ... high risk of severe physical injury, s/he was placed in locked seclusion. Pt responded positively & was released at the time of this evaluation. S/he sustained no injury." The facility listed the following required documentation on the seclusion and restraint form titled, "Part I - Initial Assessment by RN and MD":"Describe the emergency/imminent risk, direct assessment of the patient and determination regarding the need for continued seclusion/restraint. Include physical/medical assessment and note cautions or special interventions needed." The Physician Assessment failed to include a comprehensive assessment of the patient's physical condition. Except to note that the patient was not injured, there was no review of system and medications to determine if there was a medical explanation for the patient's aggression.

b. The Master Treatment Plan was not modified to reflect the use of locked seclusion to control this patient's behavior. A review of the Master Treatment Plan (MTP) submitted for this patient, dated 8/10/17, disclosed there was no statement reflecting the use of locked seclusion to control the patient's aggressive behaviors. Also, there was no specific objective aimed at the patient developing non-harmful behaviors to prevent the use of further restrictive procedures. The MTP failed to include interventions to address specific strategies regarding the prevention of further restrictive procedures with ways the patient could manage his/her aggressive without the use of seclusion. There was no document submitted that contained a "Focused Treatment Plan Review" as per facility policy. The facility policy, titled "Seclusion Use" revised 9/28/15 stated, "The treatment team will convene on the next business day to do a Focused Treatment Plan Review (FTPR), which includes a review of the seclusion episode looking at the predisposing, precipitating and perpetuating factors, any changes in the treatment plan in response to the episode, or the rationale for not making changes."

B. Interviews

1. In an interview with the acting Director of Nursing (DON) and Director of Staff Development on 9/7/17 at 9:10 a.m., episodes of seclusion and restraint were reviewed. They agreed with the finding regarding the need to modify the Treatment Plan and agreed that the treatment should be modified. When reviewing non-sample patient B2's FTPR, the Director Staff Development agreed that the including "net restraint" in the objective was not appropriate. She acknowledged that the objective regarding the use of seclusion and restraint should focus on strategies the patient can use to prevent the use of further restrictive procedures.

2. In an interview on 9/7/17, the Medical Director at approximately 11:00 a.m. the findings regarding seclusion and restraint were discussed. When reviewing non-sample patient B2 information, he stated that he believed the documentation met the requirements. The physician also noted in the "Physical Orders for Restraint or Seclusion," under the section titled, "Physical and/or Psychological Risk considerations in the use of seclusion or restraint," "[illegible] obesity, [illegible] sexual abuse."The Medical Director said that he thought this statement by the physician met the requirements.He did not dispute the findings that there were no comprehensive assessments of the patient's medical condition with documented results regarding a review of systems and medications.

3. In a discussion on 9/7/17 just before the exit at 2:35 p.m., the Medical Director stated that there were no Focused Treatment Plan Reviews completed for Patient B1 and B3 after their episodes of seclusion or restraint.

C. Policy Review:

The facility had separate policies on, "Seclusion Use" and "Restraint Use" revised 9/28/15. Both policies stipulated, "The Physician conducts a face-to-face behavioral and physical assessment of the patient with 60 minutes of the initiation of seclusion [restraint]." "The physical documents his/her face-to-face assessment of immediate risk, determination regarding the need for continued seclusion and the physical assessment noting any special interventions required." The policy on restraint also included specific language from the CSM guidelines regarding what the face-to-face evaluation should include. However, there was no stipulation in the policy on "Seclusion Use" which required the one-hour face-to-face assessment to include the CMS requirement to evaluate each episode of seclusion or restraint regarding: The patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the seclusion.

Based on observation, record review, and interview, the Medical Director failed to monitor and provide adequate medical oversight to ensure quality medical services. Specifically, the Medical Director failed to:

I. Based on record review and interview, the facility failed to provide Psychiatric Evaluations that included an assessment of patient assets in descriptive, not interpretive fashion for seven (7) of 15 active sample patients (A3, A5, A7, A9, A10, A11, and A14). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's positive attributes in therapy. (Refer to B117)

II. Provide sufficient active treatment measures for two (2) of five (5) active sample patients (A2 and A4) housed in the Woodward building. These patients were reported to be too "clinically unstable" to participate in the facility's scheduled group treatment program. Despite these patients repeated and regular non-attendance in the group treatment program, the Master Treatment Plan was not revised to reflect planned individual active treatment measures to engage them. This failure results in patients not receiving active treatment at the level and intensity for recovery, potentially delaying improvement and timely discharge from the hospital.(Refer to B125-I)

III. Ensure that a comprehensive face-to-face evaluation of the patient's status was documented for three (3) of four (4) non-sample patients (B1, B2, and B3) selected to review seclusion and restraint (S&R) episodes. Specifically, the review of physician notes during the first hour after S&R revealed that physicians did not document a comprehensive assessment. The lack of a comprehensive evaluation of a patient during the first hour of seclusion or restraint may potentially fail to identify adverse physical and mental effects of a seclusion or restraint procedure. In addition, the Master Treatment Plans (MTPs) were not modified to reflect the use of seclusion or restraint with specific goals/objectives and interventions to prevent further restrictive procedures. This deficient practice could lead to the failure to identify and implement interventions that can prevent and avoid future seclusion or restraint episodes. (Refer to B125-II)

Based on record review and interview, the Director of Nursing failed to ensure that nursing interventions on the Master Treatment Plans for 12 of 15 active sample patients (A1, A2, A3, A4, A5, A7, A9, A11, A12, A13, A14 and A15) were more than generic nursing tasks and whether the listed interventions would be delivered in individual or group sessions. These failures result in a treatment plan that did not reflect a comprehensive, integrated, and individualized approach to interdisciplinary treatment for patients receiving nursing services. (Refer to B122)

The Director of Social Work failed to assure the quality and appropriateness of services provided by the social work staff. Specifically, the Director failed to assure the Psychosocial Assessments included the anticipated social work roles in treatment for six (6) of 15 (A2, A3, A4, A5, A6, and A11) active sample patients. This failure results in a lack of professional social work information in treatment planning. (Refer to B108)