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Based on medical record review, review of facility policies and procedures, and interviews with administrative staff, it was determined that the facility failed to protect and promote the rights of each patient.

Findings include:

1. The facility failed to ensure all patients are informed of their rights (Refer to Tag A 117).

2. The facility failed to ensure that all patients receive grievance decisions (Refer to Tag A 123).

3. The facility failed to ensure that consents are signed by the legally authorized individual (Refer to Tag A 131).

4. The facility failed to ensure that patients have the right to receive care in a safe setting (Refer to Tag A 144).

5. The facility failed to ensure that clinical information is maintained in a confidential manner (Refer to tag A 147).

Based on review of three (3) of three (3) medical records of discharged patients and staff interview on 12/9/19 and 12/20/19, it was determined that the facility failed to ensure that the patient or when appropriate, the patient's representative, are informed of the patient rights in advance of discontinuing patient care.

Findings include:

1. The medical record of Patient #2 indicated that the patient was admitted to the facility on 10/3/19 and discharged on 12/3/19. The medical record contained an Important Message from Medicare (IM) form provided at the time of admission but not another copy prior to discharge.

2. The medical record of Patient #5 indicated that the patient was admitted to the facility on 11/1/19 and discharged on 11/21/19. The medical record contained an Important Message from Medicare form provided at the time of admission but not another copy prior to discharge.

3. The medical record of Patient #4 indicated that the patient was admitted to the facility on 10/28 /19 and discharged on 11/27/19. The medical record contained an Important Message from Medicare form provided at the time of admission but not one prior to discharge.

4. On the morning of 12/10/19, Staff #1 and Staff #40 confirmed that all patients are provided on admission the IM discharge notification form but were not being provided the IM patient notification form prior to discharge.

Based on a review of documentation related to three (3) of three (3) grievances filed by patients and interviews with administrative staff, it was determined that the facility failed to provide written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

1. Review of PATIENT/CONCERNED INDIVIDUAL GRIEVANCE FORMs regarding grievances made by Patient #30 (3/29/19), Patient #31 (4/8/19), and Patient #32 (5/9/19) indicated that each patient made a complaint that was not resolved at the point of contact and took at least 11 days from the date that the grievance was made until it was documented to have been resolved.

2. At 1:40 PM on 12/11/19, Staff #97 and Staff #98 stated that the patients who made the complaints did not receive a written notice of the decisions.

Based on medical record review, document review and staff interview, it was determined that the facility failed to ensure that the Consent for Medical Treatment policy is implemented.

Findings include:

Reference #1: Facility policy titled "Consent for Medical Treatment" states, "... III Procedures A. Obtaining Informed Consent for Medical Procedures... 3. Patients with impaired decision-making capacity (i.e. incapacitated patients) cannot give informed consent and must be represented by a legally appointed guardian who signs the form(s). ..."

Reference #2: Facility document titled "Administrative Bulletin 5:04" states, "... Subject: Medication Informed Consent Policy... IV. Consent ... B. Procedure... 2. The prescriber shall ask a consenting patient/guardian/mental health care representative to sign the DMHAS [Division of Mental Health and Addiction Services] Psychotropic Medication Informed Consent Form, which shall list the prescribed medication(s) and their formulations (oral vs. short or long acting injections). ... 7. The consent form shall be maintained in the patient's clinical record and shall be effective for one year, unless revoked by the patient, or where legally permissible by the consumer's guardian or mental health care representative. ..."

1. Review of Medical Record #27, on 12/11/19, revealed the following:

a. The patient was admitted to the facility on 9/12/19.

b. The "Authorization for Disclosure of Protected Health Information Primary Contact/Next of Kin Form," dated 9/12/19, identified the name, address, and phone number of the patient's legal guardian.

c. On the "Medical/Dental/Prescription Treatment Consent" form, dated 9/12/19, the line next to Signature, "need legal guardian" was handwritten.

(i) The facility failed to obtain a consent for treatment as required by facility policy (Reference #1).

c. On the "Psychotropic Medication Informed Consent Form," which lists Depakote, Lithium, Haldol, Ativan, Zyprexa and Risperdone, the following was noted:

(i) On 9/12/19 at 11:11 AM, a signature identified by Staff #100 as belonging to Patient #27 was on the line next to "Patient Signature."

(ii) Two (2) Staff/Witness Signatures were signed at 11:11 AM and 11:00 AM.

(iii) Above the line marked, "Guardian or Mental Health Care Representative Signature," "Spoke to [name of person, telephone number] at 1140 who also gave verbal ____[illegible]" was written.

(iv) There was no evidence of a follow up to obtain a signature from the legal guardian.

2. Review of Medical Record #20 on 12/11/19 revealed the following:

a. Patient #20 was identified as having a legal guardian.

b. On the "Psychotropic Medication Informed Consent Form," Remeron 7.5 MG (milligrams) was listed. The consent was signed on 4/19/18 at 3:53 PM, which is valid for one (1) year after signing.

(i) Patient #20 was receiving Remeron 15 MG through 12/9/19.

(ii) The facility failed to obtain an updated consent for the Remeron.

c. On the "Psychotropic Medication Informed Consent Form," which listed Zyprexa 5 MG, the consent was signed on 10/18/18 at 4:00 PM.

(i) Patient #20 received Zypexa 5 MG from 11/15/19 through 12/10/19.

(ii) The facility failed to obtain an updated consent for the Zyprexa.

d. These finding were confirmed by Staff #64 and Staff #88.

Based on a tour of the facility, staff interview, and review of facility policies and procedures, it was determined that the facility failed to ensure that patients receive care in a safe setting.

Findings include:

Reference #1: Facility policy titled "Patient Safety Search" states, "...A. Contraband/Prohibited Items- "Contraband" means any item or material that is unlawful to possess or use, or that has been stolen, or that has the potential to pose a danger to the health or safety of the patient or others under the circumstances that exist in living units, work areas, program spaces, dining areas, or recreational facilities to which patients have supervised or unsupervised access. Because of the possible threat to health and safety, patients may not possess such items as, but not limited to those listed on the Contraband List. ... Policy A. The hospital has a responsibility to provide a safe environment for patients and staff. Patients may not possess prohibited items. Any items identified as contraband will be removed, if brought onto hospital grounds. ...contraband items are as follows: ...Glass containers and aluminum cans...Plastic bags, including trash bags, dry cleaning bags and hospital bags...rope, string, twine, drawstrings, etc. that are greater than 12 inches long..."

Reference #2: Facility Suicide Risk Mitigation Plan dated 10/22/19 stated, "Patient Safety Status Checks; the frequency of the patient safety status checks will increase from every 30 minutes to every 15 minutes, hospital-wide."

1. A tour of Birch Hall Admissions Unit on 12/9/19 at 11:19 AM, revealed the following:

a. A large yellow plastic bag was lying on a table in the patient area.

b. A large yellow plastic bag was in a hamper in the patient area.

2. A tour of Cedar Hall C on 12/9/19 at 12:30 PM, revealed the following:

a. Bedroom 211 D contained three (3) perfume bottles made of glass.

b. Bedroom 216 C contained a belt.

3. These findings were confirmed by Staff #70.


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4. On 12/10/19 at 2:00 PM, in the presence of Staff #93, in the Larch Building, four (4) out of four (4) common area patient bathrooms contained multiple individual toilet stalls. Each toilet stall was equipped with a hinged door that covered 2/3 of the opening creating ligature points at the top of each stall door.

a. During an interview on 12/10/19 at 2:30 PM, Staff #93 confirmed the bathroom stall doors were identified during an environmental risk assessment but a permanent solution will not be implemented until 2021.

b. A review of the Suicide Risk Mitigation Plan dated 10/22/19, confirmed patients can be left unsupervised for fifteen (15) minutes in areas where ligature risks are present. This Suicide Risk Mitigation Plan does not provide a safe environment for the patients.

Based on medical record review, staff interview and document review, it was determined that patient clinical information is not maintained in a confidential manner in one (1) of four (4) medical records reviewed.

Findings include:

Reference: Facility policy titled "Documentation/Treatment Plan Manual" states, "...when documenting in a clinical record, patient or staff names should not be used in another patient's clinical record. Patient identification numbers may be used when another patient is referenced in a patient's clinical record. The functional title of the staff may be used. ..."

1. Review of Medical Record #20 on 12/10/19 revealed the following:

a. Nursing documentation dated 12/3/19 at 12:49 AM states, "...Patient attempted several times to attack female client [name of female client] but staff intervened. ..."

2. Staff #73 confirmed that in Medical Record #20, the "female client" should not have been identified by name.

Based on document review and staff interview, it was determined that the facility failed to ensure that the executive committee of the medical staff carries out its responsibilities.

Findings include:

Reference: Facility "Bylaws, Rules and Regulations of the Active Medical Staff 2019" states, "Article X - Committees Section 1 - Types of Committees: ... A. The Standing Committees shall include: 1. Executive Committee of the Medical Staff ... Section 2 - Executive Committee of the Medical Staff:
A. ... This Committee shall consist of the President 1, Vice-President 2, ... 4 elected members from the Active Medical Staff ..., the Medical Director, and Physician Department Heads of Psychiatry and Medicine. The Directors of the Department of Psychology, Social Work, Nursing, Rehabilitation, Chaplaincy, Nutrition, and Substance Abuse shall be non-voting members. They will provide reports to the Executive Committee of the Medical Staff on a quarterly basis ...
B. ... The President of the Active Medical Staff shall receive reports from all Active Medical Staff committees, as well as reports from clinical departments and task forces. These will be discussed at regular intervals and reflected in the committee's minutes."

1. On December 10, 2019, review of the Executive Committee of the Medical Staff (ECMS) from June 2019 to December 2019 were reviewed.

a. The ECMS meeting scheduled for June 19, 2019 was cancelled. The meeting was rescheduled for 7/17/19.

b. The ECMS meeting scheduled for July 17, 2019 was cancelled due to lack of quorum. The meeting was rescheduled for 8/21/19.

c. The ECMS meeting scheduled for August 21, 2019 was cancelled. The meeting was rescheduled for 9/18/19.

d. The ECMS meeting schedules for September 18, 2019 was cancelled. The meeting was rescheduled for 10/16/19.

e. The ECMS meeting for October 16, 2019 was held on this day. Documentation included only approval of credentialed physicians. There was no evidence of any clinical departments reports as required by the above reference.

f. The ECMS meeting scheduled for November 20, 2019 was cancelled. The meeting was rescheduled for December 18, 2019.

2. The above was confirmed by Staff #1 and Staff #102.

Based on review of four (4) medical records, review of facility policies and procedures, and interview with administrative staff, it was determined that the facility failed to ensure that a physician evaluated Patient #20 in accordance with facility policy.

Findings include:

Reference: Facility policy titled "Special Observation" states, "1:1 Observation: requires continuous observation with a distance... . The order is only valid for up to 24 hours and must be reviewed and renewed daily. ...During other than regular working hours, the POD (Psychiatrist on Duty) reviews the status of each patient on 1:1 [one-to-one] or 2:1 [two-to-one] observation, if not already done by the day shift treatment team. Special Observation orders must be written at least every 24 hours. This is to be done every day, including weekends and holidays. ..."

1. Review of Medical Record #20 on 12/10/19 revealed that the remained on 1:1 Special Observation on Sunday, 12/8/19.

a. There was no evidence that the 1:1 order was renewed on 12/8/19, as required by the above reference.

b. Staff #73 stated that 1:1 orders are not renewed on weekends and holidays.

Based on document review and staff interview, it was determined that the facility failed to ensure that the number of personnel providing nursing care is in accordance with the current Staffing Guidelines.

Findings include:

Reference: Facility policy titled "Staffing Protocol" states, "... Procedure: 1. The number of nursing personnel needed for each patient unit is assessed each shift by the Nursing Care Coordinator (NCC). Unit census and patient acuity are reassessed each shift to determine the adequate number of nursing personnel for that unit. Minimum staff guidelines are computer generated based upon nursing hours per patient day as predetermined by the Chief Nursing Officer (CNO) in conjunction with the Chief Executive Officer (CEO). 2. Continual assessment occurs ... Staffing adjustments are made accordingly to ensure safety ... 7. Adequate number of nursing personnel must be provided to staff critical areas as follows: Special Observation Monitoring, Every 15 Minute Safety/Status Check ..."

1. On 12/11/19, in the presence of Staff #101, the staffing coordinator, staffing coverage for 4 units out of 16 units from 11/24/19 to 12/7/19 was reviewed. The assessment of patients acuity was not provided. The following units did not meet the facility's staffing guidelines.

2. The Current Staffing Guidelines for Birch Hall C Unit were as follows:

Day Shift - Census 19-24 - RNs (Registered Nurse) 2 - HST/A (Human Services Technician/Assistant) 4
Evening Shift - Census 21-25 - 2 RNs - 4 HST/A
Night Shift - Census 0-21 - 1 RNs; Census 0-22 - 3 HST/A

a. On 11/24/19, 11/29/19, 12/1/19, 12/2/19, day shift, the patient census was 21; there were 3 assigned HST/A instead of 4 each day.

b. On 12/6/19, day shift, the patient census was 20; there were 3 assigned HST/A instead of 4.

c. On 12/1/19 and 12/2/19, evening shift, the patient census was 21; there were 3 assigned HST/A instead of 4 each day.

d. On 12/1/19, night shift, the patient census was 21; there were 2 assigned HST/A instead of 3.

3. The Current Staffing Guidelines for Cedar Hall D Unit were as follows:

Day Shift- 3 RNs - 7 HST/A
Evening Shift - 3 RNs - 7 HST/A
Night Shift - 2 RNs - 7 HST/A

Staff #101 indicated that this unit follows the "Static Staffing" pattern, indicating that the staffing requirement is the same regardless of the census or if patients are placed on a 1:1 (observation). Cedar Hall D Unit has 24 beds, however, during this timeframe the patient's census was 20 to 21. There were no patients on 1:1.

a. On 11/24/19, day shift, there were 6 assigned HST/A instead of 7.

b. On 11/25/19, day shift, there were 3 RNs; 1 LPN; and 5 HST/A. The unit was short one (1) HST/A.

c. On 11/30/19, day shift, there were 6 assigned HST/A instead of 7.

d. On 12/1/19, day shift, there were 5 assigned HST/A instead of 7.

e. On 12/2/19, day shift, there were 6 assigned HST/A instead of 7.

f. On 11/26/19, evening shift, there were 2 assigned RNs instead of 3.

g. On 11/27/19, evening shift, there were 6 assigned HST/A instead of 7.

h. On 11/29/19, evening shift, there were 2 assigned RNs instead of 3.

i. On 11/30/19, evening shift, there were 2 assigned RNs instead of 3; and there were 6 assigned HST/A instead of 7.

j. On 12/1/19, evening shift, there were 2 assigned RNs instead of 3.

k. On 12/3/19, evening shift, there were 2 assigned RNs instead of 3.

l. On 11/24/19 and 11/25/19, night shift, there were 6 assigned HST/A instead of 7 each day.

n. On 12/1//19, night shift, there were 4 assigned HST/A instead of 7.

o. On 12/2/19, night shift, there were 6 assigned HST/A instead of 7.

4. The Current Staffing Guidelines for Main F (female) 2 were as follows:

Day Shift - 2 RNs - 8 HST/A
Evening Shift - 2 RNs - 8 HST/A
Night Shift - 2 RNs - 6 HST/A

As per Staff #101, this unit follows the "Static Staffing" pattern. This unit has 32 beds, however, during this time frame the patient census was 23. Everyday, there were 2 to 3 patients on a 1:1 observation.

a. On 11/24/19 and 11/29/19, day shift, there were 2 RNs, 1 LPN and 6 HST/A. The unit was short of 1 HST/A (The LPN was utilized as a HST/A).

b. On 12/1/19, day shift, there were 2 RNs, 1 LPN and 5 HST/A. The unit was short of 2 HST/A.

c. On 12/2/19, day shift, there were 2 RNs, 1 LPN, and 6 HST/A. The unit was short of 1 HST/A.

d. On 12/3/19, day shift, there were 2 RNs, 1 LPN and 5.5 HST/A. The unit was short of 1.5 HST/A.

e. On 11/24/19, evening shift, there were assigned 7 HST/A instead of 8.

f. On 11/27/19, evening shift, there were 3 RNs and 6 HST/A (RN utilized as a HST/A). The unit was short 1 HST/A.

g. On 11/29/19, evening shift, there were 7 assigned HST/A instead of 8.

h. On 11/30/19, evening shift, there were 6 assigned HST/A instead of 8.

i. On 12/1/19, evening shift, there were 6 assigned HST/A instead of 8.

j. On 12/6/19, evening shift, there were 7 assigned HST/A instead of 8.

k. On 11/24/19, 11/29/19, 12/2/19, night shift, there were 5 HST/A assigned instead of 6, on each day.

l. On 11/25/19, 12/1/19 night shift, there were 4 HST/A assigned instead of 6, on each day.

5. The Current Staffing Guidelines for Holly B were as follows:

Day Shift, Patient Census: 21-27, 2 RNs - 4 HST/A
Day Shift, Patient Census: 28-32, 2 RNs - 5 HST/A
Evening Shift, Patient Census: 25-28, 2 RNs, 4 HST/A
Night Shift, Patient Census: 0-32, 1 RN, Census: 26-30 5 HST/A

a. On 11/24/19, day shift, the total census was 29 with 4 HST/A assigned to the unit. There was 1 patient on a 1:1 observation leaving only 3 HST/A assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by 2 HST/A.

b. On 11/27/19, day shift, the total census was 30 with 2 RNs, 1 LPN, 4 HST/A assigned to the unit. There was 1 patient on a 1:1 observation leaving 3 HST/A assigned for the remaining 29 patients on the floor. As per Staff #101, the LPN would be part of the mix of the number of the HST/A. Thus, the unit was short staffed by one (1) HST/A.

c. On 11/30/19, day shift, the total census was 30 with 6 HST/A assigned to the unit. There were 2 patients on a 1:1 observation leaving 4 HST/A assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by one (1) HST/A.

d. On 12/1/19, day shift, the total census was 30 with 1 LPN and 5 HST/A assigned to the unit. There were 2 patients on a 1:1 observation leaving 4 staff members assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by one (1) HST/A.

e. On 12/2/19, day shift, the total census was 30 with 6 HST/A assigned to the unit. There were 2 patients on a 1:1 observation leaving 4 staff members for the remaining 28 patients on the floor. Thus, the unit was short staffed by one (1) HST/A.

f. On 11/24/19, evening shift, the total census was 29 with 4 HST/A assigned to the unit. There was 1 patient on a 1:1 observation leaving only 3 HST/A assigned to the remaining 28 patients on the floor. Thus, the unit was short staff by one (1) HST/A.

g. On 11/26/19, evening shift, the total census was 30 with 5 HST/A assigned to the unit. There were 1 patients on a 1:1 observation leaving only 4 HST/A assigned for the remaining 29 patients on the floor. Thus, the unit was at short staffed by one (1) HST/A.

h. On 11/29/19 and 11/30/19, evening shift, the total census was 30 with 5 HST/A assigned to the unit. There were 2 patients on a 1:1 observation leaving only 3 HST/A assigned for the remaining 28 patients on the floor. Thus, the unit was at short staffed by one (1) HST/A.

i. On 11/24/19 and 11/25/19, night shift, the total census was 29 with 4 HST/A assigned to the unit. There was 1 patient on a 1:1 observation leaving only 3 HST/A assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by two (2) HST/A each night.

g. On 11/26/19 night shift, the total census was 30 with 4 HST/A assigned to the unit. There was 1 patient on a 1:1 observation leaving only 3 HST/A assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by two (2) HST/A each night.

h. On 11/27/19, night shift, the total census was 30 with 5 HST/A assigned to the unit. There was 1 patient on a 1:1 observation leaving only 4 HST/A assigned for the remaining 29 patients on the floor. Thus, the unit was short staffed by one (1) HST/A.

i. On 11/28/19, night shift, the total census was 30 with 2 RN and 5 HST/A assigned to the unit. There were 2 patients on a 1:1 observation leaving only 4 staff members assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by one (1) HST/A.

j. On 11/30/19, night shift, the total census was 30 with 6 HST/A assigned to the unit. There were 2 patients on a 1:1 observation leaving only 4 HST/A assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by one (1) HST/A.

k. On 12/1/19, night shift, the total census was 30 with 4 HST/A assigned to the unit. There were 2 patients on a 1:1 observation leaving only 2 HST/A assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by three (3) HST/A.

l. On 12/3/19, night shift, the total census was 29 with 4 HST/A assigned to the unit. There was 1 patient on a 1:1 observation leaving only 3 HST/A assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by two (2) HST/A.

m. On 12/4/19, night shift, the total census was 29 with 1 LPN and 4 HST/A assigned to the unit. There was 1 patient on a 1:1 observation leaving only 4 staff assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by one (1) HST/A.

n. On 12/5/19, night shift, the total census was 29 with 2 RN and 4 HST/A assigned to the unit. There was 1 patient on a 1:1 observation leaving only 4 staff assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by one (1) HST/A.

o. On 12/6/19, night shift, the total census was 29 with 5 HST/A assigned to the unit. There was 1 patient on a 1:1 observation leaving only 4 HST/A assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by one (1) HST/A.

p. On 12/7/19, night shift, the total census was 29 with 2 RN and 4 HST/A assigned to the unit. There was 1 patient on a 1:1 observation leaving only 4 staff assigned for the remaining 28 patients on the floor. Thus, the unit was short staffed by one (1) HST/A.

Based on review of two (2) medical records and staff interview, it was determined that the facility failed to ensure that the registered nurse evaluates the nursing care provided to the patients.

Finding includes:

1. Review of Medical Record #1 on 12/9/19 revealed the following:

a. The physician order dated 11/19/19 stated, "Metropolol Succ [succinate] 25 mg [milligram] ER [extended release] Tab [tablet] 1 tablet by mouth every day for hypertension (hold if SBP [systolic blood pressure] is equal to or less then 100]."

(i) The Vital Signs/Weight/Height Record form from 11/29/19 until 12/9/19 revealed that on 12/6/19, the patient's systolic blood pressure was 91/61, and on 12/8/19 the blood pressure was 100/69. The Routine Medications Charting revealed no evidence that the medication was held, or that the blood pressure was rechecked in order to determine administration of medication.

b. The physician order dated 12/4/19 at 6:40 (am or pm not indicated) stated, "Neurochecks q [every] 48 hrs [hours] x 3 days." The Neurological Check Sheet contained documentation for "Frequency: q 4 hrs" "Duration: 48 hrs x 3 days" Expiration Time: D/C [discontinue] 12/7/19 @ 6:40 pm."

(i) The Neurological Check Sheet indicated that neurological checks were performed every four hours from 12/4/19 at 6:40 PM to 12/6/19.

(ii) There was no evidence that the above physician order was clarified for the frequency of time checks/duration. The neurological checks were discontinued on 12/6/19 at 6:40 PM instead of 12/7/19. There was no evidence of a physician order to discontinue the neurological checks.

c. The above was confirmed by Staff #5.


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2. Review of Medical Record #2 revealed the following:

a. Patient #2 had a physician order dated 10/31/19 stating, "Meal monitoring for 30 days, record daily intake for 30 days, weekly body weight ... X [times] 30 days."

(i) Upon request, Staff #56 was unable to provide the meal monitoring records.

(ii) The Vital Signs/Weight/Height Record sheet lacked evidence that a weekly body weight was obtained from 11/11/19 to 12/2/19.

b. The above was confirmed by Staff #36, Staff #56 and Staff #59.


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3. Review of Medical Record #17 on 12/10/19 revealed the following:

a. A baseline ECG (electrocardiogram) was ordered on 8/5/19 at 10:00 AM.

(i) There was no evidence in the medical record that an attempt was made to obtain an ECG .

b. Staff #73 confirmed this finding.

Based on review of the medical record of one of one patient, review of facility policy and procedure, and interview with administrative staff, it was determined that nursing staff failed to ensure that the interdisciplinary care plan is kept current.

Findings include:

Reference: Policy and procedure titled DOCUMENTATION / TREATMENT PLAN MANUAL states: "......
XIV. TREATMENT PLAN A. Purpose .....3. To document the plan of treatment for the individual patient. It includes the goals, objectives, and interventions formulated by the Treatment Team that relate to self-identified problems, discharge barriers, patient assets / strengths and self-stated goals.
.....
XIV. TREATMENT PLAN A. PURPOSE ....3. To document the plan of treatment for the individual patient. It includes the goals, objectives, and interventions formulated by the Treatment Team that relate to self-identified problems, discharge barriers, patient assets/strengths and self-stated goals.
B. Procedure .....2. The treatment plan shall be completed by the seventh (7) day of admission and updated every 30 days, or more frequently if clinically indicated.
.....
XVI. INTERDISCIPLINARY PROGRESS NOTES A. Purpose 1. The purpose of Interdisciplinary Progress Notes is to document in the patient's clinical record the clinician's encounter and psychiatric/medical decision-making; the patient's progress or lack of progress related to the goals of the treatment plan; significant changes in the patient's condition, or a significant event; and used for coordination between health care providers and to communicate to future providers; .....
B. Frequency of Progress
.....
2. For clinical services that are not described in the patient's Treatment Plan, and are the result of a significant change in the patient's condition, or a significant event, a Progress Note must be completed immediately, but no longer than the end of the clinician's current shift.
C. Content of the Progress Note
1. Physicians, Nurses, Social Workers and other disciplines, i.e. Rehabilitative Therapy, and Psychology documented in the Treatment Plan as providing active treatment modalities / interventions:
a) A Progress Note must give a chronological picture of the patient's progress or lack of progress towards attaining short and long-term goals outlined in the Treatment Plan.
b) Progress Notes must contain recommendations for revisions in the Treatment Plan.
.....
2. For clinical services that are not described in the patient's Treatment Plan, and are the result of a significant change in the patient's condition, or significant event:
a) The Progress Note must include a description of the patient; the clinician's response to the change in condition / significant event, any necessary changes to be made to the patient's current Treatment Plan, and any subsequent assessments of the patient's responses and progress.
....."

1. Review of the medical record of Patient #6 revealed:

a. An INTERDISCIPLINARY PROGRESS NOTE entry dated 12/4/19 at 8:20 PM, entered by a P.O.D. (Physician on Duty) stated: "Nurse called noting that patient walked away after given medications and nurse says she does not know if pt [patient] swallowed her medication because pt was holding the pills in her mouth. ....."

b. An INTERDISCIPLINARY PROGRESS NOTE entry dated 12/4/19 at 9:30 PM stated: "NSG [Nursing] - During evening medication pass patient was asked to show the nurse her mouth, at that point the medication was seen between the lower right teeth and cheek, patient was instructed to swallow the medication and the patient quickly opened and closed mouth not allowing the nurse, and the medicine identifier who was the charge nurse, to let her, or him see her mouth. Patient was instructed to not leave the medication station. Patient stepped back against the wall and started cursing at the nurse asking, 'What is your f--- problem, do I look like I cheek my medication? I don't have a psychiatric problem" and then walked to the relaxation room. ....."

c. A TEAM NOTE entry dated 12/5/19 at 11:00 AM stated: "PT [Patient] met with the team to discuss 1:1 precautions, following the 12/4 incident for cheeking medication and aggression. PT stated 'they accused me of not taking my meds but I did.' ....."

d. An INTERDISCIPLINARY PROGRESS NOTE entry dated 12/5/19 at 4:00 PM: "SW [Social Worker] spoke with pt's sister. Pt's sister stated she visited with her sister last night and she was in an agitated mood. She expressed to her sister 'I feel better without my meds'! [sic] Pt's sister asked if she was taking her medications and the pt. 'snapped" at her and stated, 'Of course I do!' Pt's sister called in order to inform the team in case her agitation increased. ....."

e. The ADDITIONAL INFORMATION section of an "R.N. SUMMARY PROGRESS NOTES Week 8" form dated 12/7/19 at 4:41 PM stated: "Patient was suspected of cheeking medications the last few days as apparently [sic] has has been very agitated and emotionally labile recently."

f. As of the last date of the survey, 12/11/19, the "Treatment Plan" had not been revised to include the cheeking of medication by the patient.

2. Administrator #1 agreed with the findings.

Based on observation, staff interviews, and document review, it was determined that the facility failed to ensure the implementation of policies and procedures that address the storage of medications at controlled room temperature.

Findings include:

Reference #1: Facility policy titled "Medication Supply, Storage, and Maintenance" states, "...Medication storage area is maintained between 68 to 77 degrees F [Fahrenheit]..."

Reference #2: The USP (United States Pharmacopoeia) Storage definitions, https://www.uspnf.com/sites/default/files/usp_pdf/EN/USPNF/revisions/659_rb_notice.pdf, states, "...Controlled room temperature: The temperature maintained thermostatically that encompasses the usual and customary working environment of 20°-25° (68°-77° F)..."

1. On 12/10/19 at 10:00 AM, inspection of the Omnicell, automated drug cabinet, located in the Nursing Care Coordinator's Office, revealed the following:

a. A wall thermometer indicated that the room temperature was 81 degrees F.

b. A window air conditioning unit was turned on and set to a temperature of 64 degrees F.

c. Staff #50 stated that the Nursing Care Coordinator's Office was normally "like this," about 81 degrees F with the air conditioning unit turned on.

d. The Omnicell contained more than 150 (one-hundred and fifty) different medications required to be stored at controlled room temperature.

2. This finding was confirmed by Staff #8, Staff #49, and Staff #50 on 12/10/19 at 10:15 AM.

Based on observation, document review, and staff interviews, it was determined that the facility failed to ensure that medications are stored in a secure manner.

Findings include:

Reference: Facility policy titled "Medication Supply, Storage and Maintenance" states, "...Medication is stored as follows:... in locked cassettes and stored in the locked medication room. The cart and medication room remain locked except when in use..."

1. On 12/10/19 at 10:00 AM, the key to unlock and open the Omnicell, containing more than 150 (one-hundred and fifty) medications, was found stored inside an amber medication vial, hanging in a clear plastic bag attached to the side panel of the Omnicell.

a. Staff #49 and Staff #50 stated that the key opens the Omnicell manually.

b. Staff #8, Staff #49, and Staff #50 confirmed that the key was unsecured, and would allow any person access to the medications stored in the Omnicell on 12/10/19 at 10:10 AM.

2. On 12/9/19 at 10:50 AM in the Dental Clinic the following was found:

a. In Room #1, one (1) opened 473 ml (milliliter) bottle of Chlorhexidine Gluconate 0.12% Oral Rinse was found stored in a white unlocked wall cabinet.

b. In Room #2, one (1) opened 473 ml bottle of Chlorhexidine Gluconate 0.12% Oral Rinse was found stored in a white unlocked wall cabinet.

c. These findings were confirmed by Staff #11, Staff #12, and Staff #13 at the time of discovery.

Based on staff interview and document review, it was determined that the facility failed to ensure that the Medication Safety Committee meets, reviews, and completes medication error reports in accordance with facility policy and procedures.

Findings include:

Reference #1: Facility policy titled "Reporting Medication Errors/ Near Misses" states, "... The Medication Safety Committee: Meets monthly or as needed, to review all Medication Error Reports and "near misses"..."

1. Review of the Medication Safety Sub-Committee Meeting Minutes for the year 2019 on 12/10/19, revealed the following:

a. The facility failed to provide evidence of monthly committee meetings for the months of May, June, August, October, and November of 2019.

b. Staff #1 confirmed on 12/10/19 at 3:13 PM that the Medication Safety Sub-Committee failed to meet monthly in 2019.

Reference #2: Facility policy titled "Unusual Incidents-Reporting, Investigation and Follow-up" states, "...The staff person discovering the error initiates a NURS-105: Medication Error Report... All reports are forwarded to the Medication Safety Committee for review and recommendations..."

Reference #3: Facility policy titled "Reporting Medication Errors/Near Misses" states, "... The Medication Safety Committee: ...Reviews reports and supervising documentation which identifies by type of error, severity of error, and analysis of error... Provides completed Medication Error Reports to the Nursing Office for data entry and filing..."

1. On 12/10/19 at 11:55 AM, review of twenty- eight (28) Medication Error Reports (Form NURS-105) from 2019, revealed the following:

a. Fourteen (14) out of twenty- eight (28) Medication Error Reports (Form NURS-105) filed in the Nursing Office lacked "Page 2 of 2." The second page of the report titled "Part V-Medication Safety Committee Analysis and Recommendations" was not included.

b. Fourteen (14) out of twenty- eight (28) Medication Error Reports (Form NURS-105) filed in the Nursing Office contained "Page 2 of 2," titled "Part V-Medication Safety Committee Analysis and Recommendations," but the page was blank. The following sections were not completed:

(i) Check Type of Error

(ii) Policy Infraction

(iii) Category of Error

(iv) Analysis of Error

(v) Action to prevent error from reoccurring

(vi) Chairperson's Signature, Date, Time

(vii) Entered into Medication Error Database, Date, Initials

c. Staff #53 stated that each "Page 2 of 2" for the twenty-eight (28) Medication Error Reports (Form NURS-105) should have been completed by the Medication Safety Committee upon their review, in accordance with facility policy (Reference #3).

d. These findings were confirmed by Staff #8 and Staff #53 on 12/10/19 at 12:45 PM.

Based on observation, interview, and document review, it was determined that the facility failed to ensure that the Food Services Director adequately managed the daily operations of the dietary services in accordance with his/her job description and the New Jersey State Sanitary Code, Sanitation in Retail Food Establishments and Food and Beverage Vending Machines (NJAC 8:24).

Findings include:

Reference #1: The "Food Service Director job description and Expectations of Abilities" states, "... Directly supervises, assigns, and evaluates the work of senior food service workers, or other subordinate employees engaged in the service of food and the cleaning of food service, and preparation areas, utensils, dishes, silverware, furniture, and equipment. ... Must have knowledge of procedural measures to maintain proper levels of cleanliness and sanitation in food preparation and service areas. ..."

1. On 12/9/19, during observations and interview in the presence of Staff #15, Staff #16 Staff #20 and Staff #23, the following was observed:

Reference #2 : N.J.A.C. 8:24-4.5(a) states, "The Equipment and equipment components shall be maintained in a state of repair and condition that meets the requirements specified under N.J.A.C. 8:24-4.1 and 4.2."

a. At 11:15 AM, five (5) transport trucks were observed with torn and peeled door gaskets, preventing a complete door seal.

b. Refrigeration Boxes: #1 (Milk Box) and Box #2 had gaskets completely peeled off and worn out.

Reference #3: N.J.A.C. #8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

c. At 11:35 AM, the ice machine placed in the main kitchen had a visible white/blue fuzzy discoloration. The side panel of the ice machine door had visible black-brown debris. There was a wet slime-like residue on the sliding door tracks of the ice machine.

Reference #4: N.J.A.C. 8:24-6.5(f) states, "After use, mops shall be placed in a position that allows them to air dry without soiling walls, equipment, or supplies. 2. In an orderly manner that facilitates cleaning the area used for storing the maintenance tools."

d. Three (3) brooms and a dust pan were placed on the floor; three (3) mops were stored soiling the wall and floor in the utility closet.

(i) There was a broom on the floor being held together by a plastic bag and completely frayed.

(ii) Two (2) used mops were placed diagonally on the floor in the pot washing area touching sheet pans and pot scrubbers.

Reference #5: The facility policy and procedure titled, "Pots & Pans washing in an arrangement of four Sink Wells" states, "...5. Fill sink with hot water (110 degrees) up to tape line inside the sink. This is refilled a second time for each meal and tempted both times it is filled. ...6. Fill sink with hot water up to tape line inside the sink. Add 8.5 oz of "Wesco Dune Plus" sanitizing agent. The test strip must read 12.5-25.0 ppm. This water is tested twice each meal, each time the water is changed. 9. Submerge pots, pans and utensils in the sanitizing solution for a minimum of one minute. ..."

e. On 12/9/19 at 11:15 AM, Staff #19 was observed washing pots in the pot washing area. He/she washed a base plate for a slicer and dipped it in the sanitizing solution for about three (3) seconds. During interview, Staff #19 was unsure of how long the washed pots and pans have to be sanitized.

(i) During interview, Staff #19 stated that the base plate for the slicer was required right away therefore, he/she just dipped it in the sanitizing solution quickly. Staff #19 was unable to explain the Pot and Pan Washing procedure regarding the iodine solution sanitizing requirements, water temperatures and testing for the proper concentration of the final sanitizing solution.

Reference #6: N.J.A.C. 8:24-4.11(2) states, "Clean equipment and utensils shall be stored: (i) In a self-draining position that allows air drying; and (ii) Covered or inverted."

f. The pot washing area had three (3) racks filled with wet pots, pans and lids placed on top of one another.

(i) Staff #16 stated that the pots and pans should have been air dried.

Reference #7: The facility document titled, Dry Storage Bins - Cleaning Procedure states, "...PROCEDURE: All contents of each bin are to be labeled. Contents are to be cleaned every 2 weeks with date of change. ..."

g. Bins containing sugar and powdered milk failed to have a label of when they were cleaned or filled. Two (2) more bins containing white food substance identified as Rice and Flour by Staff #16 had a label stating: "... Filled: 10.25.2019 Washed: 10.1.2019. ..."

Reference #8: N.J.A.C. 8:24-2.3(g): Food employees shall clean their hands in a handwashing sink or automatic handwashing facility acceptable to the health authority and may not clean their hands in a sink used for food preparation, a warewashing sink including a three compartment sink, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid."

h. At 11:35 AM, during a tour of the main kitchen, the handwashing sink for the kitchen staff was part of a two compartment food preparation service sink.

Reference #9: NJAC #8:24-4.6(c) "Non food-contact surfaces of equipment shall be free of an accumulation of dust, dirt, food residue, and other debris."

i. At 12:00 noon in the Food Tray Assembly Area, non-food contact surfaces of various insulated food trays were worn or deteriorated, contained stains and visible debris.

2. The above findings were confirmed by Staff #15, Staff #16 and Staff #20.

Based on observation, document review, and staff interview between 12/9/19 and 12/11/19, it was determined that the facility failed to ensure a safe environment for the patients.

Findings include:

1. The facility failed to ensure compliance with the 2012 edition of the National Fire Protection Association's Life Safety Code (Refer to Tag A 710).

Based on observation and document review, it was determined that the facility failed to ensure interior finishes comply with the National Fire Protection's (NFPA) Life Safety Code (101), 2012 edition.

Findings include:

Reference #1: NFPA 101:10.2.1.4: "Fixed or movable walls and partitions, paneling, wall pads, and crash pads applied structurally or for decoration, acoustical correction, surface insulation, or other purposes shall be considered interior finish and shall not be considered decorations or furnishings."

Reference #2: NFPA 101:10.2.4.7 "Polypropylene (PP) and High-Density Polyethylene (HDPE). Polypropylene and High-Density Polyethylene materials shall not be permitted as interior wall or ceiling finish unless the material complies with the requirements of 10.2.3.7.2. The tests shall be performed on the finished assembly and on the maximum thickness intended for use."

Reference #3: NFPA 101:10.2.3.7.2 "The interior finish shall comply with all of the following when tested using the test protocol of NFPA 286, Standard Methods of Fire Tests For Evaluating Contribution of Wall and Ceiling Interior Finish to Room Fire Growth: (1) During the 40 kW exposure, flames shall not spread to the ceiling. (2) The flame shall not spread to the outer extremities of the samples on the 8 foot by 12 foot walls. (3) Flashover, as described in NFPA 286, shall not occur. (4) For new installations, the total smoke released throughout the test shall not exceed 1,000 meters squared."

Reference #4: NFPA 101:10.2.4.3 "Cellular or Foamed Plastics, Cellular or foamed plastic materials shall not be used as interior and ceiling finish unless specifically permitted by 10.2.4.3.1 or 10.2.4.3.2. The requirements of 10.2.4.3 through 10.2.4.3.2 shall apply both to exposed foamed plastics and to foamed plastics used in conjunction with a textile or vinyl facing or cover."

Reference #5: NFPA 101:10.2.4.3.1 "Cellular or foamed plastic materials shall be permitted where subjected to large-scale fire tests that substantiate their combustibility and smoke release characteristics for the use intended under actual fire conditions. The tests shall be performed on the finished foamed plastic assembly related to the actual end-use configuration, including any cover or facing, and at the maximum thickness intended fore use. Suitable large-scale fire tests shall include those shown in 10.2.4.3.1.1."

1. On 12/10/19 at 1:20 PM, in the presence of Staff #54, #93, #94, and #95, all patient bathroom doors within the "Larch" building were removed and replaced with a movable partition constructed with a foamed material. These movable partitions are constructed with polypropylene foam and wrapped in a vinyl covering. These movable partitions are held in place by magnets that allow the partition to swing like a door. Refer to Reference #1 and Reference #2.

a. During an interview with Staff #54 on 12/11/19 at 1:30 PM, no evidence could be provided to demonstrate that the Kennon, Soft Suicide Prevention Doors and Artwork were tested utilizing a large-scale test. Refer to Reference #3, Reference #4 and Reference #5.

b. During a review, the manufacture specifications for Kennon, Soft Suicide Prevention Doors and Artwork, lacked any information related to testing in accordance with NFPA 286, Standard Methods of Fire Tests For Evaluating Contribution of Wall and Ceiling Interior Finish to Room Fire Growth. Refer to Reference #3, Reference #4 and Reference #5.

A. Based on observation, staff interviews, review of nationally recognized guidelines, and review of facility documents, it was determined that the facility failed to ensure adherence to AAMI (Association for the Advancement of Medical Instrumentation) ST79 requirements. (ST79 replaces and supercedes ST46 with 4 other AAMI standards [ST33, ST35, ST37, and ST42-R] approved July 10, 2009.)

Findings include:

Reference #1: ANSI (American National Standards Institute)/AAMI ST79:2017, Comprehensive guide to steam sterilization and sterility assurance in health care facilities, pg. 14 states, "... 3.2.2 Functional workflow patterns... The sterile processing department/area should include... b) a designated, separate clean work room for packaging, sterilization, and storage of clean items... 3.3.6.2. Clean work area/room... Preparation of textile packs and of individual wrapped textiles... should be carried out in an enclosed space separate from the remainder of the clean work area/room. ... There should be sufficient space for clean textile storage (both before and after assembly into packs), an illuminated inspection table, and patching equipment. ... ."

1. Upon interview on 12/10/19, Staff #6 confirmed that the facility follows AAMI guidelines for sterilization.

2. During a tour of the Dental Clinic on 12/9/19 at 10:50 AM, the following was observed:

a. Upon interview, Staff #12 stated that he/she reprocesses the surgical instruments for the dental clinic.

b. In the sterile processing area of the dental clinic, a small decontamination and a small sterilizer room was present. There was no area observed for the preparation and packaging of instruments in preparation for sterilization.

c. Staff #12 was questioned where he/she prepares and packages instruments for sterilization. He/she stated, "Because we have limited space, we prep and pack instruments in Dental Room #3. We wait until the patient leaves, then we bring the clean instruments in and wrap them on the counter. We don't have anywhere else to do it."

d. Dental Room #3 did not contain an area for clean textile storage, an illuminated inspection table, or patching equipment.

Reference #2: ANSI/AAMI ST79:2017, Comprehensive guide to steam sterilization and sterility assurance in health care facilities, pg. 97 states, "13.8 Qualification testing... Qualification testing with a BI PCD should be performed on all sterilizers after sterilizer installation... malfunctions, major repairs... For gravity-displacement sterilizers, three consecutive cycles should be run, one right after the other, with a PCD... yielding negative results from all test BIs and appropriate readings from all physical monitors and CIs. ... ."

1. Upon interview on 12/9/19, Staff #12 was questioned if any major repairs were conducted on Sterilizer #1 or Sterilizer #2 within the last two (2) years. Staff #12 stated that Sterilizer #1 "went down about a year ago" and needed a major repair.

a. A request was made to Staff #12 for the qualification testing performed on Sterilizer #1 after the major repair. No qualification testing was provided.

b. Upon interview, Staff #12 confirmed that he/she did not perform qualification testing for Sterilizer #1. When questioned how he/she would perform qualification testing after a major repair, Staff #12 stated that he/she was unfamiliar with qualification testing and was unsure how it should be performed.

2. Staff #1 and Staff #11 confirmed the above findings.

Reference #3: ANSI/AAMI ST79:2017, Comprehensive guide to steam sterilization and sterility assurance in health care facilities, pg. 40 states, "... 7.3 Manufacturer's written IFU... The device manufacturer's current written IFU should be accessible, reviewed, and followed. ... ."

1. Review of the sterilization log form, dated 11/7/19, revealed the following:

a. For Sterilizer #1, the load report indicated that three (3) high speed Sirona handpieces were sterilized at the following parameters: Temperature: 275 degrees Fahrenheit; Exposure time: 10 minutes.

(i) The manufacturer's instructions for use (IFU) for the high speed Sirona handpiece indicated that the instrument should be sterilized at an exposure time of 3 minutes.

b. For Sterilizer #1, two (2) contra-angle handpieces were sterilized at the following parameters: Temperature: 275 degrees Fahrenheit; Exposure time: 10 minutes.

(i) The IFU for the contra-angle handpiece indicated that the instrument should be sterilized at an exposure time of 3 minutes.

2. Review of the sterilization log form, dated 11/21/19, revealed the following:

a. For Sterilizer #1, the load report indicated that one (1) "Pro tip" was sterilized at the following parameters: Temperature: 275 degrees Fahrenheit; Exposure time: 10 minutes.

(i) The IFU for the "Pro tip" indicated that the instrument should be sterilized at a temperature of 270 degrees Fahrenheit.

3. Staff #1 and Staff #11 confirmed the above findings.

Reference #4: ANSI/AAMI ST79:2017, Comprehensive guide to steam sterilization and sterility assurance in health care facilities, pg. 43 states, "... 7.6.1 General considerations... c) Devices should be thoroughly rinsed. ... The final rinse (mechanical or manual) should be with purified water (e.g., distilled, or RO water). ... ."

1. Upon interview on 12/9/19 at 11:25 AM, during a tour of the Decontamination area in the Dental Clinic, Staff #12 confirmed that after instrument cleaning and decontamination, all final rinses are conducted with tap water. He/she stated that the facility does not use purified water for final rinses.

2. Staff #1 and Staff #11 confirmed the above finding.

B. Based on observation and staff interviews, it was determined that the facility failed to ensure that clean items and dirty items are kept separate, to minimize the risk of cross contamination.

Findings include:

1. During a tour on 12/9/19 of the Decontamination Room located in the Dental Clinic, the following was observed:

a. The following were observed in open, plastic containers in a storage cabinet: four (4) small plastic bags containing dental items, one (1) plastic denture cup that was labeled with the name of a patient, and one (1) brown paper bag containing dental items.

b. Upon interview, Staff #12 stated that the dental items "came from the dental lab." He/she explained that the dental items belonged to individual patients and were stored in the Decontamination Room "until they could give them out to the patients."

2. During a tour of Unit F2 on 12/9/19 at 2:30 PM, the following was observed:

a. The community shower room contained two (2) soiled linen carts and two (2) commodes. The first commode was labeled with the name of Patient #24. The second commode was labeled with the name of Patient #30. Upon interview, Staff #33 stated that Patient #24 and Patient #30 were wheelchair bound patients with partial weight bearing capabilities.

(i) Upon interview, Staff #33 stated that when Patient #24 and Patient #30 need to use the bathroom, they are assisted into the shower room to use the commode. When questioned if the commode is ever taken out of the shower room and into the patient's room, Staff #33 stated, "No. The patients use the commode here in the shower room. Grab bars are in the shower room so it's easier for staff to help the patients use the commode."

(ii) Upon interview, Staff #33 was unable to confirm that the community shower room was cleaned after Patient #24 or Patient #30 used the commode in the shower room.

b. Upon interview, Staff #33 confirmed that the unit did not have a soiled utility room. He/she stated, "The soiled utility room is in the shower room."

3. Staff #1 and Staff #4 confirmed the above findings.

C. Based on observation, review of facility documents, and staff interviews, it was determined that the facility failed to ensure that its policy and procedure regarding respiratory equipment, is implemented.

Findings include:

Reference: Facility policy, "Management of Respiratory Equipment" states, "... 3. Upon receiving a physician order, all patients receive individual equipment, which is labeled with the patient's name by unit personnel. ... 6. ...Weekly cleaning/replacements, other than C Pap/Bi Pap, are completed by the evening shift nurse performing the Wednesday Respiratory Equipment Replacement/Cleaning Log. ... 7. All items are labeled with date, time and initials, which is utilized to determine timeframe for replacement. Upon changing respiratory equipment, a new label is applied with the above noted information. ... 10. If a hand-held nebulizer is ordered, the following procedure is followed... a. Gather all equipment including nebulizer unit, tubing, medication reservoir, and mouthpiece. b. Rinse mouthpiece/mask reservoir after each treatment. Mouthpiece/mask reservoir and tubing are changed daily. ... 16. The Clinical Support Department is notified after a treatment is discontinued. The equipment is returned to the Main Building Infirmary by unit staff. ... ."

1. During a tour of the Cedar Hall Unit on 12/10/19 at 2:00 PM, the following was observed:

a. A nebulizer unit containing a mask, mouthpiece, medication reservoir, and tubing was observed in a plastic basin at the nurse's station. The nebulizer unit was found underneath a notebook and multiple magazines.

(i) The mask and medication reservoir were labeled with the name of Patient #16. The mouthpiece was labeled with the name of Patient #15. Both patients were current patients housed on the unit. There was no date, time, or initials labeled on the equipment.

b. Upon interview, Staff #100 stated he/she did not know why the nebulizer unit was labeled with two (2) different patient names. Staff #100 stated that he/she was "pretty sure" the nebulizer belonged to Patient #15.

(i) Review of the Medication Administration Record (MAR) for Patient #16 revealed that the patient had an active physician order for nebulizer treatments as needed, however, he/she never received a nebulizer treatment.

(ii) Review of the MAR for Patient #15 revealed that the patient had an active physician order for nebulizer treatments as needed. The patient's last documented nebulizer treatment was given on 11/26/19 at 2:30 PM.

c. Upon interview, Staff #92 and Staff #100 stated that the nebulizer equipment should have been discarded.

2. Staff #1, Staff #3, and Staff #43 confirmed the above findings.

Based on a review of two (2) medical records, document review, and staff interview, it was determined that the facility failed to ensure that the physician's order for a meal time evaluation is implemented for Patient #2.

Findings include:

Reference: The facility document titled " Rehabilitation Service Individual Mealtime Risk Review Protocol" states, "... The individual Mealtime Risk Review assessment is initiated from the Physician. The Medical Physician completed Rehabilitation Services Consultation Request Form #Rehab. N-3a. On the Form at the top is a box to check stating "Mealtime Evaluation". The consult is forwarded to the appropriate Occupational Therapist for completion. Only appropriately trained Occupational Therapy Staff will complete the individual Mealtime Risk review and the Rehabilitation Services Consult Request Form: ..."

1. Patient #2 had a choking event documented in MD monthly progress notes dated 11/21/19.

a. A Physician's order dated 11/21/19 stated, "Choking Precautions X [times] 30 days...Meal Time Monitoring ASAP [as soon as possible]."

(i) Patient #2 was placed on choking precautions for all meals until evaluated by the meal time monitoring team.

2. A Rehabilitation Services Consultation Referral form was completed by the physician on 11/21/19. The form was acknowledged by the rehabilitation services staff on 11/26/19.

a. On 11/27/19 and on 12/2/19, an Occupational Therapist (OT) attempted to complete a meal time evaluation, however, on both dates, the patient was out of the facility on a day pass. The notes indicated that the OT was going to attempt to evaluate the patient at the next available meal. The next attempt was made on 12/4/19, at which time the patient had already been discharged.

b. There was no evidence that the OT staff coordinated with nursing staff to check the patients schedule and availability to complete the meal time evaluation.

(i) Staff #59 was unable to define the time frame for an ASAP order completion. During interview, Staff #59 stated that the Meal Time Evaluations are usually completed within five (5) days of a physician's order.

3. During interview, Staff #59 confirmed that Patient #2 failed to have a Meal Time Evaluation prior to discharge on 12/3/19.

This Condition is not met. Based on record review and staff and patient interview it was determined that the facility failed to ensure-

1. Psychosocial Assessments contained a description of social service staff anticipated efforts in discharge planning. For details, see B108.

2. Psychiatric Evaluations contained a description of patient assets in descriptive, not interpretive fashion. For details, see B117.

3. Master Treatment Plans were based on patient strengths. For details, see B119.

4. Master Treatment Plans contained patient goals that were measurable, observable and patient specific behaviors. For details, see B121.

5. Master Treatment Plans included individualized and specific active treatment interventions based on the unique psychiatric symptoms of each patient. For details, see B122.

6. Adequate documentation of treatment notes for active treatment interventions listed in the Master Treatment Plan. For details, see B124.

7. Active treatment measures were provided for patients who were unwilling, unable, or not motivated to attend or participate in group therapies. For details, see B125.

Based on record review and staff interview it was determined that for 5 of 16 patients (Patients 2, 3, 4, 6 and 7) the Psychosocial Assessments failed to include the anticipated role of the social service staff in discharge planning. This failure resulted in no information being available to the other members of the multidisciplinary treatment staff or the patient about what specific measures the social service staff would be pursuing in discharge planning. The findings include-

A. Record Review:

1. Patient 2: The Psychosocial Assessment dated 11/20/2019 had no description of the anticipated disposition of the patient. Rather the statement "Social Worker will advocate for [Patient 2] for appropriate discharge planning and assist with any barriers that may come up." as the unspecified, anticipated role for the social worker.

2. Patient 3: The Psychosocial Assessment dated 8/19/2019 stated, "SW (Social Worker) will collaborate with patient, team and community providers to develop appropriate discharge plans." This is a routine discipline function and lacked patient specific information.

3. Patient 4: The Psychosocial Assessment dated 3/08/2019 stated/2019 stated: "Geriatric Discharge Coordinator will meet with [Patient 4] at least once a month for discharge planning ...". This is a routine discipline function and lacked patient specific information.

4. Patient 6: The Psychosocial Assessment dated 10/18/2019 stated "SW will collaborate with team, community providers, patient and family to develop appropriate discharge plan." This is routine discipline function and was not patient specific.

5. Patient 7: The Psychosocial Assessment dated 9/19/2019 stated "The social worker will work to provide appropriate placement for [Patient 7]'s needs." Neither the "appropriate placement" nor the "needs" were described.

B. Staff Interview:

On 12/10/2019 at 9:45 a.m. the Director of Social Work was interviewed. The above findings were discussed. The Director agreed that they did not meet the printed instructions in the facility's Social Work Assessment, Section 15 which states " ...include the community resources and support systems to be utilized in discharge planning ...". and "the tasks which will need to be completed in order for discharge to occur."

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 14 of 16 active sample patients (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14). The failure to identify patient assets impairs the treatment team's ability to choose treatment interventions / modalities that utilize patient attributes in their therapy.

Findings include:

A. Medical Records

The admission Psychiatric Evaluations (dates of evaluation in parenthesis) for the following patients did not contain specific assets or personal attributes, which could be useful in treatment.

1. Patient 1 (4/6/19): The Psychiatric Evaluation listed the following non-specific or personal attributes: "[S/he] is able to communicate [his/her] needs if [s/he] wants to. [S/he] is compliant in taking [his/her] medication when administered."

2. Patient 2 (3/30/16): The Psychiatric Evaluation listed the following non-specific or personal attribute: "(Supportive and caring family / friends) good compliance with medication."

3. Patient 3 (8/12/19): The Psychiatric Evaluation listed the following non-specific or personal assets: "Motivation and readiness to change, managing surrounding demands and opportunities, access to housing residential stability."

4. Patient 4 (3/30/16): The Psychiatric Evaluation listed the following non-specific or personal asset: "Supportive and caring family / friend."

5. Patient 5 (3/22/19): The Psychiatric Evaluation listed the following non-specific or personal assets: "Motivation and readiness to change."

6. Patient 6 (10/11/19): The Psychiatric Evaluation listed the following non-specific or personal asset: "Cooperative."

7. Patient 7 (9/13/19): The Psychiatric Evaluation listed the following non-specific or personal asset: "Supportive family / father."

8. Patient 8 (9/16/19): The Psychiatric Evaluation listed the following non-specific or personal asset: "Motivation and readiness to change."

9. Patient 9 (1/23/19): The Psychiatric Evaluation listed the following non-specific or personal asset: "Setting and pursuing goals."

10. Patient 10 (3/30/16): The Psychiatric Evaluation listed the following non-specific or personal asset: "Talent / skill sets."

11. Patient 11 (7/2/19): The Psychiatric Evaluation listed the following non-specific or personal assets: "Interpersonal relationships and supports."

12. Patient 12 (10/01/19): The Psychiatric Evaluation listed the following non-specific or personal asset: "Knowledge of medication."

13. Patient 13 (1/16/19): The Psychiatric Evaluation listed the following non-specific or personal asset: "Cultural / spiritual / religious community involvement."

14. Patient 14 (8/30/19): The Psychiatric Evaluation listed the following non-specific or personal asset: "Access to housing / residential stability."

B. Interview

On 12/10/19 at 11:50 a.m., the Clinical Director was interviewed. The Psychiatric Evaluations of patients 6, 7, 8 and 9 were reviewed by him. He agreed that the preprinted check-list of assets for these patients were not descriptive patient assets. Positive attributes like, enjoys music, follows news, past accomplishments, current interests etc. that might be utilized in therapeutic efforts were lacking.

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) were based on an inventory of behaviorally descriptive strengths that reflected each patient's specific assets or personal attributes that could be used to formulate treatment goals and active treatment interventions for six (6) of 16 active sample patients (8, 9, 10, 11, 12 and 16). The failure to identify personal patient strengths can adversely affect clinical decision-making in formulating MTPs and impairs the treatment team's ability to develop individualized goals and interventions.

Findings include:

A. Record review

1. Patient 8's MTP, updated 11/22/19, included the following deficient patient strength statement: "[S/he] can communicate [his/her] needs and concerns." This statement was not descriptive of a personal attribute such as interest, skill, or accomplishment that could be used in planning active treatment interventions to assist the patient in managing presenting psychiatric symptoms during hospital treatment.

2. Patient 9's MTP, updated 11/26/19, included the following deficient patient strength statement: "[Patient 8] has knowledge of hospitalization regulations and can identify what [s/he] needs to do to be discharged." This statement was not descriptive of a personal attribute such as interest, skill, or accomplishment that could be used in planning active treatment interventions to assist the patient in managing presenting psychiatric symptoms during hospital treatment.

3. Patient 10's MTP, updated 11/16/19, included the following deficient patient strength statement: "[Patient 10] verbalizes understanding of [his/her] legal issues but chooses not to attend court." This statement was not descriptive of a personal attribute such as interest, skill, or accomplishment that could be used in planning active treatment interventions to assist the patient in managing presenting psychiatric symptoms during hospital treatment.

4. Patient 11's MTP, updated 12/6/19, included the following deficient patient strength statement: "[Patient 11] has a supportive family." This statement was not descriptive of how the family is supportive and failed to identify which family members. Also, this statement was not descriptive of a personal attribute such as interest, skill, or accomplishment that could be used in planning active treatment interventions to assist the patient in managing presenting psychiatric symptoms during hospital treatment.

5. Patient 12's MTP, updated 12/7/19, included the following deficient patient strength statement: "[Patient 11] is able to articulate [his/her] needs and advocate for [himself/herself]." This statement was not descriptive of a personal attribute such as an interest, skill, or accomplishment that could be used in planning active treatment interventions to assist the patient in managing presenting psychiatric symptoms during hospital treatment.

6. Patient 16's MTP, updated 11/13/19, included the following deficient patient strength statement: " ... [s/he] is willing participate [sic] in the DBT program and [s/he] is willing to learn new skills to help prevent suicidal ideation." This statement was not descriptive of a personal attribute such as interest, skill, or accomplishment that could be used in planning active treatment interventions to assist the patient in managing presenting psychiatric symptoms during hospital treatment.

B. Interviews:

1. In an interview on 12/9/19 at 12:15 p.m. with the Chief Nursing Officer and two Assistant Directors of Nursing, they did not refute the findings that several strengths identified could not be used to develop interventions to be implemented during hospitalization.

2. In an interview on 12/10/19 at approximately 3:50 p.m., the strength statements in the MTPs were discussed with RN7 . RN7 agreed that some of the strength statements in the MTPs were not descriptive of patients' personal attributes.

Based on record review and interview, it was determined that the facility failed to develop treatment plans that contained individualized specific goals written in measurable, observable, and behavioral terms for 11 of 16 active sample patients (2, 3, 4,7, 8, 9, 12,13, 14, 15 and 16). Several goal statements were staff expectations or treatment compliance issues rather than patient outcome statements related to what the patients would be doing or saying to show improvement in their presenting or current psychiatric symptoms. These failures prevented both the patients and the treating staff from having clear understandings as to what behavior was targeted and how to measure progress or lack thereof in treatment.

Findings include:

A. Record Review

1. Active sample patient 2's MTP developed 11/25/19 for the problem of, "Disorganized thinking related to threatening, aggressive, and assaultive behaviors" had the following short-term goal. "Patient will engage in at least 10 minutes of reality based, focus oriented conversations with staff daily."

2. Active sample patient 3's MTP developed 11/17/19 for the problem of, "Program non- adherence" had the following short term goal. "Patient will attend at least one group per day at the treatment mail within the next 30 days." Long term goal was "Patient will attend and participate in active treatment at the treatment mall on a regular basis within the next 180 days."

3. Active sample patient 4 's MTP developed 12/08/19 for the problem of, "Depression with flat affect and psychotic features" had the following short term goal. "Patient will state 2 benefits of continuing treatment in the community." The long term goal was: "Within the next 60 days, patient will report [his/her] depression at 3 or less on a scale of 1-10."

4. Active sample patient 7's MTP developed 11/19/19 for the problem of, "Affective Dysregulation as per medication and adherence" had the following long-term goal. "Over the next 90 days, [Patient 7] will actively participate in treatment by developing a written prevention plan to prevent decompensation and future hospitalization." Actively participating in treatment was a staff goal, not a patient goal. The short-term goal of "Within the next thirty (30) days patient will verbalize an understanding of the necessity of taking antipsychotic medication while in the community" was not directly related to accomplishing the long-term goal.

5. Active sample patient 8's MTP developed 11/22/19 for the problem of, "Delusional, disorganized thinking, impaired judgment and suicidal ideation" had the following short term goal. "Over the next thirty (30) days, patient will have zero incidents of making frivolous reports about lack of care, asking female staff for dates or leaving messages that can't be understood."

6. Active sample patient 9's MTP developed 1/23/19 for the problem of, "Compliance: Patient has a long term history of non-compliance with his medications and assaultive behavior with staff and his peers" had the following short term goal (STG). "Patient will not have any aggressive behaviors for the next 60 days, per nursing reports." The long term goal for this patient was, "Patient will comply with expectations taking medication as prescribed, attending the treatment mall and following the hospital rules in the next 6 months." The STG statement was not directly related to the long-term goal or steps to accomplish the long-term goal. The long-term goal reflected treatment compliance issues. It was not a patient outcome statement indicating what this patient would be saying or doing to show improvement in the presenting or current psychiatric problems.

7. Active sample patient 12's MTP developed 12/7/19 for the problem of, "Compliance ... [Patient 12] history of non-compliance with [his/her] medication and assaultive behavior with [his/her] staff and peers" had the following short-term goal. "Patient will take medication as prescribed and not have any aggressive behaviors next 60 days." The long-term goal was: "Patient will comply with expectation of taking medications s prescribed, attending the treatment mall and following the hospital rules over the next 6 months." The STG statement was not directly related to the long-term goal or steps to accomplish the long-term goal. Also, the goal statement did not include descriptive information regarding the patient's aggressive behavior. Therefore, it would be not easy for the staff to know what to observe or how to determine progress. The long-term goal reflected treatment compliance issues. It was not a patient outcome statement indicating what this patient would be saying or doing to show improvement in the presenting or current psychiatric problems/symptoms.

8. Active sample patient 13's MTP developed 11/22/19 for the problem of "Aggressive behavior with recent acts" had the following short-term goal. "Over the next 30 days, [Patient 13] will take 100% of medication and attend all of [his/her] groups on the mall to help [him/her] avoid incidents of aggression." This STG was a staff expectation or treatment compliance issues, not a goal related to what the patient would be saying or doing to show improvement in managing aggressive behaviors and understanding the need for medications.

9. Active sample patient 14's MTP developed 11/5/19 for the problem of "Disorganized Thoughts/Refusing to take Medications" had the following long-term goal. "I will improve to the extent that I will participate in my daily scheduled programming on the ward with the next 30 days." This goal statement was a staff expectation related to the patient complying with treatment rather than a patient outcome related to improving present or current psychiatric symptoms. The short-goal of " ... will verbalize 2 benefits towards taking my psychotropic medications ..." was not directly associated with steps to achieve the long-term goal.

10. Active sample patient 15's MTP developed 11/11/19 for the problem of "Assaultive Behavior as a result of Psychotic Symptoms" had the following long-term goal. "Over the next 60 days, [Patient 15] will manage [his/her] symptom safely as evidenced by zero incidents of aggressive or assaultive behaviors." The goal statement was not written in behavioral terms. Therefore, it did not include descriptive information regarding what the patient would be doing or saying to show improvement in aggressive behaviors. Consequently, it would be difficult for staff to know what to observe or how to determine the patient's progress. The short-term goal of " ... attend at least one group a day to help manage any symptoms" contained no behavioral descriptors for "symptoms" and was a treatment compliance issue or staff expectation, not a patient goal. Also, this goal was not a clear step toward accomplishing the long-term goal.

11. Active sample patient 16's MTP developed 11/13/19 for the problem of "Mood Dysregulation with Suicidal ideation and Physical Aggression" had the following long-term goal. "[Patient 16] will be free of suicidal ideation and self-destructive behavior for 90 days. This unmeasurable goal was not written in behavioral and observable terms and was not descriptive of the patient's statements or behavior.

B. Interview

In an interview on 12/9/2019 at 12:15 p.m. with the Chief Nursing Officer and two Assistant Directors of Nursing, they did not refute the findings that some patient treatment plans failed to establish individual measurable goals.

Based on record review, document review, and interviews, the facility failed to ensure that Master Treatment Plans (MTPs) for 15 of 16 active sample patients (1, 2, 3, 4, 5, 6, 7, 8, 9, 11,12, 13, 14, 15, and 16) included individualized and specific active treatment interventions based on the unique psychiatric symptoms of each patient. Intervention statements were generic or routine discipline functions. They did not provide a clear picture of what the staff would be doing to assist the patient in making improvements in psychiatric symptoms or behaviors. Several intervention statements were not directly related to the presenting or current psychiatric problems or identified treatment goals. Also, for several of the MD and RN intervention statements, there was no frequency of contact identified, or the frequency was limited to "as needed" or monthly contacts. Therefore, these intervention statements failed to include an adequate frequency and intensity of active hospital treatment and to assist with each patient's goal achievement. These deficiencies result in MTPs that failed to reflect comprehensive, integrated, individualized approaches to interdisciplinary treatment and that potentially lead to inconsistent and ineffective treatment.

Findings include:

A. Record Review

The MTPs for the following active sample patients were reviewed (dates of plans in parentheses): 1 (12/7/19); 2 (11/25/19); 3 (11/17/19); 4 (12/8/19); 5 (11/24/19); 6 (11/17/19); 7 (11/19/19); 8 (11/22/19); 9 (11/26/19); 11(12//19); 12 (12/7/19); 13 (11/22/19); 14 (11/5/19); 15 (11/11/19); and 16 (11/13/19). The following deficient intervention statements were identified for the psychiatrist (MD), registered nurses (RN), rehabilitation therapist (RT), social workers (SW), psychologists (Psy.D).

1. Patient 1's MTP had the following deficient intervention statements for the "Active Problems to Discharge: Anxiety relate [sic] to Discharge Process, Aggression, assaultive behavior" and "Barriers to Discharge: Program non-Adherence." The plan also noted, "Reasons for continued hospitalization is refusal to be discharged to appropriate placement which is to a Nursing Home."

MD Intervention: "Psychiatrist will monitor psychotropic meds [medications] monthly and make adjustments according to clinical effect. To stabilize mood to prevent assaultive behavior. 1x Per Month." Monitoring the patient's medication was a generic and routine MD function. Therefore, this intervention statement was non-specific and not individualized in that the name of the medication(s) used or the information the patient would receive were not included. Also, the statement did not include whether the patient would be seen by the psychiatrist "monthly" in individual or group settings, and which was not at a frequency and intensity necessary for hospital treatment.

RN Interventions: "Nursing will provide counseling, redirection and encouragement to use Serenity room during periods of agitation, to prevent assaultive behavioral. 0 PRN [as needed]." "Staff will provide consistent counseling and redirection as [Patient 1] continues to be very psychotic and unable to process information 0 PRN." "Nursing will encourage participation in Zonal Nursing if [s/he] is refusing to attend the treatment mall. 00x As Needed." These RN interventions were identified "as needed" and failed to have a scheduled or plan for active treatment intervention. They also included routine nursing tasks such as redirecting and encouraging the patient. The statements failed to include a focus of treatment for the counseling based on precise symptoms and behaviors to addressed. Also, the intervention statement did not identify whether the contact with the patient would be in individual or group sessions. There was no active treatment intervention assigned that reflected the RN meeting with the patient to assist him/her in managing aggressive and psychotic behaviors. This intervention also did not identify contact with the patient at a frequency and intensity necessary to provide active treatment during hospitalization.

SW Intervention: "Social Worker will discuss discharge planning for possible Nursing home placement during monthly MTP(Master Treatment Plan) meeting. To discuss expectations of Nursing home placement. 1x Per Month." This intervention statement was broad and non-specific. It was not clear what the duration of this contact with the patient would be since the discussions were to be held during the MTP meetings. This intervention did not identify contact with the patient at a frequency and intensity necessary to provide active treatment during hospitalization.

RT Interventions: There was a list of 20 identical interventions in the MTP such as "Alternative Daily Activity 1: Monday @ 9:30 AM 01x Per Week for 0:40." The only difference was the day of the week and the time of day. This intervention statement was non-specific in that it did not include the topic of intervention or whether it was to be delivered in individual or group sessions. The statements also failed to include a focus of treatment based on precise symptoms and behaviors to addressed. The statement could have applied to any patient. It failed to identify particular activities that would be appropriate for this patient based on his/her assessed needs.

2. Patient 2's MTP had the following deficient intervention statements for the "Barriers to Discharge: Disorganized thinking leading to threatening, aggressive, and assaultive behaviors." The plan also noted under "Reasons for continued hospitalization," "[Patient 2] is clinically stable at this time. [S/he] is disruptive with property, destructive with property, intrusive, disorganized and [s/he] lacks having personal boundaries in regards to personal space with others."

MD Intervention: "Medication/Monitoring. The psychiatrist will monitor and assess the efficacy of [Patient 2] antipsychotic medications in regards to [his/her] symptoms and behaviors and will monitor for side effects. 01x Per Month for :20." Monitoring the patient's medication was a generic and routine MD function. Therefore, this intervention statement was non-specific and not individualized in that the name of the medication(s) used or the information the patient would receive were not included. Also, the monthly contact with the patient was not at the frequency and intensity necessary for active treatment during hospitalization.

RN Intervention: "Therapeutic Counseling. To assist [Patient 2] in assuming control. Nursing staff will use therapeutic counseling to assist in identifying impulse control and coping skills [s/he] is upset. 02x Per Shift for :10." This RN intervention statement was non-specific and did not identify whether the contact with the patient would be in individual or group sessions. It was not clear how "Therapeutic Counseling" would be conducted on the night shift.

SW Intervention: "Community Reintegration ... The Social Worker will provide discussion on discharge appropriate behavior and discharge options in the community. 01x Per Week for 0:45." This intervention statement was broad and non-specific and did not identify whether this contact would be conducted in individual or group sessions.

RT Interventions: There were seven assigned rehabilitation therapy interventions with the following identical focus of treatment statement such as "Art Therapy Grp [Group] ... to help [him/her] in identifying impulse control and coping skills [s/he] can use when [s/he] is upset." Groups with this same focus included "Current Events, Good Grooming & Hygiene, and Dayroom Movies." The statements failed to include a focus of treatment related to the treatment strategy based on precise symptoms and behaviors to addressed. The interventions in the MTP were also broad and non-specific. They neither identified the suggested impulse control and coping skills based on the patient's assessed needs nor the particular psychiatric problems or symptoms to be addressed.

3. Patient 3's MTP had the following deficient intervention statements for the "Barriers to Discharge: Non-Adherence." The plan also noted, "[Patient 3] continues to have paranoid thoughts that places [him/her] at risk for aggressive, assaultive behavior. [S/he] also has been sexually inappropriate on the unit ..." The deficient interventions for these problems were as follows:

MD Intervention: There was no psychiatrist intervention for this problem.

RN Intervention: "Nursing will encourage [Patient 3] to participate in Zonal Nursing when [s/he] refuses to go to the treatment mall as needed. 00x As Needed." This RN intervention statement was identified "as needed" and was the only intervention statement. There was no active treatment intervention assigned that reflected the RN meeting with the patient to assist him/her in managing aggressive and psychotic behaviors. This intervention did not identify contact with the patient at a frequency and intensity necessary to provide active treatment during hospitalization.

SW Intervention: There was no social work intervention for this problem.

RT Interventions: There was a list of 20 identical interventions in the MTP such as "Alternative Daily Activity 1: Monday @ 9:30 AM 01x Per Week for 0:40." The only difference was the day of the week and the time of day. This intervention statement was non-specific in that it did not include the topic of intervention or whether it was to be delivered in individual or group sessions. The statements failed to include a focus of treatment based on precise symptoms and behaviors to be addressed. The statement could have applied to any patient and failed to identify particular activities that would be appropriate for this patient based on his/her assessed needs.

4. Patient 4's MTP had the following deficient intervention statements for the "Barriers to Discharge: Depression with flat affect and psychotic features." The plan noted, "Reasons for continued hospitalization as "[Patient 4] continues to display depression with a flat affect. [S/he] isolates [himself/herself] from others, is withdrawn ..."

MD Intervention: "Medication (Antidepressant & Antipsychotic). To provide [Patient 4] with medication education, assess for adverse effects and efficacy of medications for depressive and psychotic. To educate [him/her] on the benefits of remaining compliant with treatment and in the hospital and community. 01x Per Month." Although this was an active treatment intervention, the statement did not identify contact with the patient at a frequency and intensity necessary to provide active treatment during hospitalization.

RN Intervention: "Supportive Counseling. To assist [Patient 4] with assuming control, the RN will teach coping skills in addition to milieu therapy with a focus on providing activities to engage [him/her] attention while managing [his/her] emotion and symptoms of depression. 01x Daily for 0:10." This RN intervention statement was non-specific and did not identify suggested coping skills or whether the contact with the patient would be in individual or group sessions.

SW Interventions: There were no social work interventions in the MTP.

RT Interventions: There was a list of nine interventions in the MTP with the following identical focus of treatment statement such as "Art Therapy ... to develop insight into [his/her] mental illness and [his/her] need to continue cooperate with treatment upon [his/her] return to the community." Groups with this same focus included "Walking Club, Good Grooming & Hygiene, and Table Time." The statements failed to include a focus of treatment based on the particular intervention and precise symptoms and behaviors to be addressed.

Psy.D. Intervention: "Reminiscience [sic] 1 ...To provide [Patient 4] with a forum to discuss past life events while helping [him/her] to develop insight into [his/her] mental illness and [his/her] need to cooperate with treatment upon [his/her] return to the community. 01x Per Week for 1:30." The statement was broad and failed to include a focus of treatment based on precise symptoms and behaviors to be addressed.

5. Patient 5's MTP had the following deficient intervention statements for the problem "Mood disturbance with aggression and treatment non-compliance when decompensated."

MD Intervention: "Psychiatry. Prescribe medication to stabilize mood, monitor for efficacy and side effects. 01x Per Week for 0:15." Monitoring the patient's medication was a generic and routine MD function. Therefore, this intervention statement was non-specific and not individualized in that the name of the medication(s) used or the information the patient would receive were not included. There was no active treatment intervention that identified meeting with the patient to provide information about medications and managing presenting psychiatric symptoms.

RN Interventions: Managing Symptoms. The nursing staff will meet with [Patient 5] to review coping skills for managing [his/her] symptoms daily. 01x Daily for 0:10." "Group Skills ... Staff will prepare [Patient 5] for groups in Maple Hal while reviewing coping skills for anger management. 10x Per Week for 1:30." This RN intervention statement was non-specific and did not identify suggestive coping skills or a focus of treatment based on the patient's precise psychiatric symptoms and behaviors.

SW Intervention: There were no social work interventions in the MTP.

RT Interventions: There were no rehabilitation interventions in the MTP.

6. Patient 6's MTP had the following deficient intervention statements for the problem "Psychosis that led to Threatening Behaviors." Description: " ... [Patient 6] had made a statement that 'the Holocaust is here' and 'shut up or you're gonna be murdered.' [S/he] also believed people were talking about [him/her] ..."

MD Intervention: "Medication Monitoring. The psychiatrist will prescribe medications and monitor for tolerance, side effects, and efficacy. 00x Per Week." to stabilize mood, monitor for efficacy and side effects. 01x Per Week for 0:15." Monitoring the patient's medication was a generic and routine MD function. Therefore, this intervention statement was non-specific and not individualized in that the name of the medication(s) used or the information the patient would receive were not included. There was no active treatment intervention that identified meeting with the patient to provide information about medications and managing presenting psychiatric symptoms.

RN Intervention: "Milieu Therapy. Nursing will monitor [Patient 6] for safety and maladaptive behaviors and provide coaching and assistance with skills as necessary. 00x Per Week." Monitoring was a routine RN job duty, not an active treatment intervention. This RN intervention statement regarding coaching was non-specific and did not identify which skills would be taught or a focus of treatment based on the patient's precise maladaptive behaviors.

SW Intervention: "DBT Skills Group ... Staff will engage [Patient 6] in Structured DBT groups to teach [him/her] strategies [s/he] can use to manage symptoms/stressors in a positive, healthy manner. 05x Per Week for 0:45." This intervention statement was broad, non-specific, and failed to identify the precise symptoms or stressors that would be addressed.

RT Interventions: There was a list of seven RT interventions in the MTP with the following identical focus of treatment statement such as "Thinking for a change... to explore ... how to manage [his/her] symptoms that led to [his/her] current hospitalization." Groups with the same focus of treatment included "Health Club, Creative Expressions, and Inspirational Moments." The statements failed to include a focus of treatment based on precise symptoms and behaviors to be addressed.

7. Patient 7's MTP had the following deficient intervention statements for the "Barriers to Discharge: Affective Dysregulation as per meds non-adherence." Description: " ... As evidenced by [Patient 7] refused to take [his/her] medications causing [him/her] to rapidly decompensate and threaten staff, responding to internal stimuli ... denied not taking [his/her] medications at the Nursing home ..." [S/he] also believed people were talking about [him/her] ..." The plan also noted under "Reasons for continued hospitalization," "[Patient 7] is continued commitment status, [s/he] refuses to meet with the treatment team and believes [his/her] name is not [first name of Patient 7]."

MD Intervention: There were no psychiatrist interventions in the MTP.

RN Interventions: There were five nursing interventions for the short-term goal [STG] of "Within the next 30 days, [Patient 7] will verbalize an understanding of the necessity of antipsychotic medications while in the community." These five interventions were not directly related to assisting the patient in accomplishing the STG such as "Nursing Anger and Aggression ... Staff will engage [Patient 7] in therapeutic discussion on developing coping skills on managing anger and aggression. 05x Per Week for 0:40." This intervention and the other four interventions did not identify whether the sessions would be conducted in group or individual sessions.

SW Intervention: There were no social work interventions in the MTP.

RT Interventions: There were no rehabilitation interventions in the MTP.

8. Patient 8's MTP had the following deficient intervention statements for the "Barriers to Discharge: Delusional, disorganized thinking, impaired judgement and suicidal ideation." Description: " ... [Patient 8] continues to complain that [s/he] hasn't been discharged yet ... [S/he] has not been able recommitted and [s/he] needs to stop calling the supreme court ... and other agencies." The plan also noted under "Reasons for continued hospitalization," " ... When meeting with the team, [s/he] appeared disorganized, rambling and speaking nonsensically at times ... (She/he) was refusing to take [his/her] medication for blood pressure ..."

MD Intervention: "Medication/Monitoring. The psychiatrist will monitor and assess the efficacy of [Patient 8's] antipsychotic medications in regards to [his/her] symptoms and behaviors and will monitor for side effects. 01x Per Week for 10 [sic]." Monitoring and assessing the patient's medication were generic and routine MD functions. Therefore, this intervention statement was non-specific and not individualized in that the name of the medication(s) used or the information the patient would receive were not included.

RN Interventions: "Therapeutic Counseling To assist [Patient 8] in assuming control. Nursing staff will use therapeutic counseling to help improve [his/her] reality orientation and decrease [his/her] disorganized speech and behaviors. 02x Per Week for 10 [sic]." "Group Skills ... Staff will engage [Patient 8] in structured discussions and activities to improve [his/her] reality orientation and decrease [his/her] disorganized speech and behaviors. 10x Per Week for 1:30 [sic]." These two RN interventions were non-specific and not directly related to assisting the patient to accomplish the STG of, "Over the next 30 days, [Patient 8] will have zero incidents of making frivolous reports about lack of care, asking [male/female] staff for dates, or leaving messages that can't be understood and continue to report that auditory hallucination along with homicidal, suicidal ideations are no longer an issue."

SW Interventions: There were no social work interventions in the MTP.

RT Interventions: There were no rehabilitation therapy interventions in the MTP.

9. Patient 9's MTP had the following deficient intervention statements for:

a. Short-term Goal: "[Patient 9] will not have any aggressive behaviors in the next 60 days, per nursing reports.":

MD Intervention: "medication stabilize mental state 00x Daily. This intervention statement was incomplete, non-specific, and not clearly stated.

RN Interventions: "counsel encourage compliance on unit 00x as needed." This intervention statement was incomplete, non-specific, and not clearly stated. This intervention was also not directly related to assisting the patient in accomplishing the identified STG. There was no active treatment intervention assigned that reflected the RN meeting with the patient to assist him/her in managing aggressive and psychotic behaviors. The "as needed" contact noted was not at a frequency and intensity necessary to provide active treatment during hospitalization.

SW Interventions: There were no social work interventions in the MTP.

RT Interventions: There were six rehabilitation therapy interventions. For four statements of the six interventions, statements were broad and non-specific. They did not identify the suggested skills based on the patient's assessed needs or particular psychiatric problems or symptoms to be address such as "Thinking for a change ... Develop skills to problem solve and initiate positive changes in behavior. 01x Per Week for 0:40."

b. Short-term goal - "[Patient 9] will attend at least 75% of [his/her] scheduled treatment mall groups in the next 60 days."

MD Intervention: There were no MD interventions for this goal.

RN Interventions: There were no RN interventions for this goal.

SW Interventions: There were no social work interventions in the MTP.

RT Interventions: There were seven rehabilitation therapy interventions. For five statements of the six interventions, statements were broad and non-specific. They did not identify suggested coping strategies based on the patient's assessed needs, such as "Coping Strategies ... Develop strategies to manage daily frustration and stress to reduce aggression. 01x Per Week for 0:45."

10. Patient 11's MTP had the following deficient intervention statements for:

a. Long-term goal - "[Patient 11] will have no impulsive statements or actions indicating violence or aggression in the next 4 months."

MD Intervention: There were no interventions for the psychiatrist in the MTP.

RN Interventions: There were no interventions for registered nurses for psychiatric issues in the MTP.

SW Interventions: There were no social work interventions in the MTP.

RT Interventions: "Music Therapy Group ... use of music as coping mechanism. 4x Per Week for 4:0." "Assertiveness ... Communication group 1x Per Week for :40." These intervention statements were non-specific and had no clear purpose of the intervention based on the patient's psychiatric needs or related to the identified long-term or short-term goal.

b. Short-Term Goal - "[Patient 11] will report to staff feelings of fear/resentment that lead to suicidal thoughts, as seen through nursing reports and rehab progress notes, in the next 60 days."

RN Intervention: "Nursing counsel opportunity to receive support from staff when needed. 00x As Needed." This RN intervention statement was non-specific and did not include a clear statement of focus based on the patient's identified suicidal risk. There was no active treatment intervention assigned that reflected the RN meeting with the patient to assist him/her in managing aggressive and psychotic behaviors. The "as needed" contact noted was not an intervention at a frequency and intensity necessary to provide active treatment during hospitalization.

RT Interventions: "Stress Management Skills Group ...with a focus on recognition of and ability to manage one's stress. 2x Per Week for :40." "Understanding & Expressing Emotion w/ Art ... art as expressive mode and stress reducer 4x Per Week for :40." These intervention statements were non-specific and did not include a clear statement of focus based on the patient's suicidal behaviors or ideations.

11. Patient 12's MTP had the following deficient intervention statements for:

a. Short-term goal - "[Patient 12] will take medications as prescribed and not have any aggressive behaviors next 60 days [sic]."

MD Intervention: "Medication - (anti-psychotic or mood stabilizer) To monitor efficacy and compliance, 00x Per Week." "Medication (Anti-psychotic and/or mood stabilizer monitor efficacy, and address possible side effects/concerns. Monitor efficacy, compliance and reduce potential for aggression. 00x Per Week." Monitoring and assessing the patient's medication and aggression were generic and routine MD functions. Therefore, this intervention statement was non-specific and not individualized in that the name of the medication(s) used was not included. Also, the statement did not include providing the patient with information regarding managing his/her aggression. There was no frequency of contact identified for these interventions.

RN Interventions: Nursing Education. To provide [Patient 12] with a list of [his/her] and dosages to assist [him/her] to better manage and comply with [his/her] medication regime. 00x Per Week." This intervention statement was primarily a routine RN duty. There was no intervention statement regarding teaching the patient information about his/her particular medications, including benefits, side effects, and ways to remain compliant when discharged. There was no frequency of contact identified for this intervention.

SW Interventions: There were no social work interventions in the MTP.

RT Interventions: "Conflict Resolution ... To develop strategies to manage frustration and identify ways to make compromises without becoming aggressive or verbally abusive. 01x Per Week for 0:40." "Stress Management Skills Group ... To develop and implement skills that will assist in managing daily frustration/stress. 01x Per Week for 0:40." These interventions were broad, non-specific, and did not identify skills that the patient could use based on his/her assessed needs and descriptors of stress/frustrations experienced by the patient.

b. Short-term goal - "[Patient 12] will attend program to identify and develop strategies to assist in managing [his/her] impulsivity over the next 60 days."

MD Intervention: There were no MD interventions for this STG.

RN Interventions: There were no RN interventions for this STG.

RT Interventions: "Spirituality and Music ... Reduce impulsivity by developing strategies to challenge thoughts and reduce verbal and physical aggression. 01x Per Week for 0:45." "Games for Socialization ... To develop a network of support and learn to interact appropriately with others. 01x Per Week for 1:25." These interventions were broad, non-specific, and did not identify strategies that the patient could use based on his/her assessed needs.

c. Short-term goal - "[Patient 12] will maintain safety and identify strategies to manage frustration rather than use self-injurious behaviors/gestures."

MD Intervention: There were no MD interventions for this STG.

RN Interventions: There were no RN interventions for this STG.

RT Interventions: "Wellness Discussion & Exercise Group ... Identify and implement healthy ways to handle stress/frustration without harming self. 01x Per Week for 0:40." "Education Activities ... To build a network of support and a means to increase socialization free from self-injurious behaviors. 01x Per Week for 0:40." "Creative Expression Group ... To develop a means to express feelings through a creative outlet without resorting to self-injurious behavior. 01x Per Week for 1:30." These interventions were broad, non-specific, and did not identify skills that the patient could use based on his/her assessed needs and descriptors of stress/frustrations experienced by the patient.

12. Patient 13's MTP had the following deficiency intervention statements for the "Barriers to Discharge: Aggressive behavior with recent assault acts." The plan also noted under "Reasons for Admission," stated, "due to psychiatric decompensation ... [Patient 13] became agitated, aggressive, and threatening towards [his/her] peers ... was non-compliant with [his/her] medication, not sleeping, and responding to auditory hallucinations." The short-term goal was "Over the next 30 days, [Patient 13] will take 100% of medication and attend all [his/her] groups on the mall to help [him/her] avoid incidents of aggression."

MD Intervention: "Prescribe medications, monitor for efficacy and side effects. 01x Per Week." Monitoring the patient's medication was a generic and routine MD function. Therefore, this intervention statement was non-specific and not individualized in that the name of the medication(s) used or the information the patient would receive were not included.

RN Intervention: "Encourage [Patient 13] to remain adherent with medication that will help [him/her] avoid aggressive, threatening behavior. 01x Per Week for 0:10." Encouraging the patient was a routine RN job duty. The statement was non-specific and failed to include whether the contact with the patient would be in individual or group sessions to provide information or teaching to help him/her understand the particular medications prescribed and how to remain adherence when discharged.

Social Services: There were no social work interventions in the MTP.

RT Interventions: There were six rehabilitation therapy interventions that were broad and non-specific with the same focus of rationale for treatment. It was not clear how each of these interventions assists the patient to remain adherent to medications such as "Stretching to Decrease Stress ... Encourage [Patient 13] to remain adherent with medication that will help [him/her] avoid aggressive, threatening behaviors. 02x Per Week for 0:45." These treatment interventions did not reflect meeting with the patient in individual or group sessions to provide information regarding the importance of medication compliance when discharged.

13. Patient 14's MTP had the following deficient intervention statements for the "Barriers to Discharge: Disorganized Thoughts/Refusing to take Medications" The plan also noted under "Reasons for Admission:" "assaulted a staff by picking her up and slamming her back onto the door ... admitted to having suicidal ideations ... history of non-compliance with medications and treatment." The short-term goal was, "Within the next 30 days, I will verbalize 2 benefits toward taking my psychotropic medications each day to the Treatment Team."

MD Intervention: "Psychiatrist will prescribe antipsychotic medications to help manage [his/her] mood 01x Per Week for 0:15." Prescribing the patient's medication was a generic and routine MD function. Therefore, this intervention statement was non-specific and not individualized in that the name of the medication(s) used or the information the patient would receive were not included.

RN Intervention: "Medication Education. To help [Patient 14] learn about [his/her] illness and to develop coping skills to prevent aggression and manage stressors related to poor frustration tolerances. 01xPer Week for 0:15." This intervention statement was not directly related to medication education or the identified STG. The statement failed to include whether the contact with the patient would be in individual or group sessions to provide information or teaching to help him/her understand the particular medications prescribed, such as the benefits, side effects, and how to remain adherence when discharged.

Social Services: "Community Connections ... Engage [Patient 14] in a supportive setting to improve [his/her] orientation to reality, motivate to work towards discharge again, and development of strategies to prevent stopping meds in the future. 0003x Per Week for 40."

RT Interventions: There were five rehabilitation therapy interventions that were broad, non-specific, and not directly related to the identified STG. It was not clear how each of the following interventions would help the patient to verbalize benefits of taking psychotropic medications. "Art Therapy ... Engage [Patient 14] in a variety of artistic processes to promote self-expression, improve quality of life and manage stressors ... 03x Per Week for 0:45." "Positive Outlook ... Staff will teach [Patient 14] strategies to build [his/her] self-esteem through self-management tools ... 01x Per Week for 0:45." "Coping skills ... Staff will help [Patient 14] learn ways to manage [his/her] stressors ... develop coping skills to help decrease delusional thoughts. 01x Per Week for 0:45." "Leisure Education ... Staff will focus on positive leisure activities [Patient 14] can do in the community ... help manage [his/her] stressors and maintain [his/her] medication regimen to prevent frustration intolerances. 01x Per Week for 0:40." There was no active treatment intervention reflecting meeting with the patient in individual or group sessions to provide inf

Based on record review and interview, the facility failed to ensure adequate documentation of treatment notes for active treatment interventions listed in the Master Treatment Plan and assigned to be delivered by Registered Nurses for 12 of 16 active sample patients (1, 2, 4, 5, 6, 7, 8, 12, 13, 14, 15 and 16), by social worker for 6 of 16 active sample patients (1, 2, 6, 7, 15 and 16) and by rehabilitation therapists for 12 of 16 active sample patients (1, 2, 3, 4, 6, 9, 11, 12, 13, 14, 15, and 16). Specifically, the documentation failed to show detailed and comprehensive information about treatment provided for psychiatric problems. In addition, the notes by RNs did not consistently include the patients' attendance or non-attendance. Treatment notes for each session contained no or limited information about the specific topics discussed, activities provided, and the patient's response to interventions, including the level of understanding of the information provided, behaviors during the group sessions, and specific comments, if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' conditions, and revising the treatment plan when the patient did not respond to treatment interventions.

Findings include:

A. Record Review

The MTPs for the following active sample patients were reviewed (dates of plans in parentheses): 1 (12/7/19); 2 (11/25/19); 3 (11/17/19); 4 (12/8/19); 5 (11/24/19); 6 (11/17/19); 7 (11/19/19), and 8 (11/22/19), 9 (11/26/19), 11(12//19), 12 (12/7/19), 13 (11/22/19), 14 (11/5/19), 15 (11/11/19), and 16 (11/13/19). The review revealed the following findings regarding treatment notes for assigned interventions in the MTPs for registered nurses (RN), social workers (SW), and rehabilitation therapists (RT).

1. Nursing Interventions: "RN Summary Progress Notes" were reviewed (dates of progress notes in parentheses). This review revealed that there were no treatment notes reflecting the RNs providing the following active treatment interventions assigned in MTPs. There was no documentation about the number of contacts or attempts to provide active treatment interventions identified in MTPS for none of the interventions below. Also, there was no documentation regarding the topics discussed, handouts provided, or the patient response to interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions.

a. Patient 1: "Nursing will provide counseling, redirection and encouragement to use Serenity room during periods of agitation, to prevent assaultive behavioral. 0 PRN [as needed]." "Staff will provide consistent counseling and redirection as [Patient 1] continues to be very psychotic and unable to process information 0 PRN." The "RN Progress Notes" Form, dated 11/7/19, provided no documented evidence that these interventions were implemented.

b. Patient 2: "Therapeutic Counseling. To assist [Patient 2] in assuming control. Nursing staff will use therapeutic counseling to assist in identifying impulse control and coping skills [s/he] is upset. 02x Per Shift for :10." The monthly "RN Progress Notes" Form, dated 10/25/19, contained no documentation that the RN met with the patient two times per shift for 10 minutes. The notes under therapeutic counseling did not include any information about contact with the patient, topics discussed, or patient's response to the counseling.

c. Patient 4 - "Supportive Counseling. To assist [Patient 4] with assuming control, the RN will teach coping skills in addition to milieu therapy with a focus on providing activities to engage [his/her] attention while managing [his/her] emotion and symptoms of depression. 01x Daily for 0:10." The monthly "RN Progress Notes" Form, dated 11/12/19, contained no documentation that the RN met with the patient daily for 10 minutes. The notes under "Supportive Counseling did not include any information reflecting that this intervention was implemented. There was no information regarding the duration of contact, topics discussed, or the patient's response to the counseling, including the level of participation, the level of understanding, behaviors during the sessions, or comments by the patient.

d. Patient 5 - "Managing Symptoms. The nursing staff will meet with [Patient 5] to review coping skills managing [his/her] symptoms daily. 01x Daily for 0:10." "Group Skills ... Staff will prepare [Patient 5] for groups in Maple Hal while reviewing coping skills for anger management. 10x Per Week for 1:30." The monthly "RN Progress Notes" Form, dated 11/21/19, contained no documentation that the RN met with the patient daily for 10 minutes to review coping skills. The notes under "Group Skills" revealed that the patient "does not attend programs." There was no information reflecting attempts to meet with the patient in individual sessions to ensure that active treatment was implemented. There was no information regarding the duration of contact, topics discussed, handouts provided, or the patient's response to the counseling, including the level of participation, the level of understanding, behaviors during the sessions, or comments by the patient.

e. Patient 6 - 'Milieu Therapy. Nursing will monitor [Patient 6] for safety and maladaptive behaviors and provide coaching and assistance with skills as necessary. 00x Per Week." The weekly "RN Summary Progress Notes Form," dated 11/30/19, under the section titled "Milieu Therapy," contained no information about the patient's behavior. There was no documented evidence that the RN met with the patient to provide coaching or assistance with skills to manage maladaptive behavior.

f. Patient 7 - "Nursing Anger and Aggression ... Staff will engage [Patient 7] in therapeutic discussion on developing coping skills on managing anger and aggression. 05x Per Week for 0:40." The monthly "RN Progress Notes" Form, dated 12/11/19, contained no documentation that the RN met with the patient five times per week for 40 minutes. The section titled "Intervention: Nursing Anger and Aggression ..." was left blank. There was no information regarding the duration of contact, topics discussed, or the patient's response to the counseling, including the level of participation, behaviors during the sessions, or comments by the patient.

g. Patient 8 - "Therapeutic Counseling to assist [Patient 8] in assuming control. Nursing staff will use therapeutic counseling to help improve [his/her] reality orientation and decrease [his/her] disorganized speech and behaviors. 02x Per Week for 10 [sic]." "Group Skills ... Staff will engage [Patient 8] in structured discussions and activities to improve [his/her] reality orientation and decrease [his/her] disorganized speech and behaviors. 10x Per Week for 1:30 [sic]." The monthly "R.N. Summary Progress Notes" Form, dated 11/11/19, provided no documented evidence that the interventions in the MTP titled "Therapeutic Counseling" were implemented.

h. Patient 12 - "Nursing Education. To provide [Patient 12] with a list of [his/her] medications and dosages to assist [him/her] to better manage and comply with [his/her] medication regime. 00x Per Week." The "R.N. Summary Progress Notes" Form, dated 11/25/19, contained no Nursing Education section on the form. There was no documented evidence that the patient received a list of his/her medications or any patient teaching regarding medications.

i. Patient 13 - "Encourage [Patient 13] to remain adherent with medication that will help [him/her] avoid aggressive, threatening behavior. 01x Per Week for 0:10." The "R.N. Summary Progress Notes" Form, dated 12/4/19, contained no section related to this intervention. There was no documented evidence that the RN met with the patient for 10 minutes per week to implement this intervention.

j. Patient 14 - "Medication Education. To help [Patient 14] learn about [his/her] illness and to develop coping skills to prevent aggression and manage stressors related to poor frustration tolerances. 01xPer Week for 0:15." The "R.N. Summary Progress Notes" Form, dated 12/4/19, contained no section related to Medication Education. There was no documented evidence that the RN met with the patient for 15 minutes to provide patient teaching regarding his/her illness and coping skills.

k. Patient 15: "Nursing Counseling. The nurse will help [Patient 15] understand the importance of medication compliance especially when managing psychotic symptoms and reducing incidents of aggressive behaviors. 01x Per Week for 0:10." The "R.N. Summary Progress Notes" Form, dated 12/5/19, reported, "Continue to teach Pt. importance of compliance with [illegible]." "Nursing has been counseling Pt. on benefits of complying [with] medications." There was no information regarding the duration of the contact with the patient, what medication was addressed, or the description of the patient's behaviors during counseling sessions.

l. Patient 16 - "Nursing Education. Nursing will monitor [Patient 16] suicidal symptoms, offer education about mental illness, counseling and support. 1x Per Week for 0:15." The "R.N. Summary Progress Notes" Form, dated 11/12/19, contained no section related to Nursing Education. There was no documented evidence that the RN met with the patient for 15 minutes to provide education about mental illness, counseling, or support.

2. Social Worker Interventions

A review of the "Treatment Program Progress Note" Forms revealed there was no or limited documentation regarding the following assigned treatment interventions in the MTPs. There was no or insufficient documentation regarding the topics discussed, handouts provided, or activities offered during each group session. In addition, except for the level of participation, there was no documentation to show the patient's response to interventions, including the level of understanding, behaviors exhibited, or specific comments made during group sessions.

a. Patient 1: "Social Worker will discuss discharge planning for possible Nursing home placement during monthly MTP meeting. To discuss expectations of Nursing home placement. 1x Per Month." There were no progress notes submitted regarding this intervention.

b. Patient 2: "Community Reintegration ... The Social Worker will provide discussion on discharge appropriate behavior and discharge options in the community. 01x Per Week for 0:45." The progress notes for the period from 10/30/19 through 11/20/19 revealed that the patient did not attend or participate in the group sessions. There was no documented evidence that the social worker saw the patient in individual sessions to attempt to provide active treatment.

c. Patient 6: "DBT Skills Group ... Staff will engage [Patient 6] in Structured DBT groups to teach [him/her] strategies [s/he] can use to manage symptoms/stressors in a positive, healthy manner. 05x Per Week for 0:45." The "Treatment Program Progress Note" Forms for the period from 11/18/19 through 11/22/19 were not completely documented but noted, "She does attend group and minimally participates." There was no information regarding the topics discussed or how the patient responded during each session.

d. Patient 15: Social Services: "Community Connections ... To help [Patient 15] better manage [his/her] symptoms so [s/he] can successfully return to the community. 01x Per Week for 0:40." There were no "Treatment Program Progress Note Forms" submitted for this assigned intervention. The "Program Attendance Version 2 History" for the period from 12/3/19 through 12/9/19 reported that the patient did not attend or participate in the intervention session held on 12/9/19.

e. Patient 16: "Discharge Coordination. Social Worker will assist client for discharge by coordinating [his/her] with the ... transition case manager. 1x Bi-Weekly for 0:15." There were no "Treatment Program Progress Note Forms" submitted for this assigned intervention.

3. Rehabilitation Therapy

a. Patient 1: There was a list of 20 identical interventions in the MTP such as "Alternative Daily Activity 1: Monday @ 9:30 AM 01x Per Week for 0:40." There were ten forms submitted for 20 assigned Alternative Activity sessions for the period from 11/5/19 through 11/28/19, showing zero (0) out of 33 possible sessions. There was no documented evidence that the patient was seen in individual sessions to ensure active treatment.

b. Patient 2: There was a list of six groups assigned in the MTP. The progress notes for the period from 10/28/19 through 11/21/19 revealed that the patient did not consistently participate in the group sessions. These notes revealed that the patient participated in "Current event" and "Music Therapy" for one session. The patient attended "Art Therapy" for two sessions. There was no information reflecting the topics or activities for these sessions or the patient's response, including the level of participation, behaviors during the sessions, or any specific comments the patient made. There was no documented evidence that the therapist saw the patient in individual sessions to attempt to provide active treatment for missed sessions.

c. Patient 3: There was a list of 20 identical interventions in the MTP such as "Alternative Daily Activity 1: Monday @ 9:30 AM 01x Per Week for 0:40." There were no "Treatment Progress Note" Forms progress submitted for these 20 assigned groups. The "Program Attendance Version 2 History" Form revealed the patient did not attend or participate in these groups.

d. Patient 4: There was a list of eight interventions in the MTP with the following identical focus of treatment statement: "to develop insight into [his/her] mental illness and [his/her] need to continue to cooperate with treatment upon [his/her] return to the community." There were no progress notes submitted for the eight assigned interventions. The "Program Attendance Version 2 History" for the period from 12/3/19 through 12/9/19 revealed inconsistent attendance in the assigned group sessions. This form showed that the patient attended the following assigned groups "Art Therapy, Outdoor Expressions, Walking Club, Art Therapy, and Good Grooming & Hygiene."

e. Patient 6: There was a list of eight assigned interventions in the MTP, and the "Treatment Program Progress Note" Forms were submitted for seven of these groups for the period from 10/21/19 through 11/28/19. These forms revealed the patient's consistent participation in most assigned group sessions. Patient 6 did not attend or participate in the following groups, "Emotion Group and Creative Expressions." The documentation for groups attended failed to consistent include information regarding the topic discussed or activities provided, the patient's response to the intervention, including the level of understanding, behaviors during the sessions, and comments made. There was no documented evidence that the RT staff saw the patient in individual sessions to attempt to provide active treatment for missed sessions.

f. Patient 9: There were thirteen assigned rehabilitation therapy group interventions in the MTP, and the "Treatment Program Progress Note" Forms were submitted for nine of these groups for the period from 10/21/19 through 11/14/19. These forms revealed the patient's non-participation in all group sessions except one. The notes reported that Patient 9 attended and participated in the "Conflict Resolution" Group. The documentation for this group attended did not include information regarding the topic discussed, activities provided, or the patient's response to the intervention including, the level of understanding, behaviors during the sessions, and comments made. There was no documented evidence that the RT staff saw the patient in individual sessions to attempt to provide active treatment for missed sessions.

g. Patient 11: There were five assigned rehabilitation therapy group interventions in the MTP, including "Music Therapy Group ... use of music as coping mechanism. 4x Per Week for 4:0." "Assertiveness ... Communication group 1x Per Week for :40." The "Treatment Program Progress Note" Forms were submitted for four of these groups for the period from 10/1/19 through 10/25/19. These forms revealed the patient participated in 11 of 24 possible sessions. The documentation for these 11 group sessions did not include information regarding the topic discussed or activities provided (except for Music Therapy), the patient's response to the intervention including, the level of understanding, behaviors during the sessions, and comments made. There was no documented evidence that the RT staff saw the patient in individual sessions to attempt to provide active treatment for missed sessions.

h. Patient 12: There were ten assigned rehabilitation therapy group interventions in the MTP. The "Treatment Program Progress Note" Forms were submitted for all of these groups for the period from 10/25/19 through 11/22/19. These forms revealed the patient participated in seven of 54 possible sessions. The documentation for these seven group sessions did not include information regarding the topic discussed or activities provided. The notes lacked documented evidence of the patient's response to the intervention, including the level of understanding, behaviors during the sessions, and comments made. Also, there was no documented evidence that the RT staff saw the patient in individual sessions to attempt to provide active treatment for missed sessions.

i. Patient 13: There were six assigned rehabilitation therapy interventions in the MTP. The "Treatment Program Progress Note" Forms were submitted for all of these groups for the period from 11/18/19 through 11/28/19. These forms revealed the patient participated in five of 24 possible sessions. The documentation for these five group sessions did not include information regarding the topic discussed or activities provided. Except for the "Group Readiness" sessions, the notes lacked documented evidence of the patient's response to the intervention, including the level of understanding, behaviors during the sessions, and comments made. Also, there was no documented evidence that the RT staff saw the patient in individual sessions to attempt to provide active treatment for missed sessions.

j. Patient 14: There were eight assigned rehabilitation therapy interventions in the MTP. The "Treatment Program Progress Note" Forms were submitted for three of these groups for the period from 11/18/19 through 11/28/19. These forms revealed the patient did not attend these groups. There was no documented evidence that the RT staff provided alternative individual sessions to attempt to provide active treatment for missed sessions.

k. Patient 15: There were 14 assigned rehabilitation therapy interventions in the MTP." The "Treatment Program Progress Note" Forms were submitted for eight groups for the period from 11/18/19 through 11/28/19. These forms revealed the patient participated in three of 21 possible sessions. Except for the Music Therapy Group, the documentation for these five group sessions did not include information regarding the topic discussed, handouts used, or activities provided. The notes lacked documented evidence of the patient's response to the intervention, including the level of understanding, behaviors during the sessions, and comments made. [The documentation for the "Conflict Management" Group held on 11/25/19 was the only note with information regarding the patient's behavior during the group session]. Also, there was no documented evidence that the RT staff saw the patient in individual sessions to attempt to provide active treatment for missed sessions.

l. Patient 16: There were 13 assigned rehabilitation therapy interventions in the MTP. The "Treatment Program Progress Note" Forms were submitted for ten groups for the period from 11/7/19 through 11/29/19. These forms revealed the patient participated in 10 of 25 possible sessions conducted by RT staff. Social Work and psychology staff each led groups assigned to RT. The documentation for these ten group sessions did not include information regarding the topic discussed, handouts used, or activities provided (except for Music Therapy). The notes lacked consistent documented evidence of the patient's response to the intervention, including the level of understanding, behaviors during the sessions, and comments made. Also, RT staff did not document whether the patient was seen in individual sessions to attempt to provide active treatment for missed sessions.

B. Interviews

1. In an interview on 12/9/19 at 12:15 p.m. with the Chief Nursing Officer and two Assistant Directors of Nursing, they did not refute the findings that there was no documented evidence that nursing interventions in MTPs were being conducted by registered nurses.

2. In an interview on 12/919 at approximately 11:35 a.m., the treatment notes for intervention statements in the MTPs were discussed with RN3. RN3 agreed that information documented in the "RN Summary Progress Notes" Forms did not include documented evidence regarding the duration of contact, topics discussed, and the patient's response to the interventions.

3. In an interview on 12/10/19 at approximately 3:50 p.m., the treatment notes for intervention statements in the MTPs were discussed with RN7. RN7 agreed that there was no documented evidence that RN treatment interventions for psychiatric issues were implemented.

4. In an interview on 12/11/9 at 10:10 a.m., the lack of detailed treatment notes was discussed with Director of Rehabilitation and a Deputy staff from the Division of Mental Health. They did not refute the findings that most treatment notes by RT staff did not include the topic discussed or the patient's response during each session. The Director of Rehabilitation pointed out that the "Treatment Program Progress Note" Forms had a section for staff to document this information. However, when reviewing several forms for the active sample patients, she did not dispute the finding that this information was missing for most of these patients.

Based on record review and interview, the facility failed to ensure that active treatment measures were provided for four (4) of 16 active sample patients (7, 8, 13, and 14) who were unwilling, unable, or not motivated to attend or participate in the group treatment program. Specifically, there was an inadequate frequency and intensity of active treatment to assist with each patient's psychiatric improvement or treatment goal attainment. Also, there was no documented evidence in the medical record to show attempts to engage these patients in alternative individual active treatment measures. Despite inconsistent or lack of regular attendance in groups, Master Treatment Plans (MTP) were not revised to reflect alternative treatment measures to assist patients in making an appropriate recovery. Failure to provide active treatment at a sufficient level and intensity results in affected patients being hospitalized without all active treatment interventions for recovery, potentially delaying their improvement or being discharged without the necessary skills to prevent relapse.

Findings include:

A. Record Review

1. Patient 7
a. Patient 7's Psychiatric Evaluation (PE), dated 9/13/19, reported that the patient was admitted on 9/13/19 with a diagnosis of "Schizoaffective Disorder." Also, the patient was described as "selectively mute, not eating well, poor ADL [Activity of Daily Living] care."

b. Patient 7's MTP (updated 11/5/19) stated the problem [called reasons for admission by the facility] was "refusing [his/her] psychotropic medications, neglect self-care ... disorganized ... isolative, refusing food and interacting with staff ... [Patient 7] was combative with staff ... responding to internal stimuli, and attempted to elope from the Nursing Home ... selectively mute, agitated ...withdrawn ..." The long-term goal was. "Over the next 90 days, [Patient 7] will actively participate in treatment by developing a written prevention plan to prevent decompensation and future hospitalization." The short-term goal [STG] was "Within the next 30 days [Patient 7] will verbalize an understanding of the necessity of taking antipsychotic medications while in the community." Interventions were:
Psychiatry: There was no psychiatrist intervention for this problem.

Nursing: "Program Readiness ...Staff will engage [Patient 7] is [sic] a variety of activities and discussion to encourage [him/her] to participate in [his/her] treatment. 06x Per Week for 0:45." "Anger and Aggression ... Staff will engage [Patient 7] in therapeutic discussion on developing coping skills on managing anger and aggression. 05x Per Week for 0:40." Women's Grooming and Hygiene ... Staff will educate [Patient 7] on the importance of doing [his/her] daily ADLs [Activities of Daily Living]. 01x Per Week for 0:30." "Life Skills ... Staff will educate [Patient 7] on necessary life skills that will [sic] to reintegrate back to the community. 03x Per Week for 0:40." "Effective Communication ... To help [Patient 7] develop effective communication skills. 03x Per Week for 0:30."

Social Services: There were no social work interventions in the MTP.

Rehabilitation Services: There were no assigned rehabilitation therapy interventions in the MTP.

c. The "Program Attendance Version 2 History" for the period 12/3/19 - 12/9/19 indicated that the Patient 7 had attended none of the assigned nursing groups. There were five rehabilitation therapy and one psychology "Treatment Program Progress Note" submitted for the period from 10/14/19 through 10/23/19. These notes confirmed the patient did not attend assigned group treatment sessions. There was no documented evidence of alternative individual contact with the patient to attempt to engage him/her in active treatment activities. The monthly "R.N. Summary Progress Notes" dated 12/11/19 provide little or no documented evidence that the interventions in the MTP were implemented at all. There was a notation regarding the "Women's Grooming and Hygiene" Group. This note failed to provide information about the patient's attendance or non-attendance in this group and reported, " ...Patient has been refusing [his/her] meds at times, refusing EKG's, lab draws and attending Tx [treatment] programs. Continue to encourage patient to comply [with] medication and treatment."

d. During an observation on 12/9/19 at 3:15 p.m. on Larch C, Patient 7 was observed sitting in the dayroom and not participating in a group entitled "Personal hygiene and grooming" even though this group was part of her treatment plan. There were no alternative individual sessions offered to ensure that the patient received active treatment related to the missed group session. During an interview at approximately 3:30 p.m., RN5 confirmed that there were no alternative individual treatment sessions or activities for this patient.

e. Patient 7's MTP was not revised to address this lack of attendance in groups. There were no alternative individual intervention sessions developed to engage the patient based on his/her present level of functioning. Therefore, there were no individual active treatment sessions included ensuring the patient received active treatment at a level of intensity and frequency necessary for psychiatric hospital care.

2. Patient 8
a. Patient 8's Psychiatric Evaluation (PE), dated 9/16/19, reported that the patient was admitted on 9/16/19 with a diagnosis of "Bipolar Disorder."

b. Patient 8's MTP dated 9/16/19) stated the problem [called reasons for admission by the facility] was " ... [Patient 8] was non-compliant with [his/her] medication, and begun experiencing suicidal, and homicidal thoughts ... [Patient 8] was having thoughts of overdosing on heroin or by having the police shoot [him/her] ... reported hearing voices about murders, and having homicidal thoughts towards the Mayor of Philadelphia ..." The long-term goal was "[Patient 8] will remain on [his/her] medication for help recognizing that [s/he] shouldn't continue to make any unnecessary and improper calls, over the next 60 days." The short-term goal was "Over the next 30 days, [Patient 8] will have zero incidents of making frivolous reports about lack of care, asking [male/female] staff for dates, or leaving messages that can't be understood and continue to report that auditory hallucination along with homicidal, suicidal ideations are no longer an issue." Interventions were:
Psychiatry: "Medication/Monitoring. The psychiatrist will monitor and assess the efficacy of [Patient 8's] antipsychotic medications in regards to [his/her] symptoms and behaviors and will monitor for side effects. 01x Per Week for 10 [sic]."

Nursing: "Therapeutic Counseling To assist [Patient 8] in assuming control. Nursing staff will use therapeutic counseling to help improve [his/her] reality orientation and decrease [his/her] disorganized speech and behaviors. 02x Per Week for 10 [sic]." "Group Skills ... Staff will engage [Patient 8] in structured discussions and activities to improve [his/her] reality orientation and decrease [his/her] disorganized speech and behaviors. 10x Per Week for 1:30 [sic]."

Social Services: There were no social work interventions in the MTP.

Rehabilitation Services: There were no rehabilitation therapy interventions in the MTP.

c. The "Program Attendance Version 2 History" for the period 12/3/19 - 12/9/19 indicated that Patient 8 had attended none of the ten sessions of the group titled "Group Skills." This information also showed that the patient did not attend "Active wellness, Personal Medicine, Practical Coping Skills and empowerment, and Stress Management 1. The patient attended "Alternate Leisure Activity and Community Connections." The monthly "R.N. Summary Progress Notes" dated 11/11/19 provided no documented evidence that the interventions in the MTP titled "Therapeutic Counseling" were implemented at all. There were twelve "Treatment Program Progress Notes" submitted for the period from 10/22/19 through 11/7/19. Although none of the documented groups were included in the MTP, the documentation confirmed the inconsistent attendance in active treatment groups. There was no documented evidence of alternative RT activities or individual contact with the patient to attempt to engage him/her in active treatment measures related to the missed group sessions.

d. During an observation on 12/9/19 at 4:00 p.m. it was noted that Patient 8 was not participating in any activities. RN5 confirmed that [he/she] did not attend any groups and that there was no alternative individual active treatment provided.

e. Patient 8's MTP was not revised to address this patient's lack of attendance in some groups and inconsistent participation in others. There were no new interventions developed that reflected this patient's current level of functioning. Also, there was a failure to identify both individual and group sessions to ensure that the patient received active treatment at a level of intensity and frequency necessary for psychiatric hospital care.

3. Patient 13
a. Patient 13's Psychiatric Evaluation (PE), dated 10/16/19, reported that the patient was admitted on 10/16/19 with a diagnosis of "Schizophrenia Disorder." Also, the patient was described as "non-compliant with meds [medications] & treatment ...combative, hostile, psychomotor agitation, and had rambling speech."

b. Patient 13's MTP (updated 11/22/19) stated the problem [called reasons for admission by the facility] was, "due to psychiatric decompensation ... [Patient 13] became agitated, aggressive, and threatening towards [his/her] peers ... was non-compliant with [his/her] medication, not sleeping, and responding to auditory hallucinations." The long-term goal was, "[Patient 13] will resume medication and demonstrate improved ability to maintain behavior free from aggression or assault, over the next 60 days." The short-term goal was "Over the next 30 days, [Patient 13] will take 100% of medication and attend all [his/her] groups on the mall to help [him/her] avoid incidents of aggression." Interventions were:
Psychiatry: "Prescribe medications, monitor for efficacy and side effects. 01x Per Week."

Nursing: "Encourage [Patient 13] to remain adherent with medication that will help [him/her] avoid aggressive, threatening behavior. 01x Per Week for 0:10."

Social Services: There were no social work interventions.

Rehabilitation Services: "Education ... Encourage [Patient 13] to remain adherent with medication that will help [him/her] avoid aggressive, threatening behaviors. 02x Per Week." "Stretching to Decrease Stress ... Encourage [Patient 13] to remain adherent with medication that will help [him/her] avoid aggressive, threatening behaviors. 02x Per Week for 0:45." "OT Project Group ... Encourage [Patient 13] to remain adherent with medication that will help [him/her] avoid aggressive, threatening behaviors. 02x Per Week for 0:45." "Dance/Movement Therapy ... Encourage [Patient 13] to remain adherent with medication that will help [him/her] avoid aggressive, threatening behaviors. 01x Per Week for 0:45." "Health Club ... Encourage [Patient 13] to remain adherent with medication that will help [him/her] avoid aggressive, threatening behaviors. 01x Per Week for 0:45."

c. The "Program Attendance Version 2 History" for the period 12/3/19 - 12/9/19 indicated that the Patient 14 did not consistently attend groups with non-attendance in "Art Therapy, Education, and Stretching to Decrease Stress cancelled [sic] and no alternative session was noted. "Grooming & Hygiene, Leisure Time on the Mall, Music Therapy Relaxation, and Group Readiness" were also not attended or inconsistently attended. These groups were listed on the patient's individual schedule but not on the treatment plan. There were five Rehabilitation "Treatment Program Progress Note" submitted for the period from 11/18/19 through 11/28/19. These notes confirmed the patient's non-attendance and inconsistent participation. The patient was noted to come late, leave early, and exhibited disorganized thinking. There was no documented evidence of alternative on unit individual contact with the patient to attempt to engage him/her in active treatment activities related to the missed or canceled group sessions.

d. During an observation on 12/9/19 at 2:10 p.m., the "Open Art Studio" Group was held in the Mall with three patients participating. Patient 13 did not attend this session. When the surveyor arrived on the unit at 2:30 p.m., Patient 13 and five other patients did not participate in the treatment mall program. Four patients were sitting in front of the TV watching a news report, one patient was sleeping, and one patient appeared to be sleeping. During an interview at 2:46 p.m., RN4 noted that "The unit at one time had an on-unit program for patients that did not attend the treatment Mall. We don't have that program now."

e. Patient 13's MTP was not revised to address this patient's lack of attendance in some groups and inconsistent participation in others. There were no new interventions developed that reflected this patient's current level of functioning. Also, there was a failure to identify both individual and group sessions to ensure that the patient received active treatment at a level of intensity and frequency necessary for psychiatric hospital care.

4. Patient 14

a. Patient 14's Psychiatric Evaluation (PE), dated 11/4/19, reported that the patient was admitted on 8/30/19 with a diagnosis of "Schizoaffective Disorder." Furthermore, the patient was described as "agitated, hostile, & aggressive at Group Home ... auditory hallucinations, paranoid delusions, and reported feeling suicidal."

b. Patient 14's MTP (updated 11/5/19) stated multiple psychiatric problems [called reasons for admission by the facility] including, "assaulted a staff by picking her up and slamming her back onto the door ... admitted to having suicidal ideations ... history of non-compliance with medications and treatment." "seeing things others could not see, believing things others would not, and was aggressive." "I will improve to the extent that I will participate in my daily schedule programming on the ward within the next 30 days." The short-term goal was, "Within the next 30 days, I will verbalize 2 benefits toward taking my psychotropic medications each day to the Treatment Team." Interventions were:
Psychiatry: "Psychiatrist will prescribe antipsychotic medications to help manage [his/her] mood 01x Per Week for 0:15."

Nursing: "Medication Education. To help [Patient 14] learn about [his/her] illness and to develop coping skills to prevent aggression and manage stressors related to poor frustration tolerances. 01xPer Week for 0:15."

Social Services: "Community Connection... Engage [Patient 14] in a supportive setting to improve [his/her] orientation to reality, motivate to work towards discharge again ... to prevent stopping meds in the future. 01xPer Week for 0.40." "Getting Along with People ... Staff will help patient develop goals and methods to discuss their feelings in a respectful, productive manage [sic] to learn to get their needs met in the community. 01x Per Week for 0:45."

Rehabilitation Services: "Education - English, Math, and Computer. 02x Per Week for 0:40." "Art Therapy ... Engage [Patient 14] in a variety of artistic processes to promote self-expression, improve quality of life and manage stressors ... 03x Per Week for 0:45." "Positive Outlook ... Staff will teach [Patient 14] strategies to build [his/her] self-esteem through self-management tools ... 01x Per Week for 0:45." "Coping skills ... Staff will help [Patient 14] learn ways to manage [his/her] stressors ... develop coping skills to help decrease delusional thoughts. 01x Per Week for 0:45." "Leisure Education ... Staff will focus on positive leisure activities [Patient 14] can do in the community ... help manage [his/her] stressors and maintain [his/her] medication regimen to prevent frustration intolerances. 01x Per Week for 0:40."

Psychology: "Symptom Management ... Psychology will provide [Patient 14] with insight oriented psychotherapy to help reduce psychological conflicts that result in periods of uncontrollable delusional thinking. 0.1x Per Week for 0:45."

c. The "Program Attendance Version 2 History" for the period 12/3/19 - 12/9/19 indicated that the Patient 14 had attended none of the 15 assigned groups held in the Treatment Mall. There were five Rehabilitation "Treatment Program Progress Note" submitted for the period from 10/28/19 through 11/21/19. These notes confirmed the patient did not attend assigned group treatment sessions. There was no documented evidence of alternative on unit individual contact with the patient to attempt to engage him/her in active treatment activities related to the missed group sessions. There were no "Treatment Program Progress Note Forms submitted for social services groups titled, "Community Connections" and "Getting along with people." There were also no notes provided for "education, grooming, or stress release through spiritual music."

d. During an observation on 12/9/19 at 2:20 p.m., the "Positive Outlook" Group was held in the Mall with seven patients participating. Patient 14 did not attend this session. The topic was "what are your gratitudes," and the patients had to complete the sentence, "I am grateful for ..." When the surveyor arrived on the unit, the patient was observed in a chair in the dayroom. There were no alternative activities for the nine patients who did not attend the treatment mall. During an interview at 2:40 p.m., HST [Health Service Technician]1 stated, "[Patient 14] never goes to group."

e. A review of the "Safety Status check Day Shift - 15 minutes" from 12/3/19 through 12/9/19 revealed that Patient 14 was recorded as being on the unit, despite being assigned to treatment mall for the day and afternoon group treatment programs. This form showed that the patient was either in his/her "bedroom resting or awake," or in the "dayroom resting or awake."

d. Patient 14's MTP was not revised to address this lack of attendance and the patient's unwillingness to attend groups. There were no alternative individual intervention sessions developed to engage the patient based on his/her present level of functioning. Therefore, there were no individual active treatment sessions included ensuring that the patient received active treatment at a level of intensity and frequency necessary for psychiatric hospital care.

B. Additional Interviews

1. In a discussion on 12/9/19 at 11:20 a.m., RN1 stated that Patient 13 was resistant to treatment and usually stays in bed. RN1 acknowledged that there were no alternative individual sessions offered.

2. In a discussion on 12/9/2019 at 11:50 a.m., RN7 stated, "We don't have Treatment Mall assistance." RN7 further noted that during the scheduled treatment mall, the television was changed to a music channel.

3. In an interview on 12/10/19 at 2:10 p.m., RT1 noted, "BSTs (Behavioral Service Technicians) are responsible for alternative activities when patients don't attend the treatment mall." RT1 reported that she did not do individual sessions with patients who miss group sessions.

Based on record review, observation and patient and staff interview it was determined that the Clinical Director failed to take corrective action to ensure that--

1. Psychiatric Evaluations contained a description of patient assets in descriptive, not interpretive fashion. For details, see B117.

2. Master Treatment Plans were based on patient strengths. For details, see B119.

3. Master Treatment Plans contained patient goals that were measurable, observable and patient specific behaviors. For details, see B121.

4. Master Treatment Plans included individualized and specific active treatment interventions based on the unique psychiatric symptoms of each patient. For details, see B122.

5. Adequate documentation of treatment notes for active treatment interventions listed in the Master Treatment Plan. For details, see B124.

6. Active treatment measures were provided for patients who were unwilling, unable, or not motivated to attend or participate in group therapies. For details, see B125.

Based on record review and interview, the Director of Nursing failed to monitor and take corrective action to ensure that:

I. Master Treatment Plans (MTPs) for 15 of 16 active sample patients (1, 2, 3, 4, 5, 6, 7, 8, 9, 11,12, 13, 14, 15, and 16) included individualized and specific registered nurse (RN) interventions based on the unique psychiatric symptoms of each patient. Several intervention statements were generic or routine RN job duties. They did not provide a clear picture of what the staff was doing to assist the patient in making improvements in psychiatric symptoms or behaviors. Also, for several of the RN intervention statements, there was no frequency of contact identified, or the frequency was limited to "as needed" or monthly contacts. Therefore, these intervention statements failed to include an adequate frequency and intensity of active treatment for hospital treatment and to assist with each patient's goal achievement. These deficiencies result in MTPs that failed to reflect comprehensive, integrated, individualized approaches to interdisciplinary treatment and potentially lead to inconsistent and ineffective treatment. (Refer to B122).

II. Registered nurses (RNs) documented comprehensive and detailed treatment notes for active treatment interventions listed in the Master Treatment Plan (MTP) for 12 of 16 active sample patients (1, 2, 4, 5, 6, 7, 8, 12, 13, 14, 15 and 16). Specifically, RN failed to include the patients' participation or non-attendance for assigned intervention in the MTP associated with psychiatric problems or symptoms. There were no treatment notes written by RNs that included the duration of contact with the patient, the specific topics discussed, activities provided, and the patient's response to interventions, including the level of participation, level of understanding of the information provided, behaviors during the group sessions, and specific comments, if any. This failure hindered the treatment team from determining the patient's response to nursing interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124).

III. Active treatment measures were provided for four of 16 active sample patients (7, 8, 13, and 14) who were unwilling, unable, or not motivated to attend or participate in the group treatment program. Specifically, there was no documented evidence that registered nurses (RN) provided active treatment for these patients at the frequency and intensity necessary for hospital treatment. Also, there was no documented evidence in the medical record to show the RN staff made attempts to engage these patients in alternative individual active treatment measures. Failure to provide active treatment at a sufficient level and intensity results in affected patients being hospitalized without all active treatment interventions for recovery, potentially delaying their improvement or being discharged without the necessary skills to prevent relapse. (Refer to B125).