HospitalInspections.org

Based on document review and interview, the facility failed to maintain a list of all contracted services, including the scope and nature of services provided for 5 of 48 contracted services.

Findings include:

1. Review of the list of contracted services failed to indicate a provider for emergency generator service, fire extinguisher and fire alarm service and certification, fire suppression (dry chemical) service, fire sprinkler service, and trash disposal.

2. Review of facility maintenance documentation indicated the following: generator service by CS1, fire extinguisher and fire panel monitoring and certification by CS2, dry chemical fire suppression (kitchen) by CS3, fire sprinkler service by CS4, and trash disposal by CS5.

3. On 1-24-17 at 1533 hours, the compliance manager, staff A5 confirmed that the list of contracted services lacked the indicated services and had not been maintained.

Based on document review, observation and interview, the facility failed to ensure its procedure for submitting a grievance was clearly explained to patients and/or their representatives for one occurrence.

Findings include:

1. The policy/procedure Client Rights (approved 7-15) indicated the following: " At the time of admission to any Oaklawn service, the Access Center will provide the client or responsible party both a written copy and verbal explanation of Oaklawn ' s patient/client rights. The rights are available in both English and Spanish. A statement of rights shall be posted in appropriate places in all Oaklawn facilities. A client who feels his/her rights have been violated is referred to the Client Advocate. All patients: (sic) The client or responsible party signs for receipt of the rights on the Consent for Treatment, which is maintained in the patient record. " A notice of 16 Client Rights (no revision date or reference identifier) provided with the policy/procedure indicated the following: " If you or your family members have experienced concern about your care or safety at Oaklawn, please let us know by addressing your concern with your treatment team of by completing the " How Are We Doing " form located in the front lobby ... "

2. Review of the Consent for Services document (revised 8-15) indicated the following: " Client Rights - I have received a copy of my Oaklawn client rights and a handbook for intensive service. " A notice of 12 Client Rights was indicated on the back of the form including the following: " If you or your family members have experienced concern about your care or safety at Oaklawn, please let us know by addressing your concern with your treatment team of by completing the " How Are We Doing " form located in the front lobby. "

3. During a tour of the facility on 1-24-17 at 1250 hours, in the company of the facilities manager, staff A11, a posted notice of 21 client rights was observed and no documentation indicated how to report or submit a complaint or a verbal or written grievance to a responsible person or Client Advocate at the facility.

4. Review of the Inpatient Handbook on page 7 indicated the following: " If you or your family members have experienced concern about your care or safety at Oaklawn, please let us know by addressing your concern with your treatment team of by completing the " How Are We Doing " form located in the front lobby ...[and] ...If you wish to talk over your concerns with a staff person during or after your stay, ask to speak to the Oaklawn Patient Advocate. "

5. On 1-24-17 at 1610 hours, the compliance manager, staff A5 confirmed they are the Patient Advocate for the facility and confirmed the process for reporting written and verbal grievances at the facility is inconsistent and unclear.

Based on document review and interview, the facility failed to ensure the written notice of the grievance determination included the steps take to investigate the grievance, the results of the grievance process and date of completion for 2 of 2 grievances reviewed.

Findings include:

1. The policy/procedure Client Complaints (approved 9-16) indicated the following: "Grievances regarding inpatient services are responded to in writing, per CMS (Centers for Medicare and Medicaid)..." and no documentation indicated the necessary elements for the written response including the name of the contact person, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion.

2. Review of 2 grievance response letters dated 2-10-15 and 10-20-15 failed to indicate the investigative steps taken, the results, and the determination with a date of completion.

3. On 1-24-17 at 1450 hours, the manager of compliance, staff A5 confirmed the policy/procedure failed to ensure the written response included the steps taken to investigate the grievance, the results of the grievance process and the date of completion and confirmed the grievance letters lacked the required information.

Based on document review and interview the facility failed to ensure the implementation of its policy related to consulting the attending physician as soon as possible after a restraint or seclusion was ordered for a patient, if the attending physician did not order the restraint or seclusion, for 2 of 3 patients who had restraint or seclusion events, patients #2 and #5.

Findings Include:
1. Review of the policy Seclusion and Restraint, procedure number NR 605, last approved 12/6/16, indicated under procedures, in section 8) Evaluation, that: b) Covering medical prescriber i) Within four hours of the initiation of seclusion/restraint, the covering medical prescriber completes an in-person evaluation of the client...and updates the attending psychiatrist by phone, voice mail or CareLogic tracking note...".

2. Review of medical records indicated:
A. Patient #2 had a restraint and a seclusion ordered on 12/20/16 by physician #62 with the attending physician noted on the Admission orders as #64. The attending psychiatrist notified, as documented on Form No. 21, was physician #62.
B. Patient #5 had a seclusion ordered on 12/22/16 by physician #66 with the attending physician noted on the Admission orders as #64. The attending psychiatrist notified, as documented on Form No. 21, was physician #65.

3. At 2:00 PM on 1/24/17, interview with the nurse manager, staff member #59 confirmed that:
A. It is confusing who is the attending physician of the patients on the unit as the one listed on the admission orders may transfer care to another practitioner and nursing may not be notified of the change.
B. Doctors #63 and #64 are the two who are attending physicians "always" for the unit.
C. The attending physicians for patients #2 and #5 were not noted as being contacted after the restraint and/or seclusion events that occurred as listed in 2. above.
D. There is no documentation that would indicate the ordering physician had contacted the attending physician, as required by facility policy.

Based on document review and interview, the facility failed to implement its policy related to conducting a face to face evaluation of a patient within one hour of a restraint or seclusion for 1 of 3 patients who had a restraint and/or seclusion event, patient #2; and failed to implement its policy related to physicians evaluation a patient within 4 hours of the start of a restraint or seclusion for 1 of 3 patients, patient #5.

Findings Include:
1. Review of the policy Seclusion and Restraint, procedure number NR 605, last approved 12/6/16, indicated under procedure, section 8) Evaluation: "a) Registered Nurse Assessment within one hour of the initiation of seclusion/restraint (even if the intervention has ended):...".

2. Review of medical records indicated patient #2 had:
A. A restraint on 12/20/16 that started at 8:37 AM with a seclusion that started at 8:39 AM and a one hour face to face evaluation noted as occurring at 10:00 AM.
B. A restraint on 12/21/16 that started at 11:36 AM and a one hour face to face that lacked a time to be able to tell if it was completed within the hour that the restraint began.

3. Review of the policy Seclusion and Restraint, procedure number NR 605, last approved 12/6/16, indicated under procedure, section 8) Evaluation: "...b) Covering medical prescriber i) Within four hours of the initiation of seclusion/restraint, the covering medical prescriber completes an in-person evaluation of the client using the Face-to-Face Evaluation form (Form No. 21)...".

4. Review of medical records indicated that patient #5 had a seclusion on 12/22/16 that started at 9:22 AM and the four hour face to face evaluation was noted by the practitioner as occurring at 2:15 PM.

5. At 2:00 PM on 1/24/17, interview with the nurse manager, staff member #59 confirmed that:
A. The one hour face to face evaluations for patient #2 were not completed in the time frame required by the policy.
B. The four hour face to face for patient #4 was outside of the 4 hour policy requirement.

Based on document review and interview, the governing body failed to ensure that the quality assessment and performance improvement (QAPI or PI) program monitored and reviewed designated quality indicators for 2 of 4 quarters in in 2016.

Findings include:

1. The policy/procedure Performance Improvement Plan (approved 4-16) indicated the following: "Targeted performance assessment and improvement - to improve processes or outcomes. Targeted efforts may focus on... clinical program performance and service outcomes... "

2. Review of 1-27-16 PI meeting minutes indicated PI monitoring of Inpatient Psychiatric Facility Quality Reporting Data (IPFQR) and the indicators of (a) inpatient hours in seclusion and restraint, (b) number of patients discharged on multiple antipsychotics, and (c) the discharge plan includes required elements and forwarded within 5 days of discharge to the receiving program were selected for review using the QAPI Worksheet.

3. Review of 6-22-16 PI meeting minutes indicated PI monitoring for the selected IPFQR indicators and the 8-31-16, 9-28-16, 10-26-16 and 12-28-16 PI meeting minutes failed to indicate ongoing reporting or review for (b) the number of patients discharged on multiple antipsychotics, and (c) the discharge plan includes required elements and forwarded within 5 days of discharge to the receiving program.

4. On 1-25-17 at 1155 hours, the compliance manager, staff A5 confirmed the minutes lacked reporting on the targeted PI program indicators selected for review.

Based on document review and interview, the governing body failed to ensure that the quality assessment and performance improvement (QAPI or PI) program monitored and reviewed all medical errors, medication errors, adverse medication reactions, and other adverse patient events for 3 of 4 quarters in 2016 and failed to document implementation of corrective actions in response to 1 of 3 root cause analyses performed in 2016.

Findings include:

1. The policy/procedure Performance Improvement Plan (approved 4-16) indicated the following: "Quality monitoring - to detect changes in performance over time in... Quality control (medical records, pharmaceuticals, infection control, utilization review)... Targeted efforts may focus on... safety, including incident response..."

2. Review of 2016 PI meeting minutes failed to indicate the 2-11-16, 6-23-16 or 9-22-16 Pharmacy and Therapeutics (P&T) minutes were presented and reviewed or a summary of activity reported by the registered pharmacist, staff A8 or the Medical Director, staff MD11. The PI minutes failed to indicate a review of the adverse drug reactions (ADRs) or medication variance trending identified in the P&T committee minutes and the number of medication error occurrences reported in the PI meeting minutes did not correlate with data reported in the P&T committee minutes.

3. On 1-25-17 at 0955 hours, the compliance manager, staff A5 confirmed the 2016 PI minutes lacked a review of the P&T meeting minutes or a summary of committee activity including a review of the adverse drug reactions (ADRs) and medication variance trending.

4. Review of the policy/procedure Serious Adverse Event: Root Cause Analysis (approved 5-14) indicated the following: "To be thorough, the RCA (root cause analysis) must include... recognition of potential improvements in processes or systems that could decrease the likelihood of such events in the future - or concluding that such opportunities do not exist... Case specific aftercare and follow-up plan... assign responsibility for identified tasks including interventions with target dates, pilot testing and clear measures of effectiveness."

5. Review of administrative documentation dated 11-1-16 indicated a finding of "gaps in staff supervision on the unit" was associated with a serious adverse patient event on 10-16-16 and the documentation failed to indicate a review of the unit staffing and patient census was performed with findings and failed to indicate any objective and concrete interventions were implemented with timeframes for completion and specific indicators for effectiveness.

6. On 1-25-17 at 1145 hours, the director of nursing, staff A3 confirmed the documentation failed to indicate a review of unit staffing or patient census and acuity and failed to indicate any interventions were implemented in response to the serious adverse event and no other documentation was available.

At this Life Safety Code survey, Oaklawn Psychiatric Center, Inc. was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This one story facility with a partial basement was determined to be of Type V (000) construction and was fully sprinklered. The facility has a fire alarm system with smoke detection in the corridors, patient sleeping rooms and spaces open to the corridors. The facility has a capacity of 16 and had a census of 10 at the time of this survey.

Based on observation and interview, the facility failed to provide sprinkler coverage for 1 of 1 Cedar Courtyard exterior canopies which was wider than 4 feet. NFPA 13, 2010 Edition, Section 8-15.7.2 states sprinklers shall be permitted to be omitted where the exterior roofs, canopies, balconies, decks or similar projections exceeding 4 feet in width are noncombustible, limited combustible or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials. This deficient practice could affect staff and up to 4 patients (see Tag K351), and Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with 19.3.5.3. NFPA 25, 2011 Edition, 14.2.1 states except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. This deficient practice could affect all occupants (see tag K353).

Based on observation and interview, the facility failed to provide sprinkler coverage for 1 of 1 Cedar Courtyard exterior canopies which was wider than 4 feet. National Fire Protection Association (NFPA) 13, 2010 Edition, Section 8-15.7.2 states sprinklers shall be permitted to be omitted where the exterior roofs, canopies, balconies, decks or similar projections exceeding 4 feet in width are noncombustible, limited combustible or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials. This deficient practice could affect staff and up to 4 patients, and based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with 19.3.5.3. NFPA 25, 2011 Edition, 14.2.1 states except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. This deficient practice could affect all occupants.

Findings include:

1. Based on observation with the Facility Manager on 01/30/17 at 1:01 p.m., a canopy of wood construction outside of the Cedar Courtyard was not provided with sprinkler protection. The canopy was attached to the building and extended ten feet from the building. Based on interview at the time of observation, the Facility Manager confirmed no documentation was available for review to verify the wooden material was inherently flame retardant and was not provided with sprinkler protection, and based on record review with the Facility Manager on 01/30/17 at 11:55 a.m., no internal inspection of piping documentation was available for review. Based on interview at the time of record review, the Facility Manager the sprinkler system was greater than five years old. Additionally, the Facility Manager confirmed with their sprinkler contractor that no internal inspection was performed.

2. Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. This deficient practice could affect all occupants.

3. Based on record review with the Facility Manager on 01/30/17 at 11:55 a.m., the sprinkler system was inspected quarterly. No documentation was available for the monthly gauges or control valves inspection. Based on interview at the time of record review, the Facility Manager acknowledged the aforementioned condition.

3. Based on observation and interview, the facility failed to maintain a clearance of 1 of 1 sprinkler head in the Document Closet in accordance with LSC 9.7.5. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, 5.2.1.2 requires the minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors. This deficient practice could affect staff only.

4. Based on observation with the Facility Manager on 01/30/17 at 12:47 p.m., one Styrofoam box was within six inches of the pendant sprinkler head. Based on interview at the time of observation, the Facility Manager acknowledged the aforementioned condition and provided the measurement.

Based on document review, observation and interview, the infection control/prevention practitioner failed to develop and implement processes and policies such as; an ICRA (infection control risk assessment) for any renovation or construction that might take place, the failure of the infection control committee to approve disinfection products used by EVS (environmental services) staff and failed to have housekeeping policies for EVS staff (see tag 0748), failed to ensure that the infection plan/program was effective to control infections and communicable diseases related to: the lack of indication of immunity to infectious/communicable diseases for 9 of 9 staff, (staff members N1 through N9); the failure of one RN (registered nurse) out of 5 to have a documented annual TB (tuberculosis) test (staff member N5); the medication room sink being within 3 feet of the medication preparation area; failure of nursing staff to clean the glucose meter between (and after) patient use; failure of nursing staff to perform hand hygiene before and after removal of gloves when assisting a patient with blood glucose testing; in relation to dust observed on a wall ledge and air vent on the nursing unit, and bugs in a ceiling light on the inpatient nursing unit; in regard to eye wash stations that were not being checked; and in relation to an ice machine that was not cleaned/maintained sufficiently (see tag 0749), and the chief executive officer, medical staff, and director of nursing failed to ensure the quality assessment and performance improvement (QAPI or PI) program addressed problems identified through the infection control (IC) program and implemented corrective actions in response for 1 of 3 environmental concerns identified by the IC program in 2016 (see tag 0756). The cumulative effect of these systemic problems resulted in the facilities inability to ensure minimization of infections and communicable diseases.

Based on document review, observation and interview, the infection control/prevention practitioner failed to develop and implement processes and policies such as; an ICRA (infection control risk assessment) for any renovation or construction that might take place, the failure of the infection control committee to approve disinfection products used by EVS (environmental services) staff and failed to have housekeeping policies for EVS staff.

Findings Include:
1. At 10:55 AM on 1/23/17, interview with the ICP (infection control practitioner), staff member #51, confirmed that the facility does not have an ICRA policy.

2. At 1:00 PM on 1/23/17, interview with the ICP, staff member #51, confirmed that the infection control committee failed to:
A. Approve the products used by EVS staff to ensure the effectiveness of these products in regard to disinfection within the facility.
B. Create or approve EVS policies related to expected cleaning processes.
C. Create laundry policies for the EVS and nursing staff related to the expectations of this process and products.

3. At 3:20 PM on 1/23/17, interview with the EVS manager, staff member #54 confirmed that:
A. There is a list of products the EVS manager orders (titled Housekeeping Supply Order Form) but none of the products were ever approved by the infection control committee.
B. There are no housekeeping policies that would indicate how staff are to complete their tasks in the inpatient unit, what PPE (personal protective equipment) to wear, what products to use on what surfaces, how to mix the product(s), the difference between daily patient room cleaning and terminal cleaning, and other cleaning processes.

Based on document review, observation and interview, the infection prevention practitioner failed to ensure that the infection plan/program was effective to control infections and communicable diseases related to: the lack of indication of immunity to infectious/communicable diseases for 9 of 9 staff, (staff members N1 through N9); the failure of one RN (registered nurse) out of 5 to have a documented annual TB (tuberculosis) test (staff member N5); the medication room sink being within 3 feet of the medication preparation area; the failure of nursing staff to clean the glucose meter between (and after) patient use; the failure of nursing staff to perform hand hygiene before and after removal of gloves when assisting a patient with blood glucose testing; in relation to dust observed on a wall ledge and air vent on the nursing unit, and bugs in a ceiling light on the inpatient nursing unit; in regard to eye wash stations that were not being checked; and in relation to an ice machine that was not cleaned/maintained sufficiently.

Findings Include:
1. Review of employee files N1 through N9 for MHTs (mental health technicians) and RNs (registered nurses) indicated none had documentation related to immune status for communicable diseases including, but not limited to: Rubella, Rubeola and Varicella.

2. At 9:05 AM on 1/25/17, interview with the ICP (infection prevention/control practitioner), staff member #51, confirmed that:
A. The facility does not have a policy related to determining the immune status of newly hired employees regarding Rubella, Rubeola and Varicella.
B. The facility cares for the Amish population of the area and they are known to not receive childhood immunizations such as Rubella, Rubeola and Varicella.
C. Currently the immune status of employees on the acute inpatient unit, especially staff N1 to N9 whose records were reviewed, are at risk for contracting communicable diseases and exposing other staff and patients as their immune status is unknown.

3. Review of the policy Staff TB Screen & Chest X-Ray Requirements, procedure number IC 340, last approved 12/17/15, indicated under "Policy": "...b) Cedars inpatient staff (Department 45), psychiatrists and physicians treating inpatient clients, food service, housekeeping, and facilities staff will be tested annually."

4. Review of employee files indicated RN N5 was hired 12/15/14 and had no TB test documentation in the file for 2016. (The most recent TB test was dated 2015.)

5. At 9:30 AM on 1/25/17, interview with human resources staff member #67 confirmed that there was no 2016 TB test in the file for N5, and there should have been one done.

6. At 9:45 AM on 1/25/17, it was observed that the hand washing sink in the medication room was located in the middle of the counter top and that medication preparation occurred within 3 feet (36 inches) of the sink creating a possible contamination problem.

7. Review of the policy Blood Glucose Monitoring with TRUEtrack System, procedure number NR 814, last approved 10/22/14, indicated in the section; "3) Testing blood sugar": "...b) Wash hands with soap and water, dry thoroughly. Put on gloves...5) Care of Meter...b) Clean and disinfect meter to remove blood and potentially infectious pathogens using facility approved alcohol containing germicidal wipe while wearing gloves. Wash hands after removing gloves...".

8. At 4:40 PM on 1/24/17, while observing RN #68 performing a blood sugar check on patient #11, it was noted that:
A. The RN failed to perform hand hygiene prior to gloving and after removing their gloves
B. The RN failed to disinfect the glucometer before handing it to RN #69 for their patient's glucose check.

9. At 4:55 PM on 1/24/17, while observing RN #69 assist patient #12 with the testing of their blood glucose, it was noted that:
A. The RN failed to perform hand hygiene prior to gloving.
B. The RN failed to disinfect the glucometer both before the patient used it and after the patient's use before placing it back in the pouch and replacing the pouch in the medication room cabinet.

10. At 10:05 AM on 1/25/17, interview with the Director of Nursing, staff member #58 confirmed that the nurses (#68 and #69) failed to perform hand hygiene prior to gloving and/or after removing gloves on 1/24/17 and that both RNs failed to clean the glucometer after each patient testing, as required per facility policy and expectations.

11. At 4:45 PM on 1/24/17, while on tour of the inpatient nursing unit in the company of staff member #58, the Director of Nursing, it was observed that:
A. An accumulation of dust was noted on the top ledge of a wall above the nurses' station.
B. An accumulation of dust was present on the approximately 36 inches by 36 inches wall mounted air vent behind the nurses' station.
C. There were > 15 bugs in the light fixture above the nurses' station.

12. At 4:45 PM on 1/24/17, interview with staff member #58 confirmed the dust and bugs and that nursing staff must complete a work order to have these areas cleaned by the EVS staff, that they are not on a routine cleaning schedule.

13. At 10:55 AM on 1/24/17, while on tour of the kitchen dish room in the company of staff member A11, the facilities director, it was noted there was no check sheet for the eye wash station and staff member A11 confirmed that there is no documentation of checks as the eye wash station is not checked/maintained by staff.

14. At 11:15 AM on 1/24/17, while on tour of the maintenance area of the facility in the company of staff member A11, it was noted there was no check sheet for the eye wash station and staff member A11 confirmed that there is no documentation of checks as the eye wash station is not checked/maintained by staff. It was also confirmed that a laundry cart was parked in front of the eye wash station blocking it from possible use by an employee who might need to utilize the eye wash station.

15. At 11:05 AM on 1/24/17, while on tour of the kitchen are, it was observed that the Scotsman Prodigl ice machine had an area of brown colored biological overgrowth on the lowest edge of the black deflector pan in the ice chest. Staff member A11 confirmed the presence of the brown colored substance on the equipment and confirmed the condition was unsanitary even though the last date the ice machine was cleaned was documented as occurring in December of 2016.

16. At 11:28 AM on 1/24/17, while on tour of the facility in the company of staff member A11, it was observed in the break room that a Scotsman Prodigl ice machine and storage bin was observed to have brown colored biological overgrowth on the brushed stainless steel deflector pan in the ice chest. Staff member A11 confirmed the presence of the brown colored substance on the equipment and confirmed the condition was unsanitary.

Based on document review and interview, the chief executive officer, medical staff, and director of nursing failed to ensure the quality assessment and performance improvement (QAPI or PI) program addressed problems identified through the infection control (IC) program and implemented corrective actions in response for 1 of 3 environmental concerns identified by the IC program in 2016.

Findings include:

1. The policy/procedure Performance Improvement Plan (approved 4-16) indicated the following: "Quality monitoring - to detect changes in performance over time in ...Quality control (medical records, pharmaceuticals, infection control, utilization review)."

2. Review of 2016 PI meeting minutes failed to indicate the infection control (IC) minutes were presented and reviewed or a summary of activity reported by the IC nurse, staff A7, no PI meeting documentation indicated the IC nurse, staff A7 or the director of nursing, staff A3 attended a PI meeting in 2016, and no IC meeting documentation indicated the compliance manager, staff A5, the president and CEO, staff A1, or the Medical Director, staff MD11 attended an IC meeting in 2016.

3. Review of 6-2-16, 8-4-16, 10-6-16 and 12-1-16 IC meeting minutes indicated ongoing discussion regarding environmental dust accumulation, lack of effective response, and a trend of clients getting sick and the 12-1-16 minutes indicated the environmental services supervisor, staff A12 had a plan for throrough cleaning and... "just needs staff to do it."

Based on document review and interview, the facility failed to document the discharge plan was implemented in accordance with facility policy for 2 of 5 medical records (MR) reviewed (patient #s 41, 42).

Findings include:

1. Review of the policy/procedure Discharge Planning (approved 12-15) indicated the following: "Documentation in the clinical record: Discharge criteria, discharge planning, and aftercare plans including... the availability of appropriate services to meet the client's identified needs, are maintained in the clinical record."

2. Review of the job description titled Care Facilitator I & II indicated the following: "Position purpose: to provide case management services to clients... [including]... coordination of care, oversight for the entire case and linkage to appropriate services... [and] arrange for services in other programs and agencies on behalf of the individual ..."

3. Review of the policy/procedure Transfer of Clients (approved 1-15) indicated the following: "Inter-Agency Transfer... prior to transfer, the receiving institution must agree to accept the transfer. Acceptance of transfer must be charted including the name of the person at the receiving institution who authorized acceptance of the transfer."

4. Review of patient #41's MR entry on 1-11-17 at 1104 hours by the social worker, staff A9 indicated the inpatient treatment recommendation for discharge to the residential SGL (supervised group living) facility where the schizophrenic patient was living before they stopped taking their medications and became increasingly paranoid, agitated, and confused and no documentation indicated the social worker, staff A9 or the care facilitator, staff A10 contacted the SGL facility for transfer approval and confirmation a room was available prior to discharge.

5. On 1-25-17 at 1020 hours, the social worker, staff A9 confirmed the MR for patient #41 lacked the indicated documentation.

6. Review of patient #42's MR entry on 1-17-17 at 0745 hours by the social worker, staff A9 indicated the inpatient treatment recommendation for referral back to a religious faith-based homeless housing (FBH) facility when a bed is available and for consultation with an SGL facility for homeless housing for the schizophrenic patient reporting auditory hallucinations and suicidal thoughts and no documentation indicated the social worker, staff A9 or the care facilitator, staff A10 contacted the FBH or SGL facility for transfer approval and confirmation a room was available prior to discharge from the facility.

7. On 1-25-17 at 1040 hours, the social worker, staff A9 confirmed the MR for patient #42 lacked the indicated documentation.

Based on record review and staff interview it was determined that for eight (8) of eight (8) patients (PatientsA1, A2, A3, A4, B1, B2, B3 and B4) the facility failed to:

1. Provide Psychosocial Assessments that contained a psychosocial formulation of the data gathered and failed to describe the anticipated efforts of the social service staff in discharge planning. See, B108 for details

2. Include in Psychiatric Evaluations a description of patient assets in descriptive not interpretive fashion. See, B117 for details

3. Provide Treatment Plans that included long and short term goals that were behaviorally measurable. (See, B121 for details), modalities that were patient specific and not simply generic discipline tasks ((See, B122 for details) and specify what staff member would be responsible for monitoring the effectiveness of the interventions selected by various members of the multidisciplinary treatment team (See, B123 for details)

4. Ensure that active treatment for patient A4 was provided and that when necessary alternative interventions were selected to improve patient functioning. (See, B125 for details)

5. Ensure that nursing staff documented in Progress notes the results of patient education for medication and possible side effects cited in their treatment modalities. (See, B127 for details)

Based on record review and staff interview it was determined that for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, B1, B2, B3 and B4) their Psychosocial Assessments had no psychosocial formulation of the data gathered and failed to describe the anticipated role of the social service staff in discharge planning.

These failures result in an absence of an analysis of the patient's past and present functioning and what efforts might be pursued by the social services in discharge planning.

Findings include:

A. Record Review:

1.The facility's policy of "Planning Care, Treatment Services" states in Section "Procedures...3..g. - A preliminary plan for discharge from the service or treatment" needs to be present in the "...individualized plan...created for every client." The review of eight (8) selected patients failed to disclose what the anticipated role of social services would be for the individual needs of the patients.

2. Patient A1: The Psychosocial Assessment, dated 1/18/17, had no description of the role of the social service staff in anticipated discharge planning and lacked a psychosocial formulation of the data gathered.

3. Patient A2: The Psychosocial Assessment, dated 1/12/17, had no description of the role of the social service staff in anticipated discharge planning and lacked a psychosocial formulation of the data gathered.

4. Patient A3: The Psychosocial Assessment, dated 1/22/17, had no description of the role of the social service staff in anticipated discharge planning and lacked a psychosocial formulation of the data gathered.

5. Patient A4: The Psychosocial Assessment, dated 1/8/217, had no description of the role of the social service staff in anticipated discharge planning and lacked a psychosocial formulation of the data gathered.

6. Patient B1: The Psychosocial Assessment, dated 1/4/17, had no description of the role of the social service staff in anticipated discharge planning and lacked a psychosocial formulation of the data gathered. There was only the statement "I concur with the clinical opinion of the attending psychiatrist..."

7. Patient B2: The Psychosocial Assessment, dated 11/5/16, had no description of the role of the social service staff in anticipated discharge planning and lacked a psychosocial formulation of the data gathered.

8. Patient B3: The Psychosocial Assessment, dated 11/15/16, had no description of the role of the social service staff in anticipated discharge planning and lacked a psychosocial formulation of the data gathered. There was only the statement "I concur with the clinical opinion of the outpatient psychiatrist..."

9. Patient B4: The Psychosocial Assessment, dated 12/22/16, had no description of the role of the social service staff in anticipated discharge planning and lacked a psychosocial formulation of the data gathered.

B. Staff Interview:

On 1/24/17 at 1:10 p.m., the Director of Social Services was interviewed. The Director was told of the findings described in Section I, above. The Director agreed that there would not be found a psychosocial formulation and there would not be found a description of the anticipated social services role in discharge planning.

Based on record review and staff interview it was determined that for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, B1, B2, B3 and B4) their Psychiatric Evaluations failed to include an assessment of inherent patient assets in descriptive not interpretive fashion. This failure results in no information being determined and shared with other members of the multidisciplinary treatment team to possibly be utilized in therapeutic endeavors.

Findings include:

A. Record Review:

1. Patient A1: The Psychiatric Evaluation dated 1/18/17 stated "Strengths include 'being a good person', according to patient and positive support by his/her family."

2. Patient A2: The Psychiatric Evaluation dated 1/12/17 stated "Assets are minimal."

3. Patient A3: The Psychiatric Evaluation dated 1/21/17 stated "His/her uncle is his/her guardian. Family support."

4. Patient A4: The Psychiatric Evaluation dated 1/7/17 stated "Assets are minimal, sister is guardian."

5. Patient B1: The Psychiatric Evaluation dated 1/4/17 stated "The patient has a supportive family. He/she denies his/her psychiatric illness."

6. Patient B2: The Psychiatric Evaluation dated 11/3/16 stated "Supportive family. Reports a desire to work."

7. Patient B3: The Psychiatric Evaluation dated 11/15/16 stated "Patient does acknowledge having diabetes and the need for treatment for this."

8. Patient B4: The Psychiatric Evaluation dated 12/22/16 stated "Generally healthy but severely overweight."

B. Staff Interview:

On 1/25/16 at 8:30 a.m., the clinical director was interviewed. The Director was shown several examples of the findings described in Section A, above. He agreed that these assessments of patient assets were not inherent attributes, interests or achievements that might possibly be utilized in therapeutic endeavors.

Based on record review, facility policy review and staff interview it was determined that for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, B1, B2, B3and B4) their Treatment Plans failed to include:

1. Short and long term goals written as observable, measurable patient behaviors to be achieved. See, B121 for details.

2. Specific descriptive treatment modalities/ interventions. There was instead a listing of generic discipline functions. See, B122 for details.

3. Designation of a specific member of the multidisciplinary treatment team as responsible for monitoring the effectiveness of selected treatment modalities. See, B123 for details.

Based on record review and interview, the facility failed to formulate treatment goals that were relevant to the patients' psychiatric condition for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Many of the short and long term goals were either not measurable or were staff goals (what the staff wanted the patient to achieve) rather than an outline of a mental status or functional status level to be obtained. Without a set of defined goals against which to measure progress, it is impossible to judge effectiveness of treatment and to implement possible change in treatment in the case of lack of progress.

Findings include:

A. Record Review

1. Facility policy, No. HI150, effective 1977, stated "An individualized plan is created for every client who seeks ongoing care, treatment and/or services. The plan is based on the assess needs of the client"---"The plan of care will include: short-term, behavioral and measurable objectives which form sequential steps by which the client progresses toward goal completion." Most of the goals in the Master Treatment Plans (MTPs) were not measurable or related to what the staff wanted the patients to accomplish.

2. In patient A1's MTP, dated 1/7/17, for the problem of suicidal and homicidal ideations ("s/he admits to stressors as being very tired, sleeping all nite [sic], then taking 3 - 5 hr [hour] naps during the day. S/he feels worthless with being on disability. S/he states s/he is having nightmares with SI [Suicidal Ideations] and HI [Homicidal Ideations] in them. His/her suicidal plan was either cut his/her wrist or hanging him/herself. Has a 4 yo [year old] daughter. S/he states s/he is giving custody of daughter to his/her parent:" The non-measurable long term goal was: "[name of patient] will be free of thought of self-harm and have a plan in place to handle any future thought of self-harm by discharge."

3. In patient A2's MTP, dated 1/13/17, for the problem of "[Name of patient] will comply with treatment and medications during hospitalization to address auditory hallucinations and suicidal thoughts:" the non- measurable long term goal was: "[Name of patient] will be free of thoughts of self-harm and have a plan in place to handle any future thoughts of self-harm by discharge." The short-term staff goal was: "[Name of patient will take his/her meds [medications], attend groups, and complete a depression packet."

4. In patient A3's MTP, dated 1/21/17, for the problem of "[Name of patient] admitted on 72 hour papers due to increased paranoia, as s/he believes ISIS is getting children. S/he has been carrying a knife, menacing behavior. Throughout Nursing Assessment, pt. [patient] mentions various animals which are attacking people. Pt states s/he was trying to protect people. Crocodiles and alligators in the river, a large dog, a deer "as tall as this ceiling right here" and "big enough to lift a small car. A bed (also as tall as the ceiling):" The non- measurable long term goal was: "[Name of patient]'s psychosis will decrease to a level where it no longer interferes with his/her everyday life through use of prescribed medications and coping skills by discharge." The short-term staff goal was "[Name of patient] will accept his/her routine medications as prescribed and accept prn [as needed] medications as needed for psychosis/paranoia."

5. In patient A4's MTP, dated 1/10/17, for the problem of "[Name of patient] comes on 72 hour papers saying that s/he is not taking his/her meds properly and is getting more paranoid, mumbling to self, hallucinating and beginning to scare other residents. S/he mumbles that s/he would kid someone:" the non- measurable long term goal was: "[Name of patient] will demonstrate a decrease in paranoia and hallucinations." The short-term staff goal was "[Name of patient] will take his/her meds as ordered."

6. IN patient B1's MTP, dated 1/5/17, for the problem of "[Name of patient] admitted voluntarily accompanied by his/her son. [Name of patient] reports 'The holy spirit left me. I have no hope. God created me for this - to send me to hell.' "[Name of patient] reports feeling increasingly depressed, asking his/her son to kill him/her:" the short- term staff goals were: "[Name of patient] will agree to talk to staff when having thoughts of suicide, prior to acting on those thoughts." "[Name of patient] will compare assignments as provided by staff and safety action plan, identifying 3 people s/he can call and 3 coping skills to use when having thoughts of suicide." "[Name of patient] will cooperate with medication management and have an understanding of each of his/her medications and the importance of taking his/her medication consistently to stabilize his/her moods, as related to his/her history of non-compliance with medication." "[Name of patient] will attend 4 - 6 therapeutic groups each day while hospitalized and identify adaptive coping and communication skills that s/he can use improve his/her relationship with others and to cope with suicidal thoughts."

7. In patient B2's MTP, dated 1/23/17, for the problem of "[Name of general hospital] after being found in closed garage with car running, suffering carbon monoxide poisoning requiring intubation at ER [Emergency Room] arrival. Presently denies emotional pain or SI(suicidal ideation), stating recent attempt was again impulsive without identifiable [sic] trigger: " the short- term staff goal was: "[Name of patient] will cooperate with remaining in Quiet Room when not observed in Commons by staff, and report any SI to staff with occurrence."

8. In patient B3's MTP, dated 1/23/17, for the problem of "[Name of patient]'s psychosis will decrease to a level where it no longer interferes with his/her everyday life through use of prescribed medications as prescribed and coping skills:" the non- measurable long term goal was: "report any voices or hallucinations to staff and control intrusive behaviors."

9. In patient B4's MTP, last reviewed 1/23/17, for the problem of "[Name of patient] admitted to Cedars with SI. S/he reportedly left [name of facility] for his/her aunt's home earlier this week. S/he reports feeling unsafe at his/her aunt's due to his/her not being able to see his/her boy/girlfriend this Sunday since it's the holiday and the bus doesn't run. The [name of facility] staff report that his/her aunt made him/her do chores. S/he returned to facility before coming here. While there, s/he ran into an 'ex' boy/girl friend who gave him/her a knife for Christmas and s/he promised not to use it. However, per pt report, this 'ex' had promised to get back with him/her when s/he was free, but now s/he broke his/her promise to not hurt him/herself and cut his/her wrist. S/he admits that s/he did not want to kill [sic] him/herself:" The non- measurable long term goal was: "[name of patient] will be free of thoughts of self-harm and have a plan in place to handle future thoughts of self-harm by discharge." The short-term staff goal was "[Name of patient] will complete a safety action plan including at least three coping skills s/he can use when experiencing suicidal thoughts and at least three people s/he can call for help when experiencing suicidal thoughts."


B. Interview

1. In an interview on 1/24/17 at 7:20 a.m., the non-measurable long-term and short-term staff goals on the MTPs were discussed with RN#1. She did not dispute the problem.

2. In an interview on 1/24/17 around 11:30 a.m., the long-term and staff short-term goal on the MTPs was discussed with the Nursing Director. She agreed that the quality of the goals needed to be improved.

3. In an interview on 1/25/17 at 9:00 a.m., the problems of unmeasurable long-term goals and short-term staff goals were discussed with the Medical Director. He did not dispute the findings.

Based on record review and staff interview, it was determined that for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, B1, B2, B3 and B4) their Treatment Plans failed to describe patient specific interventions. Instead, there was present a listing of generic discipline functions. This failure results in no information available to either the patient or staff about exactly what interventions were selected and what their focus would be.

Findings include:

A. Record Review:


1. Facility's policy, titled "Planning Care, Treatment and Services, Policy No. HI 150,"... reviewed by the clinical director in 8/16, stated "An individualized plan is created for every client"...The sole comment for the selection of treatment modalities is in Section-Procedures 3. d. "The types of interventions/services (are) planned to assist with goal completion" There is no guidance to make modality selection a patient specific endeavor.

2. Patient A1: The Master Treatment Plan, dated 1/17/17, stated that for psychiatric intervention "Dr. X, Dr. Y, and other Oaklawn psychiatrists will prescribe and monitor medications to decrease psychotic symptoms and stabilize Patient A1 s psychiatric condition."

For Nursing interventions it stated "X RN, Y RN, Z RN, and other RNs will provide prescribed medication, and education on each psychotropic med..."

There were no interventions by either the Social Services or Activity staff present in the Treatment Plan.

3. Patient A2: The Treatment Plan, dated 1/13/17, stated for psychiatric intervention "Dr.X, Dr.Y, and other Oaklawn psychiatrists will prescribe and monitor medications to decrease psychotic symptoms and stabilize Patient A2's psychiatric condition."

For Nursing the Plan stated "X RN, Y RN, Z RN and other RN's [sic] will provide prescribed medication and education on each psychotropic med. They will review med. use, possible side effects and interactions." Also, "X RN and other assigned staff will assess Patient A2 for suicidal thoughts."
No interventions by Social Service staff or Activity staff were described.

Patient A3: The Treatment Plan, dated 1/21/17, stated for psychiatric interventions "Dr. X, Dr. Y and other Oaklawn psychiatrists will prescribe and monitor medications to decrease psychotic symptoms and stabilize Patient A3's psychiatric condition."

For Nursing modalities it was stated "X RN, Y RN, Z RN and other RN's [sic} will provide medication education on each psychotropic med. reviewing med. use, possible side effects and interactions."
No treatment modalities were described for the disciplines of Social Service and Activity Therapy.

4. Patient A4: The Treatment Plan, dated 1/10/17, had for psychiatric intervention "Dr. X and other Oaklawn psychiatrists will prescribe and monitor medications to decrease psychotic symptoms and stabilize pt's psychiatric condition."

For Nursing the intervention was "X RN and designated staff will give medications as ordered, give med teaching and monitor for side effects?" Also, "X RN and designated staff will provide prn (as necessary) medications to patient A4 as needed for agitation."
No interventions for the disciplines of Social Service and Activity Therapy were described.

5. Patient B1: The Treatment Plan, dated 1/05/17, had for psychiatric intervention "Dr. Y and other Oaklawn psychiatrists will prescribe and monitor medications to decrease symptoms of mood disorder and stabilize pt's psychiatric condition."

For Nursing the treatment modalities for this patient were "X RN, Y RN, Z RN and other RN's[sic] will administer medications as prescribed and document effectiveness."
No interventions for the disciplines of Social Service and Activity Therapy were described.

6. Patient B2: The Treatment Plan, dated 11/18/16, and reviewed 11/22/16, 11/25/16, 11/25/16, 12/2/16, 12/9/16, 12/30/16, 1/6/17, 1/13/17 and 1/20/17, continued the same psychiatric intervention " Dr. X, Dr. Y, and other Oaklawn psychiatrists will prescribe and monitor medications to decrease psychotic symptoms and stabilize Patient B2's psychiatric condition."

For Nursing the Treatment Plan dated 11/18/16 and reviewed 11/22/16, 11/25/16, 11/25/16, 12/2/16, 12/9/16, 12/30/16, 1/6/17, 1/13/17 and 1/20/17, continued the same interventions "X RN, Y RN, Z RN and other RN's [sic] will administer medications as prescribed and document effectiveness."
No interventions for the disciplines of Social Service and Activity Therapy were described.

7, Patient B3: The Treatment Plan, dated 1/23/17, had for psychiatric intervention "Dr. X and other Oaklawn psychiatrists will prescribe and monitor medications to decrease psychotic symptoms and stabilize pt's psychiatric condition."

For Nursing the modalities were "X RN, Y RN, Z RN's [sic] will provide medication education on each psychotropic med. reviewing med use, possible side effects and interactions and need for compliance.
No interventions for the disciplines of Social Service and Activity Therapy were described.

8. Patient B4: The Treatment Plan, last reviewed 1/23/17, had for psychiatric intervention "Dr. X and other Oaklawn psychiatrists will prescribe and monitor medications to decrease psychotic symptoms and stabilize pt's psychiatric condition."

For Nursing the Plan stated "X RN, Y RN, Z RN and other RN's [sic] will provide prescribed medication and education on each psychotropic med. They will review med. use, possible side effects and interactions." Also, "X RN and other assigned staff will assess Patient A2 for suicidal thoughts."
No interventions by Social Service staff or Activity staff were described.

B. Staff Interview:

On 1/24/17 at 10:35 a.m., the Master Treatment Plans for Patients B2 and B4 were examined with the Director of Nursing. The Director agreed with the surveyor that as described in the Treatment Plan of the 2 patients the interventions were not only generic routine discipline tasks, but also not patient specific.

Based on record review and staff interview it was determined that for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, B1, B2, B3 and B4) their Treatment Plans failed to specify which staff member was responsible for selected treatment modalities. Instead a listing of facility psychiatrists, a listing of nursing personnel and an absence of any interventions by the Department of Social Services and the Activity Therapy Department occurred. This failure results in an inability to hold any specific treatment team member accountable.

The findings include---

A. Record Review:

1. Facility's "Planning Care, Treatment and Services-Policy No. HI 150," was reviewed. The latest review of this policy was 8/16 by the facility's clinical director. There were no instructions that a responsible staff member be designated when a Treatment Plan is formulated and various treatment modalities are selected.

2. The following Master Treatment Plans with dates in parenthesis listed multiple psychiatrists and multiple nursing staff members as responsible for the selected interventions. Patient A1 (1/17/17), Patient A2 (1/13/17, A3 (1/21/17, A4 (1/10/17), B1 (1/5/17), B2 (11/18/16 with most recent update 1/20/17), B3 (1/23/17 and B4 (1/23/17. See, B122 for a detailed description of the findings.

3.. All eight (8) Master Treatment Plans failed to include interventions by Social Service and Activity Therapy staff.

B. Staff Interview:

1. On 1/24/17 at 1:10 p.m. the Director of Social Services was interviewed. The Director was told of the finding of lack of Social Service interventions on multidisciplinary Treatment Plans. He agreed with the findings.

2. On 1/25/17 at 10:50 a.m. the Director of Nursing, also, agreed that Master Treatment Plans lacked interventions by Social Services staff.

Based on record review, observation and interview, the facility failed to provide active treatment, including purposeful alternative interventions for one (1) of eight (8) active sample patients (A4). Although the treatment plan stated that "Therapeutic Groups" would be provided, the patient regularly and repeatedly did not attend most groups held on the unit. As a result, s/he spent many hours without any structured activity and occupied his/her time either sleeping in bed or dayroom or wandering around the hallways. Despite inconsistent or lack of regular attendance in groups, the patient's Master Treatment Plan was not revised to reflect more individual treatment sessions instead of treatment via groups. Failure to provide active treatment results in affected patient being hospitalized without all alternatives for recovery being delivered to him/her in a timely fashion, potentially delaying his/her improvement.

Findings include:

1. Patient A4 was admitted on 1/7/17. The Psychiatric Evaluation, dated 1/7/17, stated that "A4 is a 64 yo single African - American male/female with hx [history] of paranoid schizophrenia who presented to Cedar on apprehend and return due to non-compliance with his outpatient treatment regimen. 'I don't know why I'm here. I already have an apartment at [name of apartments].' "Pt was recently discharged from [name of facility] due to maxing out his/her benefits and it was decided to try pt on a lower level of care at the [name of facility] with the hopes that pt would be able to get a level 2 and possible NH [nursing home] placement. This however did not pan out this way. At the [other facility] pt was expected to pick up his/her medications and be compliant with medications. Nearly immediately pt did not pick up or take his/her meds. S/he saw writer a few weeks ago for o/p [outpatient] follow up prior to follow up with [name of doctor] with level 5 team and he noted his/her non-compliance with his/her meds and feeling s/he did not need them. This was concerning. S/he had scheduled to see [name of physician] on 12/21/16 and s/he no showed [sic] to that appt [appointment]. Pt only intermittently picked up his/her meds after that. It was noted over the past week that pt ' s roommate had noted that pt was mumbling more, more paranoid, more agitated and saying statements that 'I'm going to kill you' to unseen people. The roommate was understandably concerned and told case manager. 72 hour detention was taken out on patient. Unfortunately the [name of local] PD [Police Department] had some issues finding pt. So s/he did not arrive on the unit until today"... "Pt. does not feel s/he have any issues, does need medications and does not need our help in any way. S/he wants his/her own place. S/he stated 'So when my 72 hours are up I'm leaving.' "

2. During a 12:45 p.m. group on 1/23/17 in the dayroom of unit a MHT [Mental Health Technician] Activity group was being conducted. Patient A4 was sitting in a chair near the group sleeping. No staff attempted to wake patient up to see if s/he would participate in the group.

3. In an interview on 1/24/17 at 11:25 a.m., the lack of group attendance by patient A4 was discussed with MHT#2. S/he stated "We try to get him/her to go, but s/he just keeps refusing."

4. A review of A4's Master Treatment Plan (MTP), dated 1/10/17, just stated "[Name of patient] will attend Therapeutic groups in which s/he will learn strategies for long-term management of his/her mental illness." No specific groups from the unit's activity schedule were listed on the MTP. The unit schedule listed groups offered by mental health technicians, activity therapy staff and social work staff. Documentations from 1/16/17 to 1/23/17 by MHTs and activity therapy revealed the following:

1/16/17 - 8:30 a.m. - Patient A4 attended community meeting but not activity group at 10:00 a.m.

1/17/17 - 8:30 a.m. - Patient A4 attended community meeting, but not exercise group at 9:30 a.m. or spirituality group at 7:30 p.m.

1/18/17 - 8:30 a.m. - Patient attended community group at 8:30 a.m., but not exercise group at 9:30 a.m.

1/19/17 - 8:30 a.m. - Patient attended community meeting at 8:30 a.m., but not exercise group at 9:30 a.m.

1/20/17 - 8:30 a.m. - Patient attended community group at 8:30 a.m., but not social skills group at 7:30 p.m.

1/21/17 and 1/22/17 - Patient attended community group at 8:45 a.m., but not exercise group at 10:30 a.m. or social skills group at 7:30 p.m.

1/22/17 - Pt attended community group at 11:00 a.m., but not exercise group at 9:30 a.m. or art group at 7:30 p.m.

1/23/17 - 8:30 a.m. - Patient attended community meeting. No note by activity therapist of attendance to that group at 1:15 p.m.

1/23/17 - Patient attended wrap-up group at 4:30 p.m. but not community skills group at 7:30 p.m.

5. In an interview on 1/23/17 at 12:15 p.m., the lack of attendance to groups was discussed with patient A4. S/he stated "I don't go to groups."

6. In a phone interview on 1/24/17 at 6:40 p.m., the lack of group attendance by patient A4 was discussed with MD #1. He stated that the patient gets angry quickly and staff are reluctant to approach him/her. "I'm frustrated that [name of patient] is still on the unit. The group home is not ready to take him/her back. When told that there was no documentation on the MTP about alternative ways to interact with the patient, such as a 1:1 [one to one] for short periods of time on identified interests of patient, MD#1 stated "I think you have a valid point."

Based on record review and interview, the facility failed to ensure that registered nurses documented in the charts each patient's progress or lack of progress toward understanding their medications and side effects as mentioned in nursing interventions on the Master Treatment Plans for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). This failure results in lack of evidence that nurses were actively involved in the care of patients.

Findings include:

A. Medical Records

1. Facility policy No. HI205, dated January 1997, stated "Each treatment intervention is documented in a focused progress note in order to succinctly communicate the client's progress toward meeting the plan of care goals and objectives. Documentation is standardized and organized to capture the pertinent data of the service. Staff will document individualized services provided to clients in either a collaborative manner in the session or through post-intervention documentation no later than 48 hours after the provision of service"---"staff will document the client's specific goal(s) and objective(s) that were the focus of the intervention using the structured form available in the ECR [Electronic Record] for that service."

2. A review of the medical records on 1/24/2017 revealed that for eight (8) of eight (8) active sample patients (dates of Master Treatment Plans in parenthesis) there were no progress notes written by registered nurses regarding the progress or lack of programs toward medication education : A1 (1/17/17), A2 (1/13/17), A3 (1/21/17), A4 (1/10/17), B1 (1/5/17), B2 (1/23/17), B3 (1/23/17) and B4 (1/23/17).


B. Interview

In an interview on 1/24/17 at 11:30 a.m., the lack of RN documentation of patient's progress of understanding their medications and side effects was discussed with the Nursing Director. She did not dispute the findings.

Based on record review and staff interview, it was determined that for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, B1, B2, B3 and B4) the clinical director failed to ensure that----

1. The Psychiatric Evaluations contained an assessment of patient assets in descriptive not interpretive fashion. See, B117 for details

2. Treatment Plans were multidisciplinary and described long and short term goals in measurable terms, stated interventions in patient specific terms, and designated responsible staff. See, B118, B121, B122 and B123 for details.

3. Active treatment was provided for patient A4 and when endeavors or modalities were not working, other alternative treatment approaches were formulated. See, B125 for details.

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

1. Ensure nursing interventions on multidisciplinary Treatment Plans were not simply a listing of generic discipline tasks but patient specific. (See. B121 for details) and that a responsible nursing staff member was designated to monitor effectiveness of chosen modalities. (See, B123 for details).

2. Ensure that registered nurses documented each patient's progress or lack of progress toward understanding their medications and side effects as mentioned in nursing interventions on the Master Treatment Plans for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). This failure results in lack of evidence that nurses were actively involved in the care of patients. (Refer to B127)

Based on record review and staff interview, it was determined that for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, B1, B2, B3 and B4) the Social Service Director failed to ensure that---

1. Psychosocial Assessments contained a psychosocial formulation and described the anticipated role of the social service staff in discharge planning. See, B108 for details.

2. That Social Work interventions toward discharge planning were a part of the multidisciplinary Master Treatment Plan. See, B121 and B123 for details.

Based on record review and interview, the facility failed to provide sufficient numbers of activity staff to ensure the availability of activity therapist for acute care patients on evenings and weekends. This failure results in a lack of structured therapeutic group activities to assist the patients in meeting their treatment goals.

Findings include:

A. Record Review

A review of the unit's activity schedule showed that the activity therapist provided one activity per day at 1:15 p.m for patients Monday through Friday on the day shift.


B. Interview

In an interview with RT#1 on 1/24/17 at 11:40 a.m., she stated that she is the only activity therapist working on the unit. When asked who provided groups on evenings and weekends. She stated "mental health techs [technicians]."