HospitalInspections.org

Based on document review and interview, it was determined, for 4 of 30 patients (Pts. #1, 11, 13, & 21) receiving psychotropic medication, the Hospital failed to ensure patients or their representatives were notified of psychotropic medication purpose, effects, benefits, and side effects, before medication administration.

Findings include:

1. Hospital policy No. 704.12, revised 3/13, titled, "Patient Informed Consent for Psychotropic Medication" was reviewed on 7/9/13 at 9:00 AM. The policy required, "Action steps: 1. The physician and/or nurse discusses with the patient and/or patient/guardian, the proposed medications, purpose, desired effects, benefits and side effects of the medications... 4. RN/Physician ensures that patient/parent and/or guardian sign the Patient Consent for Psychotropic Medications form prior to medication administration."

2. On 7/8/13 at 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 61 year old male, admitted on 6/27/13, with diagnoses of schizoaffective disorder, dementia, and hypertension. A patient consent for psychotropic medication was dated 7/3/13 and included, Amantadine, Depakote, Exelon, Namenda, Seroquel, and Haldol. No prior psychotropic consent was found. Pt. #1's medication administration record included administration of amantadine, Depakote, and exelon, on 6/28, 6/29, 6/30, 7/1, & 7/2, five days before the consent was documented.

3. An interview was conducted with the Chief Nursing Officer (CNO) on 7/8/13 at 11:00 AM. The CNO reviewed Pt. 1's clinical record and did not find an earlier consent for psychotropic medications.

4. The clinical record for Pt #11 was reviewed on 7/9/13 and included that Pt #11 was a 42 year old female who was admitted to the Hospital on 6/17/13 with a diagnosis of bipolar disorder. The Patient Consent for Psychotropic Medication form lacked the required second witness signature for verbal consent for Zyprexa and Ativan.

5. An interview was conducted with the CNO on 7/9/13 at 2:00 PM. The CNO reviewed Pt. 11's clinical record and agreed the second witness signature was missing.

6. The clinical record for Pt. #13 was reviewed on 7/9/13. Pt. #13 was a 19 year old female, admitted on 6/19/13 with a diagnosis of suicidal ideation. The "Patient Consent for Psychotropic Medications" record included documentation indicating the guardian consented. However, the form lacked the patient's or guardian's signature.

7. The clinical record for Pt #21 was reviewed on 7/9/13 and included that Pt #21 was a 40 year old male who was admitted to the Hospital on 6/5/13 with a diagnosis of bipolar disorder. The Patient Consent for Psychotropic Medications form included the patient's signature, but lacked a physician or nurse witnessing signature and date for the following medications: Seroquel, Celexa, Thorazine, and Depakote.

8. An interview was conducted with the Clinical Manager on 7/9/13 at 11:30 AM. The Manager stated Pt. #13's mother should have signed the consent form as a witness and confirmed Pt. #21's consent lacked a witness's signature.



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30195

A. Based on document review and interview, it was determined, for 5 of 30 clinical records reviewed (Pts. #1, 9, 10, 12, & 13), the Hospital failed to ensure patient reassessment was completed each day/shift, as required by policy.

Findings include:

1. On 7/10/13 at 11:00 AM, policy no. 703.102, revised 6/12, titled, Initial Assessments of Patients" was reviewed. The policy required, "Action steps... 12. Unit RN... reassesses patient needs, status, effectiveness of interventions and precautions daily..."

2. On 7/10/13 at 11:10 AM, policy no. 706.08, revised 3/13, titled, "Precautions and Observations" was reviewed. The policy required, "... For any 1:1 [one staff to one patient monitoring]... the RN will complete a nursing assessment every shift..."

3. On 7/8/13 at 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 61 year old male, admitted on 6/27/13, with diagnoses of schizoaffective disorder, dementia, and hypertension. A physician's order dated 6/28/13, required one to one observation. Between the date of admission and day of review, reassessment for each shift (3 shifts per day) was missing on 4 days (6/29, 7/1, 7/4, & 7/7).

4. On 7/9/13 at 10:10 AM, the clinical record of Pt. #9 was reviewed. Pt. #9 was a 28 year old male, admitted on 6/21/13, with a diagnosis of schizoaffective disorder. A nursing reassessment for 6/24/13 was not found.

5. On 7/9/13 at 10:30 AM, the clinical record of Pt. #10 was reviewed. Pt. #10 was a 27 year old male, admitted on 5/31/13, with diagnoses of severe depression, bipolar disorder, autism, unspecified intellectual disabilities, and hypertension. A physician's order dated 5/31/13, required one to one observation. Between the date of the order and date of discharge, 6/10/13, reassessment for each shift was missing for 6 days, (June 1, 5, 6, 7, 8, & 9). On 6/6/13, reassessments for all 3 shifts were missing.

6. On 7/9/13 at 1:55 PM, an interview was conducted with the Director of Clinical Services. The Director stated she checked in the medical records office for Pts. #9 & 10's missing reassessment sheets, but could not find any.

7. The clinical record of Pt. #12 was reviewed on 7/9/13. Pt. #12 was a 26 year old male admitted on 6/20/13 with diagnoses of recurrent psychosis, bipolar disorder, mental retardation and head banging. The physician's order dated 7/4/13 included 1:1 observation while awake. The every 8 hour nursing assessment for patients on 1:1 was lacking for the 3-11 shift on 7/4/13.

8. The clinical record for Pt. #13 was reviewed on 7/9/13. Pt. #13 was a 19 year old female admitted on 6/19/13 with diagnoses of suicidal ideation. The physician's order dated 7/1/13 included 1:1 observations. The every 8 hour nursing assessment for patients on 1:1 was lacking for the 7-3 PM shift on 7/4/13.

9. An interview was conducted with the Clinical Manager on 7/9/13 at 11:30 AM. The Manager reviewed Pts. #12 & 13's clinical records and confirmed the findings.

B. Based on document review and interview, it was determined, for 1 of 3 diabetic patient's clinical records reviewed (Pt. #23), the Hospital failed to ensure physician's orders were followed.

1. On 7/10/13 at 9:00 AM, the clinical record of Pt. # 23 was reviewed. Pt. #23 was a 19 year old male, admitted on 5/26/13, with diagnoses of bipolar disorder, cannabis abuse, and diabetes mellitus type II. A physician's order dated 5/26/13 at 8:30 AM, required, "Accucheck BID [measure blood glucose twice a day] Metformin 500 mg PO [by mouth] BID, hold [Metformin] if accucheck is equal to or less than 100." Between the date of the order and date of discharge (6/19/13) Metformin was administered 19 times when Pt. #23's accucheck was less than 100.

2. An interview was conducted with the Chief Nursing Officer (CNO) on 7/10/13 at 10:00 AM. The CNO reviewed Pt. 23's clinical record and stated the findings were accurate.


19843

Based on document review and interview, it was determined that for one of one medical records department, the Hospital failed to ensure that medical records were completed within 30 days after discharge.

Findings include:

1. The Hospital's "Medical Staff Rules and Regulations" (adopted 4/25/13) required, "...All discharge summaries and other medical record documentation shall be completed within 30 days following the patient's discharge. Incomplete records exceeding 30 days following discharge will be considered delinquent..."

2. On 7/10/13 at approximately 1:30 pm, the Chief Nursing Officer (CNO) presented the surveyor with a letter of attestation which documented, "There are 52 delinquent records at...[Hospital]...as of 7/10/13."

3. The above findings were confirmed with the CNO on 7/10/13 at approximately 2:00 pm.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint survey conducted on July 8 & 9, 2013, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint survey conducted on July 8 & 9, 2013, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated July 9, 2013.

Based on document review and interview, it was determined that for 2 of 2 food service tray lines, the Hospital failed to ensure that trayline temperatures were monitored 3 times throughout meal service per policy, which potentially affected 89 patients on census on 7/10/13.

Findings include:

1. The Hospital's Dietary Department's policy entitled "Holding and Service" (revised 6/20/12) required, "Holding- Hot foods will be held at a minimum temperature of 135 degrees Farenheit for a maximum of 4 hours..."

2. The "Trayline Temperature Record" form required, "Temperatures should be checked for hot foods 3 times throughout meal service: before serving, middle of meal service and end of meal service."

3. The "Daily Cafe Temperature Log" (1/1/13-7/10/13) for the cafeteria's front trayline was reviewed on 7/10/13 and included only the food temperatures at the start of the trayline. Every daily log sheet lacked initials of the employee who checked the temperature, the actual start time of the trayline, and temperatures for the middle and end of the tray line. Therefore, it would not be possible to determine the maintenance of the minimum temperature throughout holding; and the total holding time is not documented.

4. During a tour of the Hospital's Dietary Department during the "back" lunch trayline on 7/10/13 between approximately 11:15 am and 11:30 am, the trayline was set up, and trays were being prepared for the meals to be delivered to the patient units. At 11:30 am, the Trayline Temperature Record for 7/10/13 was reviewed at the trayline site and included documentation of ending temperatures for foods on the trayline that was still active, rendering this information inaccurate.

5. The above information was confirmed during an interview with the Chief Nursing Officer on 7/10/13 at approximately 2:00 PM.

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

I. Develop and document a multidisciplinary Master Treatment Plan based on the individual needs for one of two sample patients (A1) on 1 North (Child and Adolescent Unit). The patient's MTP dated 7/3/13 listed several unattainable short-term goals for Patient A1. In addition, the treatment modalities specified on the MTP were not appropriate given the patient's level of functioning. Failure to set individualized goals with patient specific treatment interventions can limit the patient's ability to attain goals needed for discharge thereby potentially increasing the overall length of hospitalization. (Refer to B118)

II. Develop Master Treatment Plans that included short-term goals that were observable and measurable patient behaviors to be achieved in 5 of 8 active sample patients (A1, A3, A4, A5 and A6). Failure to specify short term goals that are measurable patient behaviors hampers treatment staff's ability to provide goal-directed care and monitor patients' responses to treatment, potentially resulting in prolonged hospitalizations. (Refer to B121)

III. Provide active treatment, including alternative interventions, for 1 of 2 active sample patients (A1) on 1 North Unit, 2 of 2 active sample patients on 2 North Unit (A3 and A4) and 1 non-sample patient (C1) on 2 North added to the sample in order to evaluate active treatment. All of the patients were unwilling or unable to attend their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125)

Based on record review, observation and interview, the facility failed to develop and document a multidisciplinary Master Treatment Plan (MTP) based on the individual needs for one of two sample patients (A1) on 1 North (Child and Adolescent Unit). The patient's MTP dated 7/3/13 listed several unattainable short-term goals for Patient A1. In addition, the treatment modalities specified on the MTP were not appropriate given the patient ' s level of functioning. Although Patient A1 was unable to participate in the treatment activities listed in the MTP, there were no modifications made to the treatment plan from 7/1/13-7/9/13. Failure to set individualized achievable goals with patient specific treatment interventions can limit the patient's ability to attain goals needed for discharge thereby potentially increasing the overall length of hospitalization.

Findings include:

A. Record Review

1. Patient A1 was admitted on 7/1/13. The Psychiatric Evaluation dated 7/2/13 documented a diagnosis of "Autistic disorder; intermittent explosive disorder and moderate mental retardation." The patient was admitted for "getting increasingly aggressive and violent over the past two weeks." The patient was in diapers and was described as mute. During the evaluation, Patient A1 was described as "Extremely hyper. The patient is swirling around, touching things, and not able to follow simple commands." The patient was described as having "poor impulse control" and "constantly on the go" and was placed on one-to-one supervision shortly after admission.

2. Patient A1's Master Treatment Plan dated 7/3/13 listed the following problems: "Danger to Others evidenced by increased aggressive behavior towards others, throwing things, yelling, biting, hitting, increased tantrums"; "Candida Intertrigo (Diaper Rash) as evidenced by reddened & affected area to [sic] buttocks" and "Bowel or Bladder incontinence as evidenced by need for assistance with ADLs (Activities of Daily Living)." The Master Treatment Plan was organized into Short-Term Goals, Specific Intervention Focus (described by Therapist 1 on 7/9/13 at 2:15 p.m. as what the staff should focus on) and Treatment Modality.

3. For the problem, "Danger to Others", the Master Treatment Plan included the following short-term goals and interventions:

Short-term goal--"Pt. (patient) will be provided the opportunity to engage with peers and staff for improved social skills." The Specific Intervention Focus section for this goal included "Evaluate the pt. for any warning signs of unsafe behaviors, changes in behavior & any suicide/homicide statements", "Assist the pt. to control impulses & implement safety measures" and "Staff to use communication board/pictures to assist in communicating with pt". The actual interventions for this short-term goal were "Goals group 7x (times) wk (week)/30 min (minutes)", "Monitoring Q (every) 15 min" (patient actually on one-to-one monitoring), "1:1 Redirection as needed" and "Wrap-up group 7xwk/20 min."

Short-term goal-- "[Patient] will be encouraged to make safe choices and take time outs when upset to maintain safety for [himself/herself] and others." The Specific Intervention Focus section for this goal included "Assist pt in exploring means of self-expression through Art, Dance/Movement and Drama", "Improve ability to cope with stressors safely" and "Assist pt in identifying healthy thinking patterns and positive self-statements and support system." The actual interventions for this short-term goal were "Expressive Therapy Group 7/wk x 45min", "Gym/Outdoor activity 7/wk x 60 m [sic]", "Skills Group (anger management/self-esteem/social skills/relaxation& meditation 4x/wk x 45 mins" and Therapeutic Play/Arts & Crafts 4/wk x 30 mins."

4. Review of the Interdisciplinary Daily Group Notes from 7/2/13-7/9/13 revealed that Patient A1 attended 2 of 16 scheduled groups (12.3%). The 2 groups attended were "Gym" and "Physical Exercise." Although Patient A1 had been unable to attend groups since admission on 7/1/13 and had displayed agitated and disruptive behaviors since admission, there were no modifications made to the treatment plan within the areas of treatment modalities and behavioral interventions as of 7/9/13.

5. Review of the Progress Notes from 7/2/13-7/9/13 included the following notes regarding Patient A1's behavior:

7/2/13 3:25 p.m.- "Pt was observed being incontinent with bowel movements, having poor boundaries, being impulsive and slow to follow."

7/3/13 10:00 p.m.- "Pt. was observed needing constant supervision from staff and [his/her] 1:1 staff AEB (As Evidenced By) [his/her] poor impulse control of getting up and running around, putting [his/her] hands on other pt's [sic] in a playful way, trying to lay on pt's [sic] during movie time."

7/4/13 12:20 p.m.- "Pt was impulse [sic] evidence by touching pts, walking and running in pt (other patient) room."

7/5/13 7:43 p.m.- "Pt observed being extremely hyper, AEB running up and down the hallways, climbing on furniture in the dayroom, jumping on [his/her] bed and running in circles."

7/6/13 9 p.m.- "Pt. was observed in the milieu displaying provoking behavior by evidence of agitating [his/her] peer by sitting in their chair when possible and taking their items (toys) when they laid them down."

7/8/13 2:05 p.m.- "Pt hyperactive, scattered and restless. Pt doesn't program, and doesn't communicate with peers or staff (non-verbal)."

7/9/13 10:50 p.m.- "Patient was observed as upset at the beginning of the shift AEB laying on [his/her] bed crying and screaming out. Pt. continued this behavior for the next couple of hours AEB not following staff directions by running away from them or screaming out when staff tried to direct and assist [him/her] in participating in programming."

6. An Individual Behavior Support Plan was written by the psychologist on 7/10/13 (second day of the survey) and placed in Patient A1's record. The plan listed specific direction for staff when working with Patient A1. Some of the interventions included in the Support Plan were "Offer simple prompts", "Focus on [patient's] next safe behavior and avoid giving redirection about stopping unsafe behaviors" and "Focus on successful, positive behaviors that reinforce [patient's] return to a safe place."

B. Observations:

1. Observations during an Expressive Therapy group on 1 North on 7/9/13 from 11:10-11:35 a.m. revealed that Patient A1 was in group for only a couple of minutes. Mental Health Associate (MHA)1 removed Patient A1 from the group, which was focusing on individual strengths of the participants, after s/he refused to sit in the chair, began making loud noises and disrupted the group process. At 11:35 a.m. Patient A1 was observed in the hallway, running up and down and yelling loudly. S/he was observed pulling MHA1 down the hallway to the door and becoming louder and more agitated when told s/he could not go outside.

2. During observations on 1 North on 7/9/13 from 3:15-3:30 p.m., Patient A1 was seen running up and down the hallway, yelling and waving his/her arms. The patient attempted to pull Therapist 1 down the hallway to the locked door.

3. During observations of a Goals Group on 1 North on 7/10/13 from 9:10-9:45 a.m., Patient A1 was observed not following directions from MHA1, running around the room and making noises. Patient A1 was removed by MHA1 after only a few minutes in the group. MHA1 returned with Patient A1 at approximately 9:40 a.m. but s/he had to be removed after 1-2 minutes for refusing to sit in a chair, walking in front of the group and trying to sit in the lap of an adolescent female patient.

4. During observations on 1 North on 7/10/13 from 10:05-10:15 a.m., Patient A1 was seen lying in the floor in the hallway. When a staff member entered the hallway from the locked door, Patient A1 ran to the staff member and tried to pull the staff member back to the door. S/he began yelling and screaming when told that s/he could not go out.

C. Interviews:

1. In interview on 7/9/13 at 11:30 a.m., when RN2 was asked about the appropriateness of Patient A1's admission to an acute psychiatric hospital, RN2 responded, "There's nowhere else for [him/her] to go."

2. In interview on 7/9/13 at 2:15 p.m., when Therapist 1 was asked about the admission of Patient A1 to an acute psychiatric hospital asked, "Where else would [he/she] go? What do other states do with them?"

3. In interview on 7/9/13 at 2:15 p.m., Therapist 1 agreed that Patient A1 would not be able to attend and benefit from the groups listed as treatment modalities on his/her treatment plan. Therapist 1 also stated that some of the short-term goals for Patient A1 were not attainable given his/her level of functioning.

4. In interview on 7/9/13 at 3:15 p.m., the one-to-one assigned to Patient A1, Mental Health Associate 1 (MHA1), stated that she could not understand any of Patient A1's verbal communications. Most of his/her communications were described as "yelling and screaming". When asked about her interactions with patient A1, MHA1 stated that she "tried to go into the dayroom (where groups are held) from time to time and [he/she] will sit in a chair for a few minutes. I just follow [his/her] lead."

5. In interview on 7/10/13 at 10:00 a.m., MHA1 explained that Patient A1 was yelling and screaming and pushing at the door because, "[He/she] wants to go to the gym."

Based on record review and staff interviews, the facility failed to develop Master Treatment Plans (MTPs) that included short- term goals that were observable and measurable patient behaviors to be achieved for 5 of 8 active sample patients (A1, A3, A4, A5 and A6). Failure to specify short term goals that are measurable patient behaviors hampers treating staff's ability to provide goal-directed care and monitor patients' responses to treatment, potentially resulting in prolonged hospitalizations.

Findings include:

A. Record Review (Date of MTP in parentheses):

1. Patient A1 (7/3/13). For problem "Danger to Others", short-term goals included "(Name of the patient A1)/guardians will be supported to identify 1-3 triggers to unsafe behaviors and establish positive behavioral supports to encourage and prompt appropriate behaviors." This short-term goal does not identify the unsafe behaviors, the "positive behavioral supports" or the appropriate behaviors sought. Another short-term goal for the same problem included "Patient will be provided the opportunity to engage with peers and staff for improved social skills." This is not a short-term goal that includes measurable outcome of patient's behavior.

2. Patient A3 (6/29/13). For the stated problem of "Alteration in Thought Process," short-term goal #1 included "(Name of the patientA3) will engage in meaningful reality based interactions with staff." This short-term goal does not include measurable outcome of patient's behavior. For the same problem short-term goal #3 included "(Name of the patient A3) will attend at least 2 appropriate groups daily to encourage reality orientation and positive socialization." This short-term goal behavior does not include measurable outcome of patient's behavior and it does not specify which groups the patient should attend to meet the goal.

3. Patient A4 (7/5/13). For the stated problem of "Alteration in Thought Process" first short term goal included "(name of the patient A4) will engage in meaningful reality based interaction with staff." This short-term goal does not include measurable outcome of patient's behavior. Another short term goal for the same problem included "(name of the patient A4) will socialize positively with others in order to address thoughts of paranoia." This short -term goal does not include measurable outcome of patient's behavior.

4. Patient A5 (7/5/13). For the state problem of "Alteration in Thought Process" one of the short term goals included "Patient will be placed in blocked room [sic]for safety." This short-term goal is a treatment intervention by staff instead of measurable targeted behavior of the patient.

5. Patient A6 (6/17/13). For the stated problem of "Alteration in Thought Process," the first short-term goal included "(name of the patient A5) will engage in meaningful reality based interactions with staff." This short-term goal does not include measurable targeted behavior of the patient. Another short-term goal for the same problem included "(name of the patient A5)" will socialize positively with others in (order) [sic] to address psychosis. This short-term goal also does not include measurable targeted behavior of the patient.

B. Staff Interviews:

1. In an interview on 7/10/13 at 11:30 a.m., Therapist I stated that the shared short-term goals for patients A1, A3 and A4 were not measurable.

2.In an interview on 7/11/13 at 9:30 a.m., Therapist I agreed with the surveyor that the short-term goals in Master Treatment Plans of patient A5 and A6 were not measurable.

Based on record review, observation and interviews, the facility failed to provide active treatment, including alternative interventions, for 1 of 2 active sample patients (A1) on 1 North, 2 of 2 active sample patients on 2 North (A3 and A4) and 1 non-sample patient (C1) on 2 North added to the sample in order to evaluate active treatment. All of the patients were unwilling or unable to attend their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement.

Findings include:

A. Patient A1

1. Patient A1 was admitted on 7/1/13. The Psychiatric Evaluation dated 7/2/13 documented a diagnosis of "Autistic disorder; intermittent explosive disorder and moderate mental retardation."

2. Patient A1's Master Treatment Plan dated 7/3/13 listed the problem: "Danger to Others evidenced by increased aggressive behavior towards others, throwing things, yelling, biting, hitting, increased tantrums". Interventions for this problem included: Goals group 7 times weekly, Wrap-up group 7 times weekly, Expressive Therapy Group 7/times weekly, Gym/Outdoor activity 7 times weekly, Skills Group (anger management/self-esteem/social skills/relaxation & meditation) 4 times weekly and Therapeutic Play/Arts & Crafts 4 times weekly.

3. In interview on 7/9/13 at 2:15 p.m., Therapist 1 agreed that Patient A1 would not be able to attend and benefit from the groups listed as treatment modalities on his/her treatment plan.

4. In interview on 7/9/13 at 3:15 p.m., the one-to-one assigned to Patient A1, Mental Health Associate 1 (MHA1), stated that she could not understand any of Patient A1's verbal communications. Most of his/her communications were described as "yelling and screaming". When asked about her interactions with patient A1, MHA1 stated that she "tried to go into the dayroom (where groups are held) from time to time and [he/she] will sit in a chair for a few minutes. I just follow [his/her] lead."

5. During observations on 1 North on 7/9/13 from 11:10-11:35 a.m. Patient A1 was observed in the dayroom where an Expressive Therapy Group (which was focusing on individual strengths) was being conducted. After only a couple of minutes MHA1 removed Patient A1 from the group due to his/her refusal to sit in the chair, making loud noises and disrupting the group process. At 11:35 a.m. Patient A1 was observed in the hallway, running up and down and yelling loudly. S/he was observed pulling MHA1 down the hallway to the door and becoming louder and more agitated when told s/he could not go outside. During observations of a Goals Group on 1 North on 7/10/13 from 9:10-9:45 a.m., Patient A1 was observed not following directions from MHA1, running around the room and making noises. Patient A1 was removed by MHA1 after only a few minutes in the group. MHA1 returned with Patient A1 at approximately 9:40 a.m. but s/he had to be removed after 1-2 minutes for refusing to sit in a chair, walking in front of the group and trying to sit in the lap of an adolescent female patient.

6. Review of the Interdisciplinary Daily Group Notes from 7/2/13-7/9/13 revealed that Patient A1 attended 2 of 16 scheduled groups (12.3%). The 2 groups attended were "Gym" and "Physical Exercise". Although Patient A1 had been unable to attend groups since admission on 7/1/13 and had displayed agitated and disruptive behaviors since admission, there were no modifications made to the treatment plan within the areas of treatment modalities and behavioral interventions as of 7/9/13.

7. Review of the Progress Notes from 7/2/13-7/9/13 included the following notes regarding Patient A1's behavior:

7/2/13 3:25 p.m.- "Pt was observed being incontinent with bowel movements, having poor boundaries, being impulsive and slow to follow."

7/3/13 10:00 p.m.- "Pt. was observed needing constant supervision from staff and [his/her] 1:1 staff AEB (As Evidenced By) [his/her] poor impulse control of getting up and running around, putting [his/her] hands on other pt's [sic] in a playful way, trying to lay on pt's [sic] during movie time."

7/4/13 12:20 p.m.- "Pt was impulse [sic] evidence by touching pts, walking and running in pt (other patient) room."

7/5/13 7:43 p.m.- "Pt observed being extremely hyper, AEB running up and down the hallways, climbing on furniture in the dayroom, jumping on [his/her] bed and running in circles."

7/6/13 9 p.m.- "Pt. was observed in the milieu displaying provoking behavior by evidence of agitating [his/her] peer by sitting in their chair when possible and taking their items (toys) when they laid them down."

7/8/13 2:05 p.m.- "Pt hyperactive, scattered and restless. Pt doesn't program, and doesn't communicate with peers or staff (non-verbal)."

7/9/13 10:50 p.m.- "Patient was observed as upset at the beginning of the shift AEB laying on [his/her] bed crying and screaming out. Pt. continued this behavior for the next couple of hours AEB not following staff directions by running away from them or screaming out when staff tried to direct and assist [him/her] in participating in programming."

B. Patient A3

1. Patient A3 was admitted on 6/27/13. The Psychiatric Evaluation dated 7/28/13 documented a diagnosis of "Schizophrenia, disorganized" and stated that the patient had multiple past psychiatric hospitalizations. The patient was admitted from a nursing home due to increasingly delusional, disorganized and bizarre behavior.

2. Patient A3's Master Treatment Plan (MTP) dated 6/29/13 listed the problem, "Alteration in Thought Process evidenced by: Pt became increasingly disorganized and bizarre, not redirectable, drinking [his/her] urine." Interventions for this problem included: Process Group 5 times weekly, Stress Management Group 1 time weekly, Coping Skills Group1 time weekly and Expressive Therapy 6 times weekly.

3. In interview on 7/10/13 at 9:00 a.m., Patient A3 stated no knowledge of why he/she had been admitted and that s/he had been there for "40 days and 40 nights." Patient A3 stated that s/he went to groups but could not identify which ones.

4. In interview on 7/10/13 at 11:30 a.m., Therapist 1 stated that Patient A3 "isolates" and did not attend many groups. When asked about staff responsibility for getting patients to group, Therapist 1 further stated that it was difficult to get "chronic" patients like Patient A3 to go to groups. When asked about Patient A3 going to groups not listed on his/her Master Treatment Plan, Therapist 1 stated that it was an expectation that patients would attend all the unit groups even if the groups were not listed as interventions on the patients' Master Treatment Plans. "We are running only one group at a time, so they (patients) are not doing anything if they are not in group."

5. During observation on 7/10/13 at 11:35 a.m. Patient A3 was observed in bed. There was an assigned Process Group being held on the unit during this time from 11:15 a.m. to 12:15 a.m. During observation on 7/10/13 from 1:20-1:40 p.m. Patient A3 was observed in the dayroom where an assigned Medication Group was being held from 1:15-2:00 p.m. S/he sat away from the group, laughing and talking to self.

6. Review of Patient A3's Interdisciplinary Daily Group Notes revealed that from 7/3/13-7/9/13 the patient did not attend 9 of the 22 scheduled groups (40.9%). Notes for the unattended groups included the comments, "Pt. refused to attend group", "Pt. remained in [his/her] room during group", "Refused to program at this time", and "Patient did not attend." The patient attended 13 of the scheduled groups but had difficulty participating in 4 of those groups. Comments on the Interdisciplinary Daily Group Notes included: "Appeared asleep during session" (Skills Group 7/3/13), "Pt was unable to remain focused while in group. Pt was continuously moving and pacing the halls. Pt excused from group" (Skills Group 7/7/13), "Pt did attend group although off topic" (Skills Group 7/8/13) and "Pt present briefly, but roaming in and out of group. Goal not achieved." (Skills Group 7/9/13)

C. Patient A4

1. Patient A4 was admitted on 7/3/13. The Psychiatric Evaluation dated 7/3/13 documented a diagnosis of "Schizoaffective Disorder and Alcohol Abuse" and stated that the patient had been discharged from the hospital on 6/24/13, nine days prior to the current admission. The patient was admitted for paranoia with suicidal ideation and hallucinations. The patient had not taken his/her medications since discharge.

2. Patient A4's Master Treatment Plan (MTP) dated 7/5/13 listed the problem, "Alteration in Thought Process evidenced by pt. reportedly increasingly paranoid, believing people are after [him/her] and that there are maggots in [his/her] stomach." Interventions for this problem included: Process Group 5 times weekly, Stress Management Group 1 time weekly, Coping Skills Group 1 time weekly, Chemical Dependence Group 1 time weekly, Expressive Therapy 6 times weekly and Medication Group 3 times weekly.

3. In interview on 7/10/13 at 8:45 a.m., Patient A4 stated that in order to go home he/she needed to "do good, eat meals and go to groups." Patient A4 did not know which groups were assigned to him/her but stated that he/she went to "some" groups.

4. In interview on 7/10/13 at 11:30 a.m., Therapist 1 stated that Patient A4 did not attend groups very often and that it was difficult to get "chronic" patients like Patient A4 to go to groups. Therapist 1 further stated that it was an expectation that patients would attend all groups even if the groups were not listed as interventions on the patients' Master Treatment Plans. "We are running only one group at a time, so they (patients) are not doing anything if they are not in group."

5. During observation on 7/10/13 at 11:30 a.m., Patient A4 was observed in bed. There was an assigned Process Group being held on the unit during this time from 11:15-12:15 a.m. During observation on 7/10/13 at 1:30 p.m., Patient A4 was observed in bed while an assigned Medication Education Group was being held on the unit from 1:15-2:00 p.m. Patient A4 was again observed in bed on 7/10/13 at 2:15 p.m. while an assigned Expressive Therapy was being held from 2:00-3:00 p.m.

6. Review of Patient A4's Interdisciplinary Daily Group Notes revealed that the patient did not attend any of his/her scheduled groups (8 groups) on 7/09/13 and 7/10/13, the first two days of the survey. Review of the notes from 7/4/13-7/8/13 revealed that the patient attended 7 of the 14 scheduled groups (50%). Notes for the unattended groups included the comments, "Invited did not attend", "Pt. declined to attend groups", "Patient was asleep and didn't attend" and "Pt. wasn't receptive to staff encouragement (to attend)."

7. Review of Patient A4's Progress Notes revealed the following documentation: (7/3/13 at 7:15 p.m.) "Patient observed in bed reporting 'I'm too tired to get up' when encouraged to participate in group activities and eat dinner", (7/4/13 at 11:30 a.m.) [Patient statement when encouraged to be in group] "I just don't want to be with other people", (7/5/13 at 7:30 p.m.) "Pt observed as isolative AEB (As Evidenced By) pt mostly spending the shift in bed sleeping. Patient doesn't engage in unit programming nor does [he/she] attend groups, pt only gets up for meals and meds", (7/6/13 at 2:30 p.m.) "Pt. was observed throughout milieu quiet [sic] isolated from peers and staff ", (7/7/13 at 7:10 p.m.) "Patient observed isolative, withdrawn, staying in bed most of this shift", (7/8/13) "Pt. spent a lot of time in [his/her] room today" and (7/9/13 at 10:10 p.m.) "Pt interacted well w/peers (with peers) and staff, but refused to attend groups."

D. Patient C1

1. Patient C1 was admitted on 7/4/13. The Psychiatric Evaluation dated 7/5/13 documented a diagnosis of "Schizoaffective Disorder" and stated that the patient had been exhibiting inappropriate behavior and experiencing auditory hallucinations.

2. Patient C1's Master Treatment Plan dated 7/5/13 listed the problem. "Alteration in Thought Process evidenced by agitation, paranoia, bathing in public fountains, non-compliance with medication." Interventions for this problem included: Process Group 5 times weekly, Stress Management Group 1 time weekly, Coping Skills Group 1 time weekly and Expressive Therapy 6 times weekly.

3. In interview on 7/11/13 at 9:15 a.m., Patient C1 stated that he/she was hospitalized to get prescriptions. When asked about attending groups, Patient C1 stated, "I have gone to at least 4 groups."

4. In interview on 7/10/13 at 11:30 A.M., Therapist 1 stated that Patient C1 did not attend groups very often and that it was difficult to get "chronic" patients like Patient C1 to go to groups. Therapist 1 further stated that it was an expectation that patients would attend all groups even if the groups were not listed as interventions on the patients' Master Treatment Plans. "We are running only one group at a time, so they (patients) are not doing anything if they are not in group."

5. During observation on 7/10/13 at 1:30 p.m., Patient C1 was observed in the shower room while an assigned Medication Education Group was being held on the unit from 1:15-2:00 p.m. During observation on 7/10/13 at 2:15 p.m. Patient C1 was observed in bed while an assigned Expressive Therapy was held from 2:00-3:00 p.m.

6. Review of Patient C1's Interdisciplinary Daily Group Notes from 7/5/13-7/10/13 revealed that the patient attended 5 of the 17 scheduled groups (29.4%). Notes for the unattended groups included the comments, "Pt slept during group", "Patient did not attend", "Pt came in at the end of group did not participate", "Sleeping in room", "Refused" and "Pt. laying down in bed and declined to attend group."

7. Review of Patient C1's Progress Notes revealed the following documentation: (7/4/13 at 9:10 p.m.) "Patient observed isolating in room", (7/6/13 at 2:35 p.m.) "Pt observed throughout milieu [sic] in bed most of the shift ", (7/8/13 at 1:15 p.m.) "Pt was anxious, nervous, no [sic] attending in groups, milieu programming" and (7/9/13 at 2:15 p.m.) "Pt was tired, sad, spent a lot of time in [his/her] room. Refused groups, milieu programming."

Observations

1. Observations on 7/10/13 at 11:15 a.m. on 2 North revealed a Discharge Planning group being held. There were 4 patients in attendance. The census on the unit on 7/10/13 was 19.

There were no other groups or therapeutic activities being held during this time.
Although this group was on the Master Treatment Plan for patients A3, A4 and C1, they were not in attendance.

2. Observations on 7/10/13 from 1:15 p.m.-1:40 p.m. on Unit 2 North revealed a Medication Education group being held. There were 6 patients in attendance. Although this group was on the Master Treatment Plan for patients A3, A4 and C1, they were not in attendance. The census on the unit on 7/10/13 was 19. There were no other groups or therapeutic activities being held during this time.

3. Observations on 7/10/13 from 2:15-2:25 p.m. on Unit 2 North revealed an Expressive Therapy group being held. There were 6 patients in attendance. Although this group was on the Master Treatment Plan for patients A3, A4 and C1, they were not in attendance. The census on the unit on 7/10/13 was 19. There were no other groups or therapeutic activities being held during this time.

Based on record review, interviews and document review, the Medical Director failed to provide adequate medical oversight to ensure quality of medical services. Specifically, the Medical Director failed to provide medical oversight to:

1. Develop and document a multidisciplinary Master Treatment Plan (MTP) based on the individual needs for one of two sample patients (A1) on 1North (Child and Adolescent Unit). In addition, the treatment modalities specified on the MTP were not appropriate given the patient's level of functioning. Failure to set individualized goals with patient specific treatment interventions can limit the patient's ability to attain goals needed for discharge thereby potentially increasing the overall length of hospitalization. (Refer to B118)

II. Develop Master Treatment Plans (MTPs) that included short-term goals that were observable and measurable patient behaviors to be achieved in 5 of 8 active sample patients (A1, A3, A4, A5 and A6). Failure to specify short term goals that are measurable patient behaviors hampers treating staffs' ability to provide goal-directed care and monitor patients' responses to treatment, potentially resulting in prolonged hospitalizations. (Refer to B121)

III. Provide active treatment, including alternative interventions, for 1 of 2 active sample patients (A1) on 1 North (Child and Adolescent Unit), 2 of 2 active sample patients on the 2 North Unit (A3 and A4) and 1 non-sample patient (C1) on 2 North added to the sample in order to evaluate active treatment. All of the patients were unwilling or unable to attend their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125)

Based on staff interviews the facility failed to provide a MSW prepared director or assign one of the MSW- level staff currently employed at the facility to fulfill the duties, functions and responsibilities of the Director of Social Work. As a result, there was no professionally designed and directed Social Work Program provided for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8), as well as the facility ' s entire patient population.

Findings are

Staff Interview:

In an interview with the Social Work Director on 7/10/13 at 3:45PM, she verified that the she had a Master's Degree in Professional Counseling but did not possess a Master's Degree in Social Work. She further verified that the MSW level staff in her department did not perform the responsibilities of a Director of Social Work: "I provide supervision as well as Q and A monitoring in the social work department."