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Based on medical record reviews, document reviews and staff interviews, it was determined the medical staff failed to provide appropriate care for a patient. This was found for 1 of 50 medical records reviewed. This was found for patient #1.

Findings include:

A review of medical record #19 on May 12, 2014 revealed this is a seventy year old patient who was admitted to the facility with a diagnosis of Schizophrenia. The patient's previous medical history included Coronary Artery Disease, Hypertension and Diabetes Mellitus. Throughout the patient's hospitalization he was awake, alert, ambulatory and independently with all activities of daily living. On July 7, 2013 the patient was erroneously given Clozapine 750 mg, Seroquel 600 mg, Cogentin 1 mg, and Lipitor 20 mg all of which were given orally at 8:15 PM.

According to the physician's documentation in the medical record at 8:50 PM that night, the patient was alert and oriented and the vital signs were temperature 98.4, pulse rate 70, respirations were 18 and the blood pressure ( B/P) was 143/80. The oxygen saturation was 96% on room air. The physician ordered vital signs every two hours, Q2H, x 2. The patient was found at 11:10 PM that night, unresponsive with a pulse rate of 108, respirations of 18 breaths per minute, B/P 120/82 and with the oxygen saturation of 79% on room air. The patient was subsequently intubated by emergency medical services, EMS and transferred to an intensive care unit at an acute care facility.

Review of the manufacturer's recommendation indicated that initial dosing of Clozapine should be 12.5 mg once or twice daily, the side effects of the medication include cardiac arrest, drowsiness, syncope, orthostatic hypotension, lethargy, seizure and rigidity that can occur on the first dose. Based on this information, the care ordered by the physician, assessing vital signs every two hours, failed to meet the patient's needs following this significant medication error.

The above findings were confirmed during an interview with the Director of Risk Management on May 8, 2014 at approximately 2:25 PM.
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Based on medical records reviews and interviews, it was determined that the facility did not develop policies and procedures specifically recognizing and addressing medications used as restraints. This was evident in 4 of 9 records reviewed for STAT IM medications.

Findings include:

On 5/6/14, while conducting the environmental walk-through with the Director of Social Service(staff#8), and while interviewing the Charge Nurses(RN) of units 45/46, 43/44, 41/42, 35/36, 33/34: Interview of all the Charge nurses revealed that the nurses believed that the facility does not use drugs to restrain patients by stating; "We do not use drugs to restrain patients at this facility, it is forbidden". During interview with Staff #18 the RN Director on 5/7/14, it was also stated that the facility does not use drugs to restrain patients.


The RN director stated that special monitoring of the patients' conditions including vital signs after the use of the drugs were not done and not required with the same intensity of monitoring as is done for physical restraints. She stated that the nurse is required to document her use of drugs given STAT over the patient's objection in the progress notes. She stated that within the Nursing department and not included in the restraint policy, she has started the use of the form "Emergency Administration of Medication over Objections" as a checklist for staff" which upon completion is sent to QA to count the number of instances of the use of such drugs. She also stated that the process of debriefing after the use of the drugs is not part of the facility process and the Medical Director, Staff #2, can explain the facility process further.

When medications were used to address violent behavior, the facility failed to distinguish when a drug is considered a restraint. Medications were not considered restraints when they were used as PRN or Stat orders or used during times when the patients become agitated and is a danger to themselves or others.

This resulted in a failure to protect the patient from harm since parameters for monitoring the patient's medical status, including timeframes for (blood pressure, pulse, and respirations) were not established.
In addition, since medications used to address violent behavior are not considered medications used as restraints, vital signs, face-to-face assessments by the physician, debriefing by the treatment team following the drugs used as a restraint, review and/or revision of the Care Plan, monitoring as to the effectiveness of the restraint, and documentation on the Restraint/Seclusion form were not required.

On 5/7/14 at 3:00PM to 3:45 PM the Medical Director, Staff #2,was interviewed by the Survey Team and she stated that the facility does not use drugs to restrain patients. Therefore, no extra monitoring is done when the drugs are given to the patients.


Example #1
The patient MR #10 was given IM STAT Olanzapine 10 mgs and Lorazepam 2 mgs IM STAT for severe agitation over his objection at 0835 on 10/30/13.

--The drug Lorazepam 2 mgs IM was written every 6 hours as needed for the patient on 10/28/13.
--The administration of the stat doses IM were not monitored as drugs used to restrain the patient.
--The uses of the drugs were not recorded on the "Restraints and Seclusion form.
--The patient's vital signs were not monitored to ensure his safety. --The uses of the drugs were not reviewed during the units debriefing sessions and the physician did not do a face to face evaluation of the patient.
--The physician did not review the patient's medication regimen. On 10/30/13 at 19:55 the patient was given IM Haldol 10mgs IM and Lorazepam 2 mgs IM for severe agitation over his objections and restrained physically.



Example #2
The patient MR #14 was given Haloperidol 10mgs IM and Lorazepam 2mgs IM over objections for severe agitation on 1/5/14 at 22:25, on 1/7/14 at 10:45 AM and on 1/11/14 at 12:55 PM.

--The uses of these doses given IM were not recorded on the restraint and seclusion form,
--the patient was not redirected or offered calming alternatives,
--the patient's vital signs were not monitored,
--there was no review of the patient's medication regimen and the use of the IM medications were not discussed during debriefing sessions on the unit.
--It was also noted that the use of these medications were not recorded on the patient's Medication Administration Record (MAR).



Example #3
The patient MR #25 received 5mgs Fluphenazine IM STAT on 10/31/13. Again, this same patient received Olanzapine 10mgs and Lorazepam 2mgs IM STAT on 11/2/13
--The patient was not monitored inclusive of vital signs after the medication was given IM
--The use of the drug was not regarded as a drug used to restrain the patient and was not recorded on the MAR.
--The patient's medication regimen was not reviewed after the use,



Example #4
The patient MR #24 was medicated over objection on 6/1/13 with Olanzapine 10mgs IM STAT at 8:43 AM and was manually restrained (take down) before the medication could be given. At 9:30AM on 6/1/13 the patient stumbled and fell while walking to the dormitory area after the IM STAT medication was given.
--The patient was not monitored inclusive of vital signs after the medication was given IM despite the observation that at 9:00 AM the patient was calm with eyes closed. At 9:30AM the patient fell. Vital signs after the fall reflected a blood pressure reading of 80/50. The addendum note written by the RN at 9:30AM stated that the patient's fall "was reported by peers to SHTA staff" and that the staff did not observe the fall as the medicated patient was not being monitored. The fall resulted in a 2-3 inch laceration on the patient's chin area, chipped tooth, and laceration of the lip and fracture of the patient's jaw (multi focal comminuted bilateral fractures with TMJ dislocations) which resulted in surgery and hospitalization from 6/1/13 to 6/7/13.


A review of the facility policy and procedure titled "Restraint and Seclusion" approved by cabinet on 1/14/14 defined "Drugs used as a restraint" to mean the use of medication as a restriction to manage the patient's behavior or to restrict the patient's freedom of movement that is not standard treatment for the patient's medical or psychiatric condition. The use of medication to completely immobilize an individual is considered an inappropriate medical practice, is not an acceptable method of drugs used as a restrain and is prohibited".

The policy further stated on page 10 of 35 that:
1. "All drugs used as a restraint can only be implemented following a written order.
2. The order must specify the duration of the time the patient must be monitored once the medication has been given as determined by the physician based on the anticipated effect of the medication on the patient.
3. Monitoring and observation must include post- medication administration assessment by a registered nurse and shall include the same monitoring requirement as any other method of restraint, as set forth in the policy directive, provided, however, that the monitoring of vital signs shall be done more frequently than with other forms of restraint, in accordance with good clinical practice. Vital signs, when drugs are used as restraints are ordered, must have frequency defined by the ordering physician".

Because the facility has chosen another term to call these orders for "Drugs used as a restraint" as "Drugs used over objection" of the patient, the monitoring component for the use of these IM STAT medications are excluded. This has resulted in staff not performing vital signs as required, not offering alternatives, not using deescalating techniques, not debriefing after the use of the drug, not adjusting the medication regimen as required and exposing the patients to un-toward side effects without monitoring the effects of the drugs on the patients, consequently causing bodily harm to the patient. The patient MR #24 incidence of 6/1/13 is a good example of what can happen when use of these IM STAT drugs is not monitored as restraints.

The facility also failed to analyze the use of STAT IM drugs through the hospital's quality assessment and performance improvement program. Cross refer to A283.

Based on document review and interview, there is no documented evidence that the hospital effectively analyzed all data collected in order to identify systematic problems and develop actions for improvement. This was evident in review of the medication errors reports, mortality review for , restraints reports, incident reports and QAPI (Quality Assurance Performance Improvement) for 8/12-present.


Findings include:

A review of the "Medication Error Review" minutes for 12/19/13-3/20/14 indicated that the hospital documented the number of medication errors, however, there was no evidence that this information was trended, analyzed and a plan developed for improvement.
The minutes did not indicate where these errors occurred, its implication on the patient and whether or not staff in-service was necessary.

Upon interview on 5/8/14 at 3 PM, the Director of Quality Management stated that the Pharmacy Department was responsible for collecting and monitoring medication errors. He acknowledged that the Quality Improvement minutes for the time frame indicated above had no information regarding the medications errors, patients outcome, goal and plan for improvement.

A review of the Hospital's mortality report for 9/8/11-11/8/12 revealed that they are conducting mortality review, however, there is no evidence that this information was trended and analyzed.


A review of hospital documentation revealed that between January and August 2013, the "number of restraints or seclusion" was greater than 72.27, this is an increase from the previous year which was 60.41.
The document offered no justification for the increase and no plan to reduce the number. There is no documented evidence the hospital trended this information or analyzed it. The hospital's documentation did not indicate whether or not this number was acceptable. The documentation did not indicate the types of restraints, and the reason for using restraints. There is no evidence that the hospital analyzed the data to determine whether or not the number of restraints and the types can be reduced.


A review of the"Incidence Review Committee Minutes" for 5/17/13-12/6/13 revealed the hospital documented the number of incidences, but failed to trend and analyze the data for causation and develop plan for improvement. The report did not differentiate whether or not these incidences were Patient or Staff related.
The Committee Minutes indicated an increase in the number of incidence for June and September 2013.
There was no analysis undertaken to assess the possible reasons for the increase in number of incidence. The report had no plan or goal for improvement


Review of logs for patient grievances on 5/7/14 found that the hospital failed to consistently track the date that each grievances were received, and dates the they were completed.

Upon interview on 5/8/14 at 11:20 AM, the Director of Risk Management stated that her Department was responsible for investigating all incidences/allegations. She stated that information from these reports were and analyzed, however they were not documented in reports.

Based on review of hospital documents, policy and procedure, observations and staff interviews there was no evidence that the Hospital adequately investigated incidents/allegations nor did the hospital consistently trend and analyze the data.

In addition, there was no evidence that the Hospital evaluated the information collected to identify opportunities for improvement in patient care. This was evident in 100% (90 of 90) Risk Management Reports reviewed.

Findings include:

During a tour of the Hospital on 5/5/14 at 11:50 AM, it was noted that the hospital posted three contacts for patients to use to file allegations. Telephone numbers were listed for each of the following:
1. Hospital internal grievance telephone number
2. New York State Justice Center
3. Office of Mental Health
A review of the hospital Risk Management Reports does not show the number of incidents received from each source. It was noted that the majority of the patient allegations were reported from the NYS Justice Center.


There was no documented evidence in the Quality Improvement Committee (Extended Cabinet) minutes that this Hospital provided appropriate oversight of the number of incidents/allegations that occurred.
The Quality Improvement minutes for 8/28/12-9/30/13 showed no evidence of review, discussion and analysis of the Risk Managements Reports.

The Risk Management reports from November 2012 to present revealed allegations of:
1. Psychological abuse
2. Sexual abuse
3. Physical abuse
4. Neglect
5. Medication error
6. Assault
7. Attempt assaults



A review of a hospital document titled "Summary By Ward Program." dated 8/01/12-8/31/13 revealed a review of incidents by Ward. Of the 17 Wards reviewed, #31 had 59 incidents, which was significantly higher than the others. The Summary showed that 12 Wards had less than 10 incidents for the same period. There was no evidence that the hospital analyzed whether or not the type of patient on a particular ward contributed to the number of incidents.
The hospital did not indicate whether or not the numbers indicated above included patient restraints or "take downs."

The hospital did not conduct a root cause analysis to determine the reason Ward #31 had that many incidents. They did not evaluate whether or not this was a trend for that particular Ward nor was a plan developed to reduce the number of incidents. There was no evidence of any discussion regarding staff in service or re-training.

A review of incidents titled: "Summary By Shift" dated 8/1/12-8/31/13 revealed that during this period there were 107 incidents for the evening, 74 for day, and 10 for night.
There was no evidence that the hospital developed a benchmark to determine an acceptable numbers of incidents.


On 5/8/14 at 11:20 AM, The Director of Risk Management (Staff #5) was interviewed regarding the Hospital's investigation process for incidents. She stated that: "Allegations are a category of an incident."
She stated that she was responsible for operations of The Risk Management Department, her staff collects and investigates all incidents/allegations.
All allegations/ incidents are reported to the "Extended Cabinet" This Cabinet functions as the hospital Quality Improvement Committee.
The (IRC) Incident Review Committee reviews all incidents/allegations which are received from three different sources.
1. Hospital internal grievance line
2. The Justice center
3. The Office of Mental health.
The allegations/incident may be lodged verbally or in writing.
Allegations/incidents consist of sexual abuse, physical and psychological abuse, neglect, medication errors and patient falls.


Upon interview on 5/8/14 at 3 PM, the Director of Quality Management (Staff#4) was asked about the process for reporting to The Quality Improvement Committee.
He stated that each Department attends the monthly Quality Improvement meetings and reports their findings.
When told that copies of QA minutes provided to State Surveyor did not reflect this information, he stated he would provide the information later to the State Surveyor. This information was not provided through the date of the end of the Survey (5/12/14).

The hospitals' policy and procedure subject: "Reporting, Documentation and Internal Notification of Incidents" indicated that all incidents are reported to the Director of Quality Management.
The hospital's "Performance Improvement Plan" states that; "The cabinet reviews key management and performance improvements measures regularly, including data from high risk processes such as staffing, restraints and seclusion and risk management concerns."
The Hospital did not adhere to their own policy and procedure.


A review of the "Risk Management" Reports revealed that the Hospital failed to adequately investigate incidents/allegations and analyze the data collected. Specific reference is made to the fact that the hospital failed to evaluate data of patient injury or harm contained in the incidents/allegation reports.


For example:

#1. Medical Record #12867- A Risk Management Report dated 12/10/12 described an incident that occurred on 11/12/12.
The patient alleged that he was assaulted and beaten by two staff members in the day room.
The patient's mother also called the hospital and "reported allegation of physical abuse to her son."
The investigative summary revealed that the patient was physically restrained by at least two (SHTA) Security Hospital Treatment Assistants using a wrist belt restraint. In addition the report stated that the patient was given (IM) intra-muscular medication "to help him get control of himself."
A photograph of the patient showed that the patient had a "subconjunctival hemorrhage" of the left eye."
In reference to the patient's injury the reports states; "The probable cause was patient action during the medication administration and staff action to stop patient from acting out."

The report failed to determine whether or not excessive force was used in placing the patient in physical and chemical restraint.
The hospital investigation did not evaluate the restraint and "take down" process to determine whether or not the staff followed the appropriate protocol. It did not evaluate whether or not there is need for staff re-training, to prevent patient injury in the future.



#2. Medical Record #12776- A Risk Management Report described an incident that took place on 6/1/13. It describes a patient "fall with moderate injury."
The investigative report stated that the patient attempted to elope by climbing over the hospital's fence on 6/1/13 at 8:15 AM. The patient did not respond to "redirection" and was "placed in manual."
The report indicated that the patient received medication over objection at 8:43 AM and 8:45 AM. It is not clear whether or not these medications were administered once or twice. The report indicated that the patient was given "Olanzapine" 10 mg IM. The report also indicated that this drug causes orthostatic hypotension. The report indicated that the patient fell, at approximately 9 AM on the same day, while ambulating in the hallway causing injury to his chin. It also indicated that the patient fell a second time, however, there was no documentation of the exact time this fall occurred.
The patient was taken to a local hospital where an x-ray "indicated a multi-focal comminuted mandibular fracture bilaterally, with bilateral TMJ dislocations." The patient was transferred from the local hospital to another for "surgical repair."

The report did not indicate whether or not this patient was monitored closely after the administration of the IM medication for severe agitation. In addition the report did not indicate whether or not the patient should have been given assistance with ambulation, or allowed to rest.



#3. Medical Record #7584-A Risk Management Report dated 9/18/13 revealed an incident that took place on 8/25/13. The patient alleged neglect, stating that on three occasions staff failed to provide medication for pain. The patient also stated that a staff slammed a door in his face after his repeated request for pain medication. The report revealed that the patient has a history of Colon cancer and "8 days post-op. The patient is on narcotic for pain."

The report indicated that the patient requested medication at 1 AM, 2 AM, and 6 AM. The patient received the medication at 7:15 AM.
The report indicated that the Registered Nurse was interviewed. She stated that she made rounds during the night and that she was never informed that the patient requested pain medication.
The (SHTA) Security Hospital Treatment Assistant denied having any request from this patient for medication.

The hospital investigation was inconclusive. It did not state whether or not the patient was given considerate and respectful care when he requested medication for pain on the night shift.
The report failed to evaluate the frequency staff should conduct nightly rounds and whether or not this was met. There was no evidence that the staff evaluated the needs of this patient during nightly rounds taking into consideration the patient's medical condition. There was no evidence that the RN conducted an assessment of the patient's pain levels and comfort.
The report did not state whether or not the nightly rounds consisted of only visual inspection.


#4. Medical Record #11818-A Risk Management Report dated 12/30/13 described an allegation that took place on 8/9/13. The patient alleged "that four staff beat her up."
The Investigative Reports revealed that on the above mentioned date, "the patient became agitated from something that occurred earlier in the day."
The patient became physically aggressive, there was a struggle on the stairs and an attempt was made to restrain the patient. The patient was accused of attacking staff and was "maintained on 1:1 level of supervision for assault.
The report indicated that the patient "sustained some bruising around, and a subconjunctival hematoma to the left eye."
The Security Hospital Treatment Assistant (SHTA) feels the patient injury "may have been caused by her actions."

Based on review of Hospital documents, Quality Improvement and Governing Body minutes for 1/29/12-9/25/13 and staff interview the Hospital does not have evidence that they conducted any Performance Improvement Projects.


Findings include:

A review of hospital documents including Risk Management Reports, "Extended Cabinet", and "Executive Cabinet" (Quality Improvement and Governing Body) minutes revealed that the hospital had not conducted any Performance Improvement Projects.


Upon interview on 5/6/14, The Director of Quality Management (Staff#4) was asked whether or not the Hospital had any Performance Improvement Projects(s), he replied that he "was not sure." Staff #4 did not provide any documents to the State Surveyor regarding this subject.

Based on review of Hospital documents (Quality Improvement Programs) "Extended Cabinets" and "Executive Cabinet" meetings and staff interview it was determined that the Hospital failed to ensure that the Quality Improvement Program includes all Departments and Services.

Findings include:
A review of the Hospital Committee minutes for 2/13-present, revealed no documented evidence that: The Department of Social Services and Dietary Services participated in the Quality Improvement Program. These minutes had no information regarding the quality of the services rendered.
The Hospital Committee meetings revealed that the Director of Social Services attended some meetings, however, there is no evidence that the hospital conducted a review of the Service rendered to determine Departmental compliance with set standards to identify possible problem areas and implement changes if necessary.
Upon interview on 5/6/14, The Director of Quality Management (Staff#4) confirmed the findings and stated that The Director of Social Services attended the Quality Improvement meetings. There was no documentation that Staff #8 submitted any report to the Quality Improvement.

Based on medical record reviews, document reviews and staff interviews, it was determined the nursing staff failed to administer medications according to a physician's order. This was found for 1 of 50 medical records reviewed. This was found for patient #19.

Findings include:

Patient #19 was given another patient's medication. A review of patient #19's medical record revealed this is a seventy year old patient who was admitted to the facility with a diagnosis of Schizophrenia. The patient's previous medical history included Coronary Artery Disease, Hypertension and Diabetes Mellitus. Throughout the patient's hospitalization he was awake, alert, ambulatory and independent with all activities of daily living. On July 7, 2013 the patient was erroneously given Clozapine 750 mg, Seroquel 600 mg, Cogentin 1 mg, and Lipitor 20 mg all of which were given orally at 8:15 PM.

A review of the medical record revealed the patient was found at 11:10 PM that night unresponsive with a pulse rate of 108, respirations of 18 breaths per minute, B/P of 120/82 and with the oxygen saturation at 79% on room air. The patient was subsequently intubated by EMS and transferred to an intensive care unit at an acute care facility.

The above findings were confirmed during an interview with the Director of Risk Management on May 8, 2014 at approximately 2:25 PM.

Based on review of records, observation and staff interview, the facility's food and dietetic services failed to a) meet the nutritional needs of the patients, b) ensure that proper safety practices for handling food are maintained, and c) be integrated with the hospital-wide Quality Assurance Performance Improvement (QAPI) program.
Findings include:
(a) On 5/8/14 at approximately 11:40 AM the temperature of the walk-in freezer (Freezer # HMH005-01FZW01) was noted to be at 28 degrees Fahrenheit outside of the acceptable range. To maintain food safely freezer temperature should be held at 0 degree Fahrenheit or lower. Review of the freezer logs for February, March and April 2014 noted that the temperatures taken daily were recorded outside the acceptable range. Temperatures were noted to range from 11 degrees Fahrenheit to 31 degrees Fahrenheit.

On 5/9/14 the kitchen was visited by the sanitarian who noted the freezer temperature to be 22 degree Fahrenheit which was outside of the acceptable range. The facility discarded all food items from the freezer and took appropriate action to address the freezer temperature problem. Cross refer to A620

(b) On interview Staff #9, the Nutrition Service Administrator, and Staff # 10, a cook, did not recognize that the freezer temperatures were out of the acceptable temperature parameter for storing food safely. This was confirmed by reviewing a sample of 3 months temperature logs for freezer # HMH005-01FZW01. These temperatures were recorded out of range for 3 months yet no one recognized and took corrective action. Cross refer to A620

(c) the Food and Nutrition Department did not ensure that physician prescribed diets met the nutritional needs of patients. Cross Refer to A628

(d) The Food and dietetic services QAPI program was requested from Staff #9, the Nutrition Service Administrator, on 5/8/14. It was noted that the department does not have a QAPI program that analyze and track measurable indicators to monitor the effectiveness of the food and dietetic services and to identify opportunities for improvement. Cross refer to A620

Based on review of records, observation and staff interview the food service director did not take responsibility for the daily management of the service to ensure (a) proper safety practices for handling food are maintained (b) training programs for dietary staff. (c) Menus meet the nutritional needs of patients and (d) service Quality Assurance Performance Improvement (QAPI) program.

Findings include:

During a tour of the main kitchen on 5/8/14, the following observations were made.
(a) On 5/8/14 at approximately 11:40 AM the temperature of the walk-in freezer (Freezer # HMH005-01FZW01) was noted to be at 28 degrees Fahrenheit outside of the acceptable range. To maintain food safely freezer temperature should be held at 0 degree Fahrenheit or lower. Review of the freezer logs for February, March and April 2014 noted that the temperatures taken daily were recorded outside the acceptable range. Temperatures were noted to range from 11 degrees Fahrenheit to 31 degrees Fahrenheit.

On 5/9/14 the kitchen was visited by the sanitarian who noted the freezer temperature to be 22 degree Fahrenheit which was outside of the acceptable range. The facility discarded all food items from the freezer and took appropriate action to address the freezer temperature problem.

(b) On interview Staff #9, the Nutrition Service Administrator, and Staff # 10, a cook, did not recognize that the freezer temperatures were out of the acceptable temperature parameter for storing food safely. This was confirmed by reviewing a sample of 3 months temperature logs for freezer # HMH005-01FZW01. These temperatures were recorded out of range for 3 months yet no one recognized and took corrective action.

(c) Cross reference Tag 0628.

(d) The Food and dietetic services QAPI program was requested from Staff #9, the Nutrition Service Administrator, on 5/8/14. It was noted that the department does not have a QAPI program that analyze and track measurable indicators to monitor the effectiveness of the food and dietetic services and to identify opportunities for improvement.

These findings were confirmed with Staff #9, the Nutrition Service Administrator, when the observations were identified.

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Based on staff interview, review of menus, it was determined that the Food and Nutrition
Department did not ensure that physician prescribed diets met the nutritional needs of patients.

Findings include:

The hospital menus and nutrient analysis were requested from Staff # 9, the Nutrition Service Administrator on 5/8/14. A review of the hospital four week cycle menus noted that the diets were not identified. The menus did not indicate whether the diet was regular, diabetic, low sodium, etc. There was no nutrient analysis calculated for these diets. These diets were not analyzed to assess compliance to the national standard titled "Recommended Daily Intakes".

Therefore the nutrition adequacy and dietary restrictions on the menu is unknown. Due to lack of nutrient analysis calculated for these menus, there is no way to verify that the diet orders are provided as prescribed by the practitioner(s) responsible for the care of the patient.

Based on observation, staff interview and records review, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.

Findings are:

During tours of the hospital on 5/6, 5/8 and 5/9/2014 the following findings were identified in the presence of the facility staff who were accompanying the state surveyor throughout the time of the survey:

1-The hospital is licensed for 264 beds and during the survey they had 280 patients, 16 patients in excess of the licensed beds. Also, there were some rooms that was used for (4) patient beds and were very crowded. Examples included but were not limited to: room 235 and 236 of building #2.

2- On 5/6/2014, at approximately 11:45 am, during a tour of building #2 of the hospital, which includes patient bedrooms and patient care areas, the following were identified and brought to the attention of the Director of Facilities Administration and the Chief of the Security Hospital Treatment Association who acknowledged the findings.

Building #2 - 1st floor:
All of the rooms including the patients' bed rooms were observed to have regular door handles which is potential for looping.
All of the rooms, including the patients' bed rooms, were observed to have a protruded strike plate that extended beyond the door frame which is a potential for harm to self or others.

Room 132
1- The activity room for high acuity patient which according to the staff on the floor is considered a violent patient, it was noted that the room had (3) three chairs which were light in weight and can be used as weapon or to harm others.
2- The wiring of the TV and Wii game console were found to be long, exposed and not secured and is potential for looping.
3- There was a desk in the room that was noted to be broken and missing its middle drawer.
Room 133:

1- The TV Video game room: the cable of the TV and Video was observed to be long and not secured properly and could be used for looping.
2- There was one plastic chair in the room that could be used as a weapon or for others' harm.
3- The Door's strike plate at the latch pocket was noted to be protruding beyond the door frame which is a potential for harm to self or others.
4- The door handle of the room's door was the regular type, rather than the safety type that is required for the psychiatric hospital. The regular type handle can be used for looping.
5- There was a phone that was mounted to the wall next to room 135 and it had a very long wire that can be used for looping or chocking others.
Room 137 and room 137 A were observed to have plastic chairs that can be used as weapons.
The Quiet Room: has one bed that had a total of 10 restrain hooks, 5 on each side of the bed. This is a potential looping hazard.
Also, there were two mattresses on the floor and two big plastic bags with soft material on them and they were referred to as bean bags and the staff said that they are used by patient to rest on them.
It should be noted that the presence of the bed, two mattresses and two bean bags is a concern since this room is used only for one patient at a time. The use of this room to house or store all the above mentioned furniture will delay its availability once it is needed.
Additionally, the quiet room like all the other rooms on the floor, had a strike plate that protruded beyond the door frame which is safety hazard, and also had a regular door handle that is a potential looping hazard.
Grab Bars: All the grab bars on the corridors were mounted at a height of approximately 3 feet from the floor and with a gap between the bars and the walls that is open and is potential of looping hazard.
Restroom 156: The grab bars on the patient bathroom have space between the wall and the bars witch is a potential of looping hazard.
The laundry Room:
1- There were (4) four cabinets that were mounted at > 36 inches from the floor and they had metal handles and are potential of looping hazard.
2-The wirings and hoses of the washing machines were exposed and are potential of looping hazard.
3-The Soap dispenser was mounted at > 5 feet from the floor and had a pad lock which is a looping hazard.
Infirmary Ward - 1st floor of Building #2:
The SHTA work station:
1-This work station was observed to have phone, computer, monitor, printer, two light weight chairs, and 2 fans with exposed wiring on the top of the work station. All the above items a potential for harm to self or others as well as a looping hazard.
2- There was a cabinet that was mounted to the wall at 4 feet from the floor which is potential of looping hazard.
Room 113, 109, and 106:-
1-The patient cupboard in this patient bedroom had an opening in the middle of its door at approximately > 3 feet from the floor which is a looping hazard.
2- There was at least one 10 gallon plastic container in each bed room of the patient bed rooms which is risk of being used as a weapon.
3-The door hinges of this room and all other bed rooms were of the regular type and not the continuous type. The regular type can be used for looping.
4- The strike plates of the doors had sharp metal that protruded beyond the door frames which are safety hazard for self and others.
Restroom 107:
All the fixtures in this room are of the regular type that imposed looping hazards; examples included, but were not limited to:
a- The water faucets and the water control knobs are of the regular type rather than the safety type, and are a potential looping hazard.
b- The tissue dispensers and waste dispenser are metal, square shaped boxes that were mounted to the wall at approximately 4 feet from the floor and impose looping risk.
c- The door hinges of the shower rooms are of the regular type rather than the piano hinge type (continuous from the top to the bottom of the door), and are a potential looping risk.
d- The toilet flushing mechanism is of the regular type and its pipes are exposed, both are a potential looping hazard.
e- There was a pad lock on the toilet tissue dispenser which is a looping hazard.
f- The locking mechanism of the door of the shower is a potential of looping hazard.

Shower Room 105:
a- The shower heads of the three (3) showers are looping hazards.
b- The water control knobs are looping hazard.
c- There was a 4 gallon bottle of soap that had about one liter of soap and was found unattended or secured in the shower area.
Room 103- patient bedroom:
a- The patient cupboard was found to have a sliding lock on the inside surface, a potential looping hazard.
b- The piano hinges of the cupboard did not extend to the top leaving a space at the top portion that is a potential looping hazard.
c- There was a plastic container of 10 gallon capacity that can be used as weapon and is a potential safety risk.
d- One leaf of the door was found to be broken and its hinges were coming off.

Exit signs with looping hazards:
The exit signs were observed to be mounted to the ceiling or walls throughout the hospital with gaps between them and the ceilings or walls which are potential for looping hazard.
Phones with looping hazards:
Phones were observed mounted to the walls with very long cords that are potential for looping hazard throughout the hospital in the three buildings that housed patient areas (Building 2, 3 and 4) i.e. patient day rooms, treatment areas and corridors of patient dorms.
The Emergency Supply Box:
A big metal box that is mounted to the walls in each patient unit at >4 feet from the floor and is a potential for looping hazard. This finding was observed in all the patient care areas of the three buildings that house patients including building #2, #3 and # 4.
Water Fountains as looping Hazards:
Water fountains were observed in the day rooms, and other patient care areas throughout the hospital in the three buildings and in all the floors where patients are housed, including buildings #2, #3, and #4.
The water fountains are mounted at >3 feet from the floor and are potential for looping hazard.

On 5/6/2014 at 2:15 PM, during a tour of the infirmary wing of building #2 on the 1st floor the followings were identified in the presence of the Chief SSO and the Main Supervisor 11 who acknowledged the findings:
Day Room:
The TV electric and cable wirings were exposed and are potential for looping hazard.
Two water fountains were noted as being mounted to the floor with height of approximately >3 feet from the floor creating a potential looping hazard.
There were (3) three chairs in the treatment room that can be used as weapons and are a potential for harm to others.
There were 2 phones with very long cords that are a potential looping hazard.
There were 18 patient property lockers that had metal plates with holes for padlocks that are a potential looping hazard.

Patient bathrooms:
1- There were pad locks on the toilet tissue dispensers in the patient bathrooms of the day room which are looping hazard.
2- The tissue dispensers and waste dispenser are metal, square shaped boxes that were mounted to the wall at approximately 4 feet from the floor and impose looping risk.
3- The door hinges of the shower rooms are of the regular type rather than the piano hinge type (continuous from the top to the bottom of the door), that are a potential looping risk.
4- The toilet flushing mechanism is from the regular type and its pipes are exposed and are looping hazard.
5- There was pad lock on the toilet tissue dispenser which is a looping hazard.
6- The water faucets and the water control knobs are of the regular type and they are a potential looping hazard.

During a tour of the 2nd floor of building #2 which includes ward #22 that has rooms 231 through 242, the following was identified:
1- The Emergency medication box which is a metal square box with a pad lock was mounted to the wall at a level 4-4 feet from the floor and is a potential for looping hazard.
2- The grab bars of the corridor are mounted to the wall with gaps between them and the wall which is potential of lopping hazard.
3- The cabinets near to the entry door, the cabinet handles, and the pad locks on them are looping hazards.
4- There was a desk, a light weight chair, and a phone with a very long cord on top of the desk near the entry door of the unit. All these items pose safety and looping risks.
5- There was a motion sensor mounted next to a wall clock at >5 feet from the floor which is potential of looping hazard.
6- There was a mail box mounted to the wall on the corridor and is a potential of looping hazard.

Patient rooms- 231-242:
a- Hinges of the cupboards are not continuous to the top and had gaps that are potential of looping hazard.
b- The locking mechanisms on some of the cupboards were missing which left a hole on the center of the cupboards, which are potential looping hazard.
c- There were plastic containers with capacity of 10 gallons in the patient rooms which can be used as weapons and are a safety risk.
d- The doors of the patient rooms have regular hinges which are potential of looping hazard.
e- The door handles of patient rooms are a type that are a potential hazard.
f- The patients beds are not bolted to the floor.

Patient shower room 241:
a- The three shower areas were found to have regular shower heads that are potential of looping hazards.
b- The towel holders are mounted to the wall approximately 5 feet from the floor and are potential for looping hazard.
c- The soap dispensers are box shaped that were mounted to the wall at least (4) feet from the floor and are a potential looping hazard.
d- The door hinges of the shower areas and the door knobs are potential for looping hazards.]
e- The fire alarm strobes in the shower room as well as in the corridors were metal and box shaped that were mounted to the wall at approximately 6 feet for the floor, which is a potential looping hazard.
f- The door hinges of the shower room were from the regular type which is potential for looping hazard.

Restroom #240:
a- The water control knobs were of the regular type and are a potential looping hazard.
b- The water faucets were of the regular type and are a potential looping hazard.
c- The tissue dispenser boxes which are a metal box that is mounted to the wall at approximately 4 feet from the floor is a potential looping risk.
d- The tissue waste box is mounted to the wall at approximately 3 feet from the floor and can be used for looping.
e- The toilet flushing mechanism and its pipes were not covered and is potential for looping hazard.
f- The toilet tissue dispensers had padlock and is potential for looping hazard.
g- The doors of the bathrooms had regular hinges which is potential for looping hazard.
h- The urinals were mounted to the wall at 3-5 feet from the floor and are a rectangular box that are a potential looping risk.

On the morning of 5/8/2014, during a tour of Building #3 - 3rd floor that houses wards 35 and 36 and has 38 patient beds, the following looping hazards were identified:
1- Day room area:
a- The fire alarm pull stations were metal squares that are mounted to the wall at approximately 3 feet from the floor and are a potential looping hazard.
b- The fire alarm horn was a metal square that are mounted to the wall at approximately > 6 feet from the floor and is a potential looping hazard.
c- There were wall phones mounted to the wall with very long wires and cord that were not secured and are a potential looping hazard.
d- There was desk near to the unit's door that has a regular handle and is missing one of its drawers, both potential looping hazards.
e- There was a mirror mounted to the wall at >5 feet from the floor next to the staff bathroom that had gap between the mirror and the wall of approximately 6 inches, that is a potential looping hazard.
f- All the door handles of the doors including the doors of the bathrooms were of the regular type, that is a potential looping hazard.
g- The medical document secure box is a metal square box that was mounted to the wall at approximately 5 feet from the floor and had a padlock, both are a potential looping hazard.
h- The doors of the staff bathrooms were observed to have a sign that states "occupied or not occupied" that was fixed to the outside surface of the door with a chain that was about one (1) foot long, that is a potential looping hazard.
i- There were two (2) TVs that had electric and cable wirings that were exposed and not secured, which is a potential looping hazard.
j- The end pieces and the knobs of the heat pipes were exposed and are a potential looping hazard.
k- The emergency medical supply box is a metal square box that was mounted to the wall at 3-4 feet from the floor and had a metal handle and a padlock, which is a potential looping hazard.
l- There were at least three phones mounted to the walls at least 4 feet from the floor with very long wires and cords, which are a potential looping hazard.
m- There was an unattended and open work station with many loose items that could be used to harm oneself or others, as well as many looping hazards.

2- Patient laundry Room:
a- The soap dispenser was observed to have a padlock and it was mounted at 4-5 feet from the floor, which is a potential looping hazard.
b- The exhaust pipes had gaps between them and the walls and are a potential looping hazard.
c- The hoses of the washing machines were exposed and not secured which is a potential looping hazard.
d- The door handles of the room are of the regular type and are a potential looping hazard.

3- Quiet Room # 13:
a- The door handles of the quiet room were of the regular type, which is a potential looping hazard.
b- The door strike plate of the room protruded beyond the door frame which presented a safety risk for the psychiatric patients.
c- There was a wooden chair that can be used as a weapon, which is a potential safety risk.
d- The Plexiglas cover of the air conditioner unit, which was mounted to the wall at 3-4 feet from the floor, was found to have sharp edges which presented a safety risk for the psychiatric patients.

4- Patient Bathroom I and Bathroom II and other bathrooms had the following looping hazards:
a- The electric switch which is a metal box with elevated edges on its cover was mounted to the wall at about 5 feet from the floor and was connected to an electric feed via tubing that has a gap between it and the wall, all of which presented looping hazards.
b- The towel hangers were mounted at about 5 feet from the floor, which presented a looping risk hazard.
c- The metal box of the tissue dispenser and waste container were mounted at approximately 4 feet from the floor, potential looping hazards.
d- The water faucets are of the regular type and present a looping risk.
e- The water control knobs were of the regular type and present a looping risk.
f- The door hinges of the toilet have a space between them, a potential looping hazard.

5- Dorms of all the buildings that house patient bed rooms, examples included, but were not limited to, wards 36, 35, 34, 33, 32 and 31. Every floor on each building has 2 wards with an average of 38 patient beds. The patient bedrooms had the following looping hazards:
Looping hazard within the patient rooms:
a- Hinges of the cupboards are not continuous from the top to the bottom of the door and had gaps that presented potential looping hazard.
b- The locking mechanisms on some of the cupboards were missing leaving holes in the center of the cupboards which are potential looping hazards.
c- There were plastic containers with capacity of 10 gallons in the patient rooms which can be used as weapons and are a safety risk.
d- The doors of the patient rooms have regular hinges which are a potential looping hazard.
e- The door handles of patient bed rooms are of the regular type and present looping hazards.
f- The patient beds are not bolted to the floor and can be used for looping.
g- Many patient beds had holes on their wooden board, which can be used for looping.
h- The light fixtures in some patients' rooms were found to have gaps between them and the ceilings which present looping hazards.
Looping hazard in Corridors:
a- The fire alarm manual pull stations by the stairs and exits were found to be square metal boxes that are mounted to the walls more than 4 feet from the floor and present a looping hazard.
b- The fire alarm strobes were found to be square metal boxes that are mounted to the walls more than 4 feet from the floor and present a looping hazard.
c- The exit signs were mounted to the ceiling and or the walls leaving gaps between them and the walls or ceilings which present looping hazards.

Looping hazards in the Occupational Therapy (OT) and Recreation areas and in the basements of patient buildings 2, 3, and 4:
a- The sprinkler pipes were not secured, running from one end to the other end in those areas at a height of approximately 8 feet from the floor, which presented a looping hazard.
b- The steam lines and heat pipes were not secured, running from one end to the other end in those areas at a height of approximately 8 feet from the floor, which presented a looping hazard.
c- Electric conduit was not secured, running from one end to the other end in those areas at a height of approximately 8 feet from the floor, which presented a looping hazard.
d- The cabinets and their handles present a looping hazard.
e- Light weight chairs in these areas presented a safety risks.
f- There were computers on the counters and desks with wiring that was not secured which presented a looping risk.
g- There were phones with their long cords and wirings that were not secured and present a looping risk.

On the morning of 5/9/2014, during a tour of the medical clinic in the basement of building #5, the followings items were identified in the presence of the SHTA Supervisor and the clinic nurse manager:
1- The wooden chairs of the waiting area are light weight and present a safety risk.
2- The TV was mounted at > 6 feet from the floor and its cords and wirings were exposed and presented a looping risk.
3- The sprinkler heads in this clinic were of the regular type and presented a looping risk.
4- The patient bathroom had regular door handles which present a looping hazard.
5- The water faucets and water control knobs were of the regular type and presented a looping hazard.
6- The toilet flushing mechanism was not secured and presented looping hazard.
7- The tissue dispenser and the toilet paper dispenser presented a looping hazard.

On the morning of 5/9/2014, during a tour of the Dental Clinic the followings items were identified in the presence of the nurse manager and the SHTA Supervisor:
a- The soiled utility room that is also used for the sterilization of the dental instruments was found to have a positive air flow, instead of the required negative air flow for this type of room per AIA Guidelines.
b- There was no hand wash sink provided in this room for the staff to wash their hands as required per AIA Guidelines.
c- The window of the patient bathroom was found to be stuffed with towels. The staff stated that this window does not close properly so they place the towels to prevent the flow of air.
d- No patient bathroom was provided in the dental clinic.
e- The electric outlets in this clinic were not tamper resistant as per AIA guidelines.

Based on observations and staff interviews, it was determined that the facility failed to meet the applicable provisions of the Life Safety Code, NFPA 101, 2000 Edition.

Findings include:

During the survey of the facility from 05/6/2014 - 05/9/2014, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire / Life Safety Code K-Tags:

K 18 (Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors are provided with a means suitable for keeping the door closed. 19.3.6.3)

K 56 (The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully supervised. There is a reliable, adequate water supply for the system. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system. 19.3.5)


K 70 (Portable space heating devices are prohibited in all health care occupancies, except in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees F. or 100 degrees C. 19.7.8)

K 135 (Flammable and combustible liquids are used from and stored in approved containers in accordance with NFPA 30, Flammable and Combustible Liquids Code)

Based on observations and staff interviews, it was determined the infection control officer was not effective in the role to ensure that patients received care in a clean environment to minimize the spread of infections.

Findings include:

The facility did not maintain a clean environment in various areas at the facility. The following findings were identified on May 5, 2014 through May 6, 2014.

There was no ceiling in the nursing central supply room as the HVAC system, various pipes and roof were visible as observed on May 6, 2014 at 12:25 PM.

The floor in the property room was in need of cleaning and repair at 12:30 PM on May 6, 2014.

The code cart on the Infirmary unit had an accumulation of dust at 11:50 AM on May 5, 2014.

At 12:20 PM on May 5, 2014 the clean linen closet on the infirmary unit was noted to have an accumulation of dust.

Two of 2 stairs were noted to have an accumulation of dust and cobwebs in the gym at 3:05 PM on May 6, 2014.

Storage rooms in the treatment building were noted to be dusty and were noted to have accumulations of cobwebs at 3:23 PM on May 6, 2014.

There was a large stain on a ceiling tile in the Therapy Clinical Program group room at 3:28 PM on May 6, 2014.

There were cobwebs on the floor in the locked emergency crash cart room in the treatment building on May 6, 2014 at 3:26 PM.

The stairs to the dining hall had an accumulation of dirt at 2:55 PM on May 6, 2014.

The above findings were witnessed by the Clinical Director at the above noted times.





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On 5/6/14 the following patient units were toured witnessed by Staff #8, the Director of Social Service and Staff #18 the RN Director:
Units 45/46, 43/44, 41/42, 35/36, 33/34. Noted in the patients' lounges on these units were a total of 35 chairs and sofas with torn and worn upholstery that prevents the through cleanliness of the chairs and sofas. On interview with Staff #17, the Infection Prevention Nurse, she stated on 5/6/14 at 3:25 PM that she was never invited to the rounds conducted by the environmental staff, but she monitors hand washing events within the patient and staff populations.

1 - Based on observation, staff interview and review of records during the Federal Survey
(1) the food service director did not take responsibility for the daily management of the service to ensure that (a) proper safety practices for handling food are maintained, (b) training programs for dietary staff are readily available, and (c) a Quality Assurance Performance Improvement (QAPI) program in place and maintained.
(2) the infection control officer was not effective in the role to ensure that patients received care in a clean environment to minimize the spread of infections.


Findings include:

1) During a tour of the main kitchen on 5/9/14, the following observations were made:
(a) On 5/9/14 at approximately 12:30 PM the temperature of the walk-in freezer (Freezer # HMH005-01FZW01) was noted to be at 22 degrees Fahrenheit outside of the acceptable range. To maintain food safely freezer temperature should be held at 0 degree Fahrenheit or lower. Review of the freezer logs for February, March and April 2014 noted that the temperatures taken daily were recorded outside the acceptable range. Temperatures were noted to range from 11 degrees Fahrenheit to 31 degrees Fahrenheit.
The food temperature was taken by the staff member for some items and was found 22 F.
Interview with, the Nutrition Service Administrator II, revealed that the staff member did not know that the freezer temperature was outside the acceptable range of temperature for the freezer.
The surveyor asked about the facility's Hazard Analysis Critical Control Point (HACCP) plan or policy that addresses the Food Safety Standards and requirements and guides the staff on proper handling, storing, cooking, and heating of food, and the actions to be taken if the temperature of food is found to be outside the acceptable / safe range. The facility did not have a HACCP plan or policy.
It was explained to the facility's Nutrition Service Administrator II and the Director of Administration the magnitude of the problem and the surveyor asked them to provide an acceptable plan that corrects the issue.
The facility voluntarily decided to discard all food items from the freezer and took appropriate action to address the freezer temperature problem.

(b) On interview Staff #9, the Nutrition Service Administrator and Staff # 10, a cook, did not recognize that the freezer temperatures were out of the acceptable temperature parameter for storing food safely. This was confirmed by reviewing a sample of 3 months temperature logs for freezer # HMH005-01FZW01. These temperatures were recorded out of range for 3 months yet no one recognized and took corrective action.
(c) The Food and dietetic services QAPI program was requested from Staff #9, the Nutrition Service Administrator, on 5/8/14. It was noted that the department does not have a QAPI program to analyze and track measurable indicators to monitor the effectiveness of the food and dietetic services and to identify opportunities for improvement.


These above findings were confirmed with Staff #9, the Nutrition Service Administrator when the observations were identified.

2) On the morning of 5/9/2014, during a tour of the Dental Clinic the following items were identified in the presence of the nurse manager and the SHTA (Security Hospital Treatment Assistant) Supervisor:
a- The soiled utility room that also is used for the sterilization of the dental instrument was found to have a positive air flow instead of the required negative air flow for this type of room per AIA (American Institute of Architects) Guidelines for Design and Construction of Hospital and Health Care Facilities Edition 1996-97 .

b- There was no hand wash sink provided in this room for the staff to wash their hands as required per AIA Guidelines for Design and Construction of Hospital and Health Care Facilities Edition 1996-97 (American Institute of Architects.
c- The window of the patient bathroom was found to be stuffed with towels. The staff stated that they put the towels to prevent the drafts as this window doesn't close properly.
d- No patient bathroom was provided in the dental clinic.




26259


2 - Based on medical records reviews and staff interviews, the facility failed to ensure that the system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel was followed. This is evident in 2 of 50 medical records reviewed. MR #10 and MR #14.

Findings include:

1. The patient MR #10 was admitted on 10/21/13. According to facility document titled "Immunization Screening Record" tuberculosis screening with Mantoux TB skin testing was not done until 10/25/13.
2. Similarly, the patient MR #14 was admitted on 12/31/13. The medical record showed that tuberculosis screening with Mantoux TB skin testing was not done until 3/13/14.
A review of the facility policy and procedure titled "Infection Control & Prevention Protocol" posted 2/21/05 states in the policy statement; "Patients receive TB skin testing (Mantoux) on admission and yearly thereafter, if there is no history of a positive skin test.
During interview with Staff #17, the Infection Prevention RN, stated on 5/7/14 at 11:00 AM, that the facility ensures that the policy is followed but these identified cases were missed.
The patients' records did not contain information on why the Mantoux TB tests for the patients were delayed and not administered on admission as per facility policy and what measures were taken to prevent the spread of Tuberculosis in this highly susceptible population.

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

l. Develop and document comprehensive multidisciplinary treatment plans based on the individualized needs for five (5) of nine (9) active sample Patients (A2, A3, A6, A7, and A9). The facility failed to modify and/or update the treatment goals and/or interventions even though the patients had completed the identified goals. (A6) had failed over long periods of time to accomplish the identified goals (A7) or were unable to accomplish the identified goals because of dementia (A2, A3 and A9). Failure to individualize the treatment plan of patients can prevent patients from progressing in their treatment and prevent staff from knowing how to address each patient's specific problems which can result in unmet needs and potentially longer lengths of hospitalization. (Refer to B118)

ll. Provide Comprehensive Treatment Plans (CTPs) that included long-term and short-term goals stated in measureable, patient focused terms for seven (7) of nine (9) active sample patients (A1, A2, A3, A4, A5, A6, and A7). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of staff interventions based on changes in patient behaviors. (Refer to B121)

lll. Provide active treatment to three (3) of nine (9) active sample patients (A2, A3, and A9). These patients carried a diagnosis of dementia and were being treated in the infirmary (Ward 25). Although providing psychiatric management, medical care, skilled nursing, and a variety of support services, the hospital failed to provide 24-hour specialized psychiatric intervention that could not be provided outside the psychiatric hospital setting. (Refer to B125)




F

Based on document review, record review and interview the facility failed to develop and document comprehensive multidisciplinary treatment plans based on the individualized needs of patients. Specifically the facility failed to modify and/or update the treatment goals and/or interventions for five (5) of nine (9) sample patients during the treatment team review process of patients (A2, A3, A6, A7, and A9). The treatment team instead continued the same goals and interventions even though the patients had completed the identified goals (A6), had failed over long periods of time to accomplish the identified goals (A7), or were unable to accomplish the identified goals because of dementia (A2, A3 and A9). Failure to individualize the treatment plan of patients can prevent patients from progressing in their treatment and prevent staff from knowing how to address each patient's specific problems which can result in unmet needs and potentially longer lengths of hospitalization.

Findings include:

A. Document Review

The facility "Treatment Planning" policy dated 4/23/2004 listed the minimum requirements for the treatment plan review as, "The Treatment Plan Review should review progress and/or lack of progress in terms of each Treatment Plan objective. The review should not simply be a description of the patient's behavior in term of the objective with an implied statement of progress or lack of progress. It must be quite explicit. For each objective, an indication must be made as to whether it will be continued, discontinued, revised or attained and a clinical rationale given."


B. Record Review

1. Patient A2, a 69-year old individual with Parkinson's Disease initially diagnosed approximately five (5) years prior to admission and characterized by aggressive behavior, paranoia (fears of being poisoned, being followed, or about to be killed), restlessness, depression, slowed speech, resting tremor, muscle wasting in the upper and lower extremities, slowed and unstable gait, and incontinence, was admitted to the facility on 8/1/13 for restoration to competency.

Diagnoses were Psychotic Disorder due to Parkinson's Disease with delusions, dementia due to Parkinson's Disease with behavioral disturbance, and mood disorder (depression) due to Parkinson's Disease. Although described as capable of attending a minimum of 20 hours of active programming per week and in need of competency restoration treatment, the Treatment Plan dated 8/6/13 with most recent Treatment Plan Review dated 4/22/14 prescribed only 15 minutes of psychiatrist contact per month, one (1) hour per week of individual treatment related to court behavior, 30 minutes per week of "reality orientation" group, 45 minutes per week of "social skills" group, 30 minutes per week of "structured activities" group, and 45 minutes per week of "Health and Wellness" group. Other interventions were directed towards A2's medical care, with physical assistance in ADLs (Activities of Daily Living), range of movement exercises, stretching and walking sessions to improve gait and balance, close observation to prevent falls and assistance with transfers. The 4/22/14 Treatment Plan Review noted that A2 "has made little to no progress...." and "is often sleeping" or "declining to meet...due to inability/lack of motivation."

2. Patient A3, a 72-year old individual, with a past personal history of alcohol, marijuana and cocaine abuse, pre-existing diabetes mellitus, hypertension, kidney disease, hypercholesterolemia, hypertension and valvular heart disease, cervical cancer, previous psychiatric inpatient treatment for hallucinations, paranoia and depression, and the more recent diagnoses of dementia NOS and mood disorder NOS, was admitted to the facility on 6/18/12 for restoration to competency. Admission mental status was notable for inconsistent cooperation, disorientation to place and time, orientation to person, confabulation, inability to interpret simple similarities, inability to clarify pre-admission living situation, or if any family members provided any support, and lack of understanding regarding her current hospitalization. Subsequent treatment on Ward 21 aimed at competency restoration was unsuccessful due to the patient's cognitive impairments. A3 was not able to actively participate in or gain insight from a variety of forensic education groups, skill building and socialization groups, stress management groups, and psychoeducation groups. In addition, serious medical problems developed leading to medical treatment at the local community medical facility for sepsis, acute renal failure, and bilateral hydronephrosis (swelling of the kidneys when urine flow obstructed) requiring the insertion of bilateral nephrostomy tubes and a Foley catheter into the bladder prior to return to the facility. The Comprehensive Treatment Plan dated 12/12/13, at the time of A3's transfer from Ward 21 to the infirmary (Ward 25), continued to prescribe individual and group modalities that required A3 be able to acquire and retain new information, despite describing the inability to restore A3 to competency through group interventions and individual counseling due to persisting memory deficits. No other treatment interventions were listed in the treatment plan. The primary treatment interventions provided were medical, addressing control of the patient's diabetes mellitus and hypertension, treatment of anemia, and treatment of a vesiculovaginal fistula (opening between the bladder and the vagina).

3. Patient A6 was admitted on 10/4/06. The "Annual Psychiatric Assessment" dated 10/24/13 listed the diagnoses as "Bipolar Disorder severe most recent episode manic with psychotic features", "Anxiolytic Dependence" and "Cannabis Abuse". The annual Comprehensive Treatment Plan (CTP) dated 10/10/13 listed the following goals for Patient A6: "Over the next 90 days, I will be able to" (Goal 1A) "Identify 5 triggers from my daily life at (hospital) that make me feel anxious", (Goal 1C) "Identify 3 factors that led to my instant offense and other violent rather than withdrawing", (Goal 1D) "Identify 4 warning signs that I am becoming anxious" (Goal 1E) "State four triggers from my daily life at (hospital) that cause me to become angry" and (Goal 2A) "Identify 5 emotional factors that led to my continuing use of substance." The Treatment Plan Reviews (dated 4/8/13, 7/5/13 and 10/4/13) conducted prior to the formulation of the annual CTP revealed that Patient A6 had already accomplished Goals 1A, 1C, 1D, 1E and 2A. The "Outcomes" section of the Treatment Plan Reviews listed Patient A6's responses to all the above mentioned goals. During the meeting scheduled to complete the Treatment Plan Reviews (dated 1/3/14 and 4/14/14) conducted after the formulation of the annual CTP, Patient A6 was asked again to respond to each of the goals and those responses were included in the "Outcomes" section of the Treatment Plan Reviews. Although Patient A6 had accomplished all five (5) of these goals, the treatment team decided to continue the goals and modify the target dates.

4. Patient A7 was admitted on 8/8/05. The most recent Annual Psychiatric Assessment dated 2/10/14 listed the diagnosis as "Bipolar Disorder, Most Recent Episode Manic, Severe with Psychotic Features". The annual CTP dated 8/16/13 listed among the goals for Patient A7: (Goal 1A) "(Patient) will demonstrate an awareness of psychiatric symptoms, such as his/her erotomanic delusions (delusions in which the patient believes another person, usually a stranger and in this case a famous person, is in love with him/her), as evidenced by one comment describing differences between psychosis-based and reality-based thinking, as they relate to [his/her] dangerous behavior, next 90 days" and (Goal 1C) "Patient will demonstrate via group discussion one key skill taught during Functional Sills Development Group 1x (time)/session for 25% of the attended sessions by target date." The Treatment Plan Reviews (dated 2/15/13 and 5/6/13) conducted prior to the formulation of the annual CTP revealed that Patient A7 had been unsuccessful in meeting Goals 1A and 1C. The "Outcomes" section of the Treatment Plan Reviews for 2/15/13 and 5/6/13 summarized the patient's progress to the goals as: (Goal 1A- reality-based thinking - 2/15/13 and 5/6/13 reviews) "Symptoms of psychosis, namely delusions of grandeur and persecution, pretty much unchanged for years such as believing that [he/she] is married to several famous [actors/actresses]" and (Goal 1C-group discussion) 2/15/13 "[His/ Her] participation has been more episodic. At times [he/she] will tune out, other times sleeps" and 5/6/13 "Progress has bee [sic] minimal due to impact from [his/her] delusional beliefs." The "Outcomes" section of the Treatment Plan Review for 11/15/13 and 2/14/14, conducted after the formulation of the annual CTP, summarized the patient's progress to the goals as: (Goal 1A-reality - based thinking) 11/15/13 "[His/Her] delusions of grandeur and persecution remain unchanged" and 2/14/14 "[His/Her] delusional system has remained pretty much unchanged" and (Goal 1C-group discussion - both 11/15/13 and 2/14/14 reviews) "Progress has been minimal due to impact from his/her delusional beliefs." Even though Patient A7 had been unable to make progress toward Goals 1A and 1C for at least 14 months, the treatment team decided to continue the goals and modify the target dates. There were no goals added nor were the interventions changed.

5. Patient A9, a 58 year old individual with a personal history of polysubstance abuse and one (1) prior psychiatric inpatient admission in late 2012 at the age 57 years for "bizarre behavior" and self-starvation, was admitted to the facility on 8/20/2013 on an order of commitment for restoration to competency. On the day of admission, A9 was triaged to a local medical facility due to low blood pressure and elevated heart rate secondary to insufficient oral intake of food and fluids, stabilized and returned to the psychiatric facility and admitted to the infirmary (Ward 25) prior to transfer to ward 43. Admission mental status was notable for disorientation to person, place, and time. Repeat mental status evaluation on day 3 of admission (8/22/13) was remarkable for orientation only to person (responded to name being called); assessment of memory could not be performed due to lack of cooperation (patient covering face or indicating that the assessing psychiatrist should stop questioning). A9 appeared "emaciated" and poorly groomed with a BMI of only 16.5 (5'7" and 106# documented in Physical Examination and Assessment dated 2/2/14). After two weeks on Ward 43, A9 was transferred back to the Infirmary (Ward 25) on 9/11/13, still grossly underweight, not able to eat a meal unattended (observed eating inanimate objects) despite indicating a desire for food, and deemed "not capable of attending a minimum of 20 hours of active programming per week, due to neurological condition," in need of further assessment "to determine an accurate diagnosis and possible cause for dementia," and in need of careful monitoring of nutritional status and diabetes mellitus. However, the Comprehensive Treatment Plan of 9/11/13 and the most current Treatment Plan Review of 4/18/2014 did not provide updated problems, goals, or objectives aimed at clarifying the basis of the dementia. Treatment modalities ("methods") listed in the plan did not constitute active psychiatric treatment, but rather provided feedback on orientation and skilled nursing and nursing support services for maintenance of physical safety, periodic ambulation and range of motion exercises, maintenance of adequate nutrition and personal cleanliness; ongoing medical management of diabetes mellitus; and ongoing psychopharmacologic management of irritability and impulsivity.

C. Interview

1. During interview on 4/28/14 at 11:40 a.m., Patient A3 was sitting at a small table alone with his/her head down on the table and not involved in any activity. A3 responded to his/her name, but could not describe any aspect of his/her treatment or provide the reason for his/her hospitalization.

2. During interview on 4/28/14 at 2:00 p.m., MD3 stated "[A3] has a dementia work-up; thyroid function was normal; the CT scan showed atrophy."

3. During interview on 4/29/14 at 8:45 a.m., the Chief Executive Officer when asked why goals would be continued after they were accomplished by patients answered, "It's hard to get the legal and clinical together."


4. During interview on 4/29/14 at 9:15 a.m., the Clinical Director when shown the completed goals for Patient A6 stated, "If [he/she] has attained it (goal) then we need to move on to something else."

Based on record review and interview the facility failed to provide a substantiated diagnosis in the Comprehensive Multidisciplinary Treatment Plan for one (1) of nine (9) active sample patients (A9). Failure to provide an updated diagnosis based on new information and assessment impedes the treatment team in providing care and services consistent with the patient need and can delay patient recovery.

Findings include:

A. Document Review

Despite a mental status examination on admission (Screening Admission Note and Psychiatric Evaluation Part II dated 8/22/13) indicating that A9 was "oriented in one sphere" and was unable to provide the time or place, as well as a Psychiatrist Progress Note dated 10/25/13 indicating that the patient was oriented "in only one sphere," another Psychiatrist Progress Note dated 11/8/13 indicating that the "patient continues oriented in one sphere...is unable to register place," and the team conference note within the plan indicating that the patient was transferred to the Infirmary (Ward 25) "to determine an accurate diagnosis and possible cause for [his/her] dementia...." the updated Treatment Plan dated 9/11/13 continued to diagnosis the patient with "Psychotic Disorder" and Depressive Disorder."

B. Patient Interview
During interview on 4/28/14 at 11:30 a.m., Patient A9 was mainly nonverbal, sitting passively in front of the TV with a staff member alongside providing 1:1 coverage. Although A9 responded to name by turning his/her head, A9 was not able to engage in any meaningful interchange or dialogue.

C. Staff Interview

During interview on 4/28/14 at 12:05 p.m., Security Hospital Treatment Assistant (SHTA) 1 stated that Patient A9 "requires total care....we have to help [him/her] dress....sometimes [he/she] scrapes the table with [his/her] spoon and I have to help [him/her] use it for [his/her] food....The OT (occupational therapist) came this morning and walked [him/her] around the day room."

Based on document review, record review and interview, the facility failed to provide Comprehensive Treatment Plans that included long-term and short-term goals stated in measureable, patient focused terms for seven (7) of nine (9) active sample Patients (A1, A2, A3, A4, A5, A6, and A7). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of staff interventions based on changes in patient behaviors.

Findings include:

A. Document Review

The facility "Treatment Plan" policy dated 4/23/04 described "Objectives" (short-term goals) as "...relate to the behavioral description, focus on a specific behavior, and are observable and measureable and realistic."

B. Record Reviews

1. Patient A1 was admitted 10/22/07. The Treatment Plan Review dated 4/23/14 for the problem "Patient has a history of psychiatric illness involving impulsive, aggressive, self-injurious, and at this point, occasionally assaultive behavior" had the short-term goal, "(Patient) will interact with others using a respectful tone of voice as well as respectful language within the next 90 days."

2. Patient A2 was admitted 8/1/13. The Treatment Plan Review dated 4/22/14 for the problem, "(Patient) was sad and depressed, with flat affect and expressions of hopelessness and that he/she is 'a burden' on others" had the long-term goal, "(Patient's) depressive symptoms will not interfere with his/her restoration to fitness." The short-term goal for this problem was, "(Patient) will make at least one statement free of confusion or depressive symptoms during individual programming/group, for 1 out of 3 sessions/week, for a 60 day period."

3. Patient A3 was admitted 6/18/12. The Treatment Plan Review dated 3/5/14 for the problem, "(Patient) has not yet been made competent to proceed with trial, she/he has short and long term memory impairment, and has been having difficulty remembering most of the material needed to proceed" had the short-term goal, "Over the next 90 days (patient) will communicate with his/her treatment providers so they continue to provide him/her with appropriate treatment over 30 days."

4. Patient A4 was admitted 2/12/14. The Treatment Plan Review dated 3/20/14 for the problem, "You were found unfit to proceed as evidenced by hearing voices and having paranoid/delusional thoughts" had the short-term goal, "I will have a significant decrease in symptoms; hearing voices and having paranoid/delusional thoughts, so that they do not interfere with my restoration to fitness for 1 of 3 sessions/week for a 30 day period."

5. Patient A5 was admitted 3/28/13. The Treatment Plan Review dated 4/3/2014 for the problem, "(Patient) has a history of substance use" had the short-term goal, "(Patient) will demonstrate (1) key concept regarding substance abuse education, 1x/session (one time a session), for 25% of the attended sessions."

6. Patient A6 was admitted 10/4/06. The Treatment Plan Review dated 4/16/2014 for the problem, "(Patient) has exhibited a limited grasp of the legal information necessary for fitness, and has had mood instability in the past" had the short-term goal, "(Patient) will have a stable mood so that it doesn't interfere with his/her restoration to fitness, for 1 out of 3 sessions a week, for a 60 day period."

7. Patient A7 was admitted 8/18/05. The Treatment Plan Review dated 2/14/14 for the problem, "(Patient) presents with paranoid delusions of grandiose/erotomanic (delusions in which the patient believes another person, usually a stranger and in this case a famous person, is in love with him/her) and persecutory nature, history of substance abuse and assaultive behaviors" had the short-term goal, "(Patient) will demonstrate an awareness of psychiatric symptoms, such as his erotomanic delusions, as evidenced by one comment describing differences between psychosis based and reality-based thinking, as they relate to his dangerous behavior, next 90 days."

C. Interview

During interview on 4/29/14 at 9:15 a.m., the Clinical Director when shown examples of unmeasurable objectives (short-term goals) stated "They should have been more concrete and measurable."

Based on record review, observation, and interviews, the facility failed to provide active treatment to three (3) of nine (9) active sample patients (A2, A3, and A9). These patients carried a diagnosis of dementia and were being treated in the infirmary (Ward 25). Although providing psychiatric management, medical care, skilled nursing, and a variety of support services, the hospital failed to provide 24-hour specialized psychiatric intervention that could not be provided outside the psychiatric hospital setting. Failure to provide psychiatric treatment can result in patients remaining in the hospital past the time when they require acute psychiatric care and can result in patients sitting idly in dayrooms for periods of time as seen throughout the survey.

Findings include:

A. Record Review

1. Patient A2, a 69-year old individual with Parkinson's Disease initially diagnosed approximately five (5) years ago and characterized by aggressive behavior, paranoia (fears of being poisoned, being followed, or about to be killed), restlessness, depression, slowed speech, resting tremor, muscle wasting in the upper and lower extremities, slowed and unstable gait, and incontinence, was admitted to the facility on 8/1/13 for restoration to competency. Diagnoses were psychotic disorder due to Parkinson's Disease with delusions, dementia due to Parkinson's Disease with behavioral disturbance, and mood disorder (depression) due to Parkinson's Disease. Although initially described as capable of attending a minimum of 20 hours of active programming per week and in need of competency restoration treatment, the Treatment Plan dated 8/6/13 with most recent Treatment Plan Review dated 4/22/14 Treatment Plan Review noted that A2 "has made little to no progress...." and "is often sleeping" or "declining to meet...due to inability/lack of motivation." Current modalities consisted of skilled nursing interventions such as "close supervision by RN and SHTAs [Secure Hospital Treatment Assistant] as assigned to monitor patient....Offer physical assist and verbal prompts to ensure safety" and "range of movement exercises and ambulation 2X/week" and "stretching and walking 10-15 min 2x/week" as well as "assisted by SHTA and nursing staff with all transfers..."

2. Patient A3, a 72-year old individual, with a past personal history of alcohol, marijuana and cocaine abuse, pre-existing diabetes mellitus, hypertension, kidney disease, hypercholesterolemia, hypertension and valvular heart disease, cervical cancer, previous psychiatric inpatient treatment for hallucinations, paranoia and depression, and the more recent diagnoses of dementia NOS and mood disorder NOS, was admitted to the facility on 6/18/12 for restoration to competency. Admission mental status was notable for inconsistent cooperation, disorientation to place and time, orientation to person, confabulation, inability to interpret simple similarities, inability to clarify pre-admission living situation, or if any family members provided any support, and lack of understanding regarding her current hospitalization. Subsequent treatment on Ward 21 aimed at competency restoration was unsuccessful due to the patient's cognitive impairments. Patient A3 was not able to actively participate in or gain insight from a variety of forensic education groups, skill building and socialization groups, stress management groups, and psychoeducation groups. In addition, serious medical problems developed leading to medical treatment at the local community medical facility for sepsis, acute renal failure, and bilateral hydronephrosis requiring the insertion of bilateral nephrostomy tubes and a Foley catheter into the bladder prior to return to the facility. At the time of Patient A3's transfer from Ward 21 to the Infirmary (Ward 25), the updated Treatment Plan dated 12/12/13 described Patient A3's inability to be restored to competency through group interventions and individual counseling due to persisting memory deficits. The Treatment Plan continued to prescribe individual and group modalities that required Patient A3 be able to acquire and retain new information; no other treatment interventions were listed in the treatment plan. The primary treatment interventions that were continued consisted of medical care and skilled nursing care, addressing the monitoring and pharmacological control of the patient's diabetes mellitus and hypertension, treatment of anemia, and treatment of a vesiculovaginal fistua.

3. Patient A9, a 58-year old individual with a personal history of polysubstance abuse and one (1) prior psychiatric inpatient admission in late 2012 at the age 57 years for "bizarre behavior" and self-starvation, was admitted to the facility on 8/20/2013 on an order of commitment for restoration to competency. On the day of admission, Patient A9 was triaged to a local medical facility due to emaciation, low blood pressure and elevated heart rate secondary to insufficient oral intake of food and fluids, stabilized and returned to the psychiatric facility and admitted to the Infirmary (Ward 25) prior to transfer to Ward 43. Admission mental status was notable for disorientation to person, place, and time. Repeat mental status evaluation on day 3 of admission (8/22/13) was remarkable for orientation only to person (responded to name being called); assessment of memory could not be performed due to lack of cooperation (patient covering face or indicating that the assessing psychiatrist should stop questioning). After two weeks on Ward 43, Patient A9 was transferred back to the Infirmary (Ward 25) on 9/11/13, still grossly underweight, not able to eat a meal unattended (observed eating inanimate objects) despite indicating a desire for food, and deemed "not capable of attending a minimum of 20 hours of active programming per week, due to neurological condition." The Treatment Plan dated 9/11/13 described A9 as in need of further assessment "to determine an accurate diagnosis and possible cause for dementia", and "in need of careful monitoring of nutritional status and diabetes mellitus." Treatment modalities ("methods") listed in the plan did not constitute active psychiatric treatment, but rather provided feedback on orientation ("reality orientation group 1x/week for 45 minutes"), skilled nursing ("fingersticks daily as ordered...monitor for daily BM"), and nursing support services for maintenance of physical safety ("staff will observe and offer reminders when patient is walking/changing positions"), periodic ambulation and range of motion exercises ("stretching and walking and balance Mondays @ 1730"), maintenance of adequate nutrition ("RN to monitor and record amount of food intake each meal...obtain weight and record at least weekly") and personal cleanliness; ongoing medical management of diabetes mellitus; and ongoing psychopharmacologic management of irritability and impulsivity.

B. Observation

1. Patient A2 was observed on 4/29/14 at 11:15 a.m. in the day room of the Infirmary. Patient A2 was sitting at a small table eating lunch. SHTA3 was providing 1:1 coverage. Patient A2 was not able to communicate with surveyor. Despite several attempts to gain the patient's attention, Patient A2 continued to be focused on the meal.

2. Patient A3 was observed and interviewed in the day room of the Infirmary (Ward 25) on 4/28/14 at 11:40 a.m. Patient A3 was sitting at a small table alone with her head down on the table and not involved in any activity. Patient A3 responded to his/her name, but could not describe any aspect of his/her treatment or provide the reason for his/her hospitalization.

3. Patient A9 was observed on 4/28/14 at 11:30 a.m. in the day room of the infirmary. Patient A9 was primarily nonverbal and responded to his/her name by briefly turning his/her head. Patient A9 was not able to engage in any meaningful interchange. A9 sat without movement passively watching the TV with SHTA1 providing constant observation.

C. Interview

1. During interview on 4/28/14 at 12:15 p.m., MD1 and MD2 concurred and stated, with regard to patient A9, "He has dementia....[He's/She's] only oriented in one sphere." SHTA1 added "He requires total care...We watch him so he doesn't urinate on the floor....The OT came this morning and walked him around the day room....We have to help him dress."

2. During interview on 4/29/14 at 11:15a.m., SHTA3 was providing 1:1 coverage to Patient A2 at this time while Patient A2 was eating alone at a small table. SHTA3 stated, "I communicate with [A2] with gestures...we assist with dressing...we prompt to use the bathroom...[A2] requires 1:1 supervision."

3. During interview on 4/29/14 at 3:25 p.m., the Clinical Director, in reviewing the treatment plans for Patients A2, A3, and A9, stated, "We need the court to grant 'Jackson' relief so we can place these patients...Until it is granted, we need to take care of them." When asked if she felt that the patients in question were receiving active psychiatric treatment that could only be provided in a psychiatric hospital, she stated "No. But they have nowhere else to go and we must treat them."

Based on record review and interview, the Medical Director failed to monitor the quality and appropriateness of clinical care provided. Specifically, the Medical Director failed to ensure that:

1. Develop and document comprehensive multidisciplinary treatment plans based on the individualized needs for five (5) of nine (9) active sample patients (A2, A3, A6, A7, and A9). The facility failed to modify and/or update the treatment goals and/or interventions even though the patients had either completed the goals or had failed over long periods of time to accomplish the identified goals. Failure to individualize the treatment plan of patients can prevent patients from progressing in their treatment and prevent staff from knowing how to address each patient's specific problems which can result in unmet needs and potentially longer lengths of hospitalization. (Refer to B118)

2. Provide a substantiated diagnosis in the comprehensive multidisciplinary treatment plan for one (1) of nine (9) active sample patients (A9). Failure to provide an updated diagnosis based on new information and assessment impedes the treatment team in providing care and services consistent with the patient need and can delay patient recovery. (Refer to B120)

3. Provide Comprehensive Treatment Plans (CTPs) that included long-term and short-term goals stated in measureable, patient focused terms for seven (7) of nine (9) active sample patients (A1, A2, A3, A4, A5, A6, and A7). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of staff interventions based on changes in patient behaviors. (Refer to B121)


4. Provide active treatment to three (3) of nine (9) active sample patients (A2, A3, and A9). These patients carried a diagnosis of dementia and were being treated in the infirmary (Ward 25). Although providing psychiatric management, medical care, skilled nursing, and a variety of support services, the hospital failed to provide 24-hour specialized psychiatric intervention that could not be provided outside the psychiatric hospital setting. Failure to provide psychiatric treatment can result in patients remaining in the hospital past the time when they require acute psychiatric care and can result in patients sitting idly in dayrooms for periods of time as seen throughout the survey. (Refer to B125)