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Based on record review and interview, the facility failed to adequately develop and document individualized treatment plans that clearly delineated interventions to address the specific problems for 10 of 10 sample patients (A16, A25, B10, B16, C14, C22, D8, D22, E6 and E12). Instead, interventions were generic, lacked guidance to care for patients presenting aggression and irrational behaviors in the clinical area, and/or failed to include a specific purpose and focus of treatment based on patient findings. These deficiencies result in a lack of guidance for staff in providing individualized treatment that is purposeful and goal-directed.

Findings include:

A. Record Review

1. Patient A16-comprehensive treatment plan dated 1/11/11:

a. For problem, "Mood Instability," with goal listed as "Will show improvement in his mood AEB [as evidenced by] not expressing feelings of helplessness or hopelessness during all conversations with staff," the Rehabilitation staff intervention was listed as "see Mall Schedule for current programming to address (patient's) identified treatment needs of symptom recognition and management." A list of 20 groups was attached to this treatment plan; all groups were cross-referenced to this goal and were accompanied by a list of rationales (2-6 listed for each group). It was not clear how these groups were to specifically address this patient's need for symptom recognition and management.

For this goal, a social worker intervention was listed as "Evaluate (patient's) readiness for discharge and discuss discharge options with him." This intervention failed to list discharge options based on specific patient needs.

b. For problem, "Suicidal ideations", with goal listed as "will be free from expressing suicidal ideations during all conversations with staff," the only nursing intervention was listed as "Will collaborate with (patient) for at least 10 minutes twice weekly to identify the chronic aspects of his mental health care needs, and to discuss (patient's) feeling about his mental health issues and assist (patient) to develop adaptive strategies." This intervention failed to directly correlate with the stated problem and goal and failed to include specifics based on patient findings.

The plan did not include nursing interventions to monitor this patient's potential suicidal behaviors, nor did it address preventive techniques to ensure the patient's safety.

2. Patient A25-comprehensive treatment plan dated 12/30/10:

a. For problem, "Dangerousness to self," with goal listed as "Will be free from suicidal ideations and self-injurious behavior during this review period," there were no nursing interventions to guide nursing personnel in the monitoring of this patient based on presenting behaviors.

A nursing intervention was stated as "If (patient's) behavior poses a danger to herself staff will utilize the least restrictive interventions to protect (patient)." This was a generalized statement that failed to include specific interventions for staff to follow based on patient's needs.

b. For problem, "Dangerousness to others," with goal listed as " Will be free from assaultive behavior or threatening behavior to others during this review period," the only nursing interventions to care for this patient in the clinical area were listed as "If needed, Nursing staff may intervene to protect (patient) and/or others from an immediate risk of harm utilizing approved PMCS [patient management] techniques. Will provide verbal redirection and refocusing to reality based issues, if (patient) demonstrates the presence of assaultive behavior." These interventions failed to include structured techniques based on patient's presenting behaviors, other than redirection and refocusing. Even though this patient had been restrained 8 times since admission (12/19/10), there was failure to provide a specific plan for staff to follow during periods of aggression to include preventive interventions based on past events involving this patient.

3. Patient B10-comprehensive treatment plan dated 5/4/09 with last review of 10/6/10:

For problem, "Psychotic Symptoms," with goal listed as "Will have reduced interference from internal stimuli AEB [as evidenced by] (patient) verbalizing only focused statements with not repetitious phrases/questions," the Rehabilitation staff intervention was listed as "see Mall Schedule." A list of 23 groups was attached to this treatment plan; 19 of these groups were cross-referenced to this goal. It was not clear how each of these groups were to address this patient's treatment needs.

For this goal, a social worker intervention was listed as "Will meet with (patient) for at least 10 minutes once weekly to evaluate (patient's) readiness for discharge and discuss discharge options with him." This intervention failed to list discharge options based on specific patient needs.

4. Patient B16-comprehensive treatment plan dated 3/29/10 with last review of 12/7/10:

a. For problem, "Mood instability," with goal listed as "Will have reduced mood lability and reduced pressured speech AEB [as evidenced by] she will be able to maintain a coherent five minute conversation on a single topic at a normal speed," the Rehabilitation staff intervention was listed as "See Mall Schedule for current programming to address her identified rehab [rehabilitation] needs of reducing/managing symptoms." A programming list with 21 groups highlighted was attached to this treatment plan. It was not clear how each of these groups were to address this patient's treatment needs.

b. For problem, "aggressive behavior," with stated goal of "Will be free from aggressive behavior," the only nursing interventions to care for this patient in the clinical area were listed as "Will provide verbal redirection and refocusing to reality based issues, if (patient) demonstrates the presence of aggressive behavior. If indicated, obtain order for stat medication to relieve her distress." These interventions failed to include structured techniques based on patient's presenting behaviors, other than redirection and refocusing.

5. Patient C14-comprehensive treatment plan dated 3/27/08 with review on 12/8/10:

a. For problem, "Dementia with self-care deficits," a Rehabilitation staff intervention was listed as "See Mall Schedule." A list of 22 groups was attached to this treatment plan. All groups were cross-referenced to this goal and were accompanied by a list of rationales (2-4 listed for each group). It was not clear how each of these groups were to specifically address this patient's treatment needs.

b. For problem, "Depression related to lack of placement due to history of pedophilia," with goal listed as "Will have no aggressive behavior towards staff or peers," a nursing intervention was listed as "Will meet with (patient) weekly for 10 minutes to evaluate and monitor any aggressive behaviors." There were no specific interventions to ensure proper monitoring and prevention of aggression based on the patient findings.

For this problem and goal, a social worker intervention was listed as "Will meet with (patient) for at least 15 minutes weekly to evaluate his behavior and discharge placement needs. Will work with (patient) regarding his options for discharge." This intervention failed to list discharge options based on specific patient needs.

For this problem and goal the same list of 22 groups as identified for problem of Dementia with Self-Care Deficits in 5.a. above was attached to this treatment plan. All groups were cross-referenced to this goal and were accompanied by the same list of rationales (2-4 listed for each group) as for the problem of Dementia. It was not clear how each of these groups were to address this patient's treatment needs.

6. Patient C22-comprehensive treatment plan dated 8/12/09 with review on 11/3/10:

For problem, "Mood instability," with goal listed as "Will not have more than three (3) crying episodes during a review period," a generic nursing intervention was stated as "Will collaborate with (patient) for at least 10 minutes weekly to assess (patient's) learning needs regarding medication education and symptom management, and Nursing staff will provide teaching as indicated." Content for this educational intervention based on patient's needs was not specified.

Another nursing intervention was listed as "Will offer praise and support when (patient) seeks out staff to express reality-based, future oriented goals for herself that focus on (patient's) interests in living in the community." It was not clear how this intervention related to the stated problem and goal.

The rehabilitation therapy intervention was stated as "See Mall Schedule." A list of 22 groups was attached to this treatment plan with all being cross-referenced to this problem and goal. All groups were accompanied by a list of rationales (2-5 listed for each group). It was not clear how each of these groups were to address this patient's treatment needs.

A social worker intervention was stated as "Will meet with (patient) for at least 15 minutes once weekly to...evaluate (patient's) readiness for discharge and discuss discharge options with her." This intervention failed to list discharge options to be considered based on specific patient needs.

7. Patient D8-comprehensive treatment plan dated 12/28/08 with review on 1/3/11:

For problem, "Psychotic symptoms," with goal stated as "During this review period (patient) will engage in reality-based conversations with staff for at least two minutes daily," the rehabilitation intervention was listed as "See Mall Schedule." A list of 17 groups was attached to this treatment plan with all being cross-referenced to this problem and goal. All groups were accompanied by a list of rationales (1-3 listed for each group). It was not clear how each of these groups were to address this patient's treatment needs.

A social worker intervention was listed as "Will meet with (patient) for 10 minutes at least one time weekly to discuss (patient's) progress in treatment and evaluate his readiness for discharge and discuss discharge options with him when ready." This intervention failed to list discharge options to be considered based on specific patient needs.

8. Patient D22-comprehensive treatment plan dated 7/21/10 with review on 12/15/10:

For problem, "Psychotic symptoms," with goal stated as "Will have reduced psychotic symptoms AEB [as evidenced by] his ability to complete ADLs [Activities of Daily Living] and function in the general milieu," a nursing intervention was listed as "Will engage (patient) with each interaction to emote some kind of appropriate response." This intervention did not clearly direct nursing personnel's communication with this patient.

Another nursing intervention was "Will assist (patient) in completing all ADLs." This intervention did not clearly direct staff in care of this patient based on specific abilities.

A rehabilitation intervention for this goal was listed as "See Mall Schedule for current programming to address (patient's) identified treatment needs of symptoms management." A programming list that highlighted 23 groups was attached to this treatment plan. It was not clear how these groups were to specifically address this patient's need for symptom management.

9. Patient E6-comprehensive treatment plan dated 12/28/10 with review on 1/24/11:

For problem, "Anger and aggression and self-harming behaviors that result in situation where she is putting herself or others at a safety risk," with goals listed as "During this review period (patient) will have zero acts of aggressive behavior...Will be free from expressing or having self-injurious behaviors during all conversations, observations and interactions with all staff," there were no specific nursing interventions to guide nursing personnel in monitoring and prevention of aggressive behavior to ensure safety for this patient and others in the clinical area.

10. Patient E12-comprehensive treatment plan dated 10/8/10 with review on 10/8/10:

a. For problem, "Verbalizing that he wanted to kill his mother, his step-father and himself," and goal listed as "Will be able to verbalize an understanding of five of his motivators for suicidal and homicidal ideations," there were no specific nursing interventions to guide nursing personnel in monitoring and prevention of aggressive behavior to ensure safety for this patient and others in the clinical area.

Even though this patient had required manual restraint 4 times (last restraint on 12/24/10) since admission to the facility on 10/2/10, there was failure to provide a specific plan for staff to follow during periods of aggression based on past events involving this patient.

b. For problem, "Reported that he has been experiencing auditory hallucinations and personality changes," with goals listed as "Will name three stressors that contribute to his reactive psychosis" and "Will name 3 coping strategies to cope with his reactive psychosis," there were no nursing interventions to guide staff in caring for this patient in the clinical area when presenting these irrational symptoms.

B. Interviews

1. In an interview with the Clinical Director on 1/26/11 at 9:30a.m., the above information was discussed and verified as correct.

2. In a group interview with the Director of Nursing, the Director of Social Services and the Director of Rehabilitation Services on 1/26/11 at 9:50a.m., all of the above treatment plan findings were reviewed and verified by these staff members. They acknowledged that structured treatment plans for Patients A25 and E12 should be developed by the treatment teams.

Based on the record review and staff interview, the facility failed to ensure that the patient discharge summaries contained a summary of the patient's condition on discharge for 2 of 5 patients (Patients G1 and G5). This failure results in critical clinical information indicating the patient's level of psychiatric symptoms and risk not being available to the aftercare providers.

Findings Include:

A. Record Review

1. Patient G1: This 15 years old female patient was admitted on 11/23/2010 for depression and being suicidal. She was discharged on 12/08/2010. The discharge summary dated 12/22/2010 under sub-heading "CONDITION ON DISCHARGE" included only Diagnosis on discharge. The "Condition on Discharge" was not addressed.

2. Patient G5: This 8 years old male patient was admitted on 10/15/2010 for being aggressive and hyperactive. He was discharged on 12/01/2010. The discharge summary dated 12/17/2010 did not include "CONDITON ON DISCHARGE" at all.

B. Staff Interview:

During an interview on 01/26/2011 at 10:40a.m., the Clinical Director acknowledged that the "Condition on Discharge" was missing in the discharge summaries of the patients G1 and G5. He remarked "I see the problem."

Based on the record review and staff interviews, the Clinical Director failed to:

I. Ensure adequate development and documentation of clearly delineated treatment interventions to address the specific problems in 10 of 10 active sample patients (A16, A25, B10, B16, C14, C22, D8, D22, E6 and E12). This failure results in lack of guidance for the treatment staff in providing individualized treatment that is meaningful and goal directed. (Refer to B122)

II. Ensure that the discharge summary included patient's condition on discharge for 2 of 5 discharge sample patients (G1 and G5). This failure results in critical clinical information not being available to the aftercare staff to provide continuity of treatment. (Refer to B135)