HospitalInspections.org

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

A. Provide housing for one of 15 active sample patients (Patient C15) on a treatment unit that was appropriate to his treatment needs. The patient was housed on a forensic unit that did not have a treatment program appropriate for his needs. This deficient practice results in patients being hospitalized without receiving all interventions for recovery, potentially delaying their improvement and discharge (Refer to B125-I).

B. Provide sufficient alternative active treatment measures for 1 of 5 active sample patients (A67) and 8 non- sample patients (A1, A5, A32, A35, A57, A60, A63 and A64) on the Gero-psychiatric Unit (GPU) who were identified by the facility as refusing to participate in their scheduled active treatment program. This failure results in the potential for delaying improvement in the patients' level of function and delaying their subsequent discharge. (Refer to B125 II)

C. Provide active psychiatric treatment for 1 of 5 active sample patients (A28) and 3 non-sample patients (A22, A39, and A47) on the Gero-psychiatric wards who were unable to consistently participate in their scheduled active treatment program due to their cognitive condition or behavior problems. These patients received limited benefit from scheduled treatment activities due to their level of functioning and lack of participation. This results in patients being hospitalized without all interventions for their recovery being provided and possibly delays their discharge to appropriate placements. (Refer to B125 III)

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

I. Provide housing for one of 15 active sample patients (Patient C15) on a treatment unit that was appropriate to his treatment needs. The patient was housed on a high security forensic unit that did not have a treatment program appropriate for the patient's needs. This deficient practice results in patients being hospitalized without receiving all interventions for recovery, potentially delaying improvement and timely discharge.

II. Provide alternative active treatment measures for 1 of 5 active sample patients (A67) and 8 non-sample patients on three Gero-psychiatric Wards: Patients A1 and A5 on Ward B (census 27), Patients A32 and A35 on Ward E (census 28) and Patients A57, A60, A63 and A64 on Ward D (census 26). These patients refused to participate in their scheduled treatment program and were not provided alternative treatment. This failure can result in delays of patients' level of functioning and timely discharge.

III. Provide active psychiatric treatment for 1 of 5 active sample patients (A28) and 3 non-sample patients (A22, A39, and A47) who were gero-psychiatric patients and who were unable to consistently participate in their scheduled treatment program because of their cognitive impairments and/or problematic behaviors. These patients received limited (if any) benefit from the scheduled treatment activities assigned to them because of their low level of functioning and related difficulty participating. This deficiency results in patients being hospitalized without receiving appropriate interventions and potentially delays their discharge to appropriate placements.

Findings are:

I. Failure to house one patient on an appropriate treatment unit:

A. Record Review

1.) Facility Policy

The Program Description for the FSU (Forensic Services Unit) provided by the Director of Quality Improvement on 2/25/10 at 9:00 a.m. states that the Forensic Unit "1S1" is "the Competency, Evaluation and Treatment Program designed to evaluate and/or treat criminally committed patients in the following categories: 15 Day Observation/Evaluations, Order Staying Proceeding (OSP) for competency restoration, NGRI, and patients who have been in the community on Conditional Release and have returned to the hospital (Return from Conditional Release [RFCR]) for evaluation, stabilization, and recommendation regarding modification/revocation of the Conditional Release. The Evaluation Program's primary focus of treatment is to evaluate the patient's readiness for court proceedings."

2.) Specific Patient Findings:

a. Patient C15

(1) The "Annual Clinical Profile Psychiatric Evaluation," dated 1/15/10, states that the patient "is a 49 year old, single, Caucasian male admitted for the fifth time to the hospital on 1/15/09....Although he was initially admitted to 2S1... [on] 9/17/09, he was part of the group that went to the State Fair but, he jumped on the opportunity and went on Unauthorized Leave that same day. He was eventually picked up by law enforcement and returned back to the hospital on 9/21/09 but this time he was kept on the more restricted 1S1. Since then he has not had an opportunity to get off the ward. He has been on phone restriction due to his inappropriate calls to the media. He has also been wanting [sic] to call his "legal advisor" who is actually a friend that has provided him with a lot of documents from legal books and such. (Patient's name) has not had much treatment in the form of group activities and/or classes until about the past two weeks."

(2) The Treatment Plan update of 1/13/10 stated that the patient is "diagnosed with Schizophrenia, Chronic Paranoid Type and Personality Disorder NOS, Narcissistic and Antisocial Features." Staff interventions included "individualized meetings by the physician" (no schedule specified); "assigned FT (forensic therapist) will offer 1:1 counseling sessions 5 times per week focusing on communication skills" (no set time or place specified); "RT (Recreation Therapy) groups 10-12 times per week to promote acceptance social interactions [sic]; craft groups M/W 1530-1630; Ping Pong Tournaments Tuesdays 1530-1630; Social Work group" (schedule not specified), and "social work meetings" (schedule unspecified)

(3) A Social Work Progress Note dated 12/6/09 stated "he has been participating in some recreational activities on the ward."

(4) A Nursing Progress Note dated 1/30/10 said "Every little thing that happens here is blamed on him."

(5) A Social Work Progress Note dated 2/17/10 said "He does not feel that anything is being done for him to transfer to 2S1 or 3S1 and that is why he has been talking about going to Western (Western State Hospital)." The patient had made a formal request for transfer to another state hospital.

B. Interview

1.) In interview on 2/23/10 at 3:15 p.m., Patient C15 stated that he did not feel that there was anything being done in response to his request to be moved back to Unit 2S1 and that he believed he was kept on 1S1 for political reasons. He stated that a forensic therapist met with him in individual therapy occasionally but that, otherwise, his daily program consisted of therapeutic recreation activities only. He stated that he did not believe his requests for more access to artistic endeavors were seriously considered. He also stated that he had more access to develop his artwork when he was on 2S1.

2.) In interview on 2/24/10 at 3:00 p.m., the Forensic Service Director in presence of the Director Quality Improvement stated that Patient C15 was not on an appropriate unit to meet his needs. The Forensic Service Director agreed that he [patient C15] had been continuously housed on 1S1 (the Forensic Service Admissions Unit) although he was not in need of court ordered competency evaluation or competency restoration. The Forensic Service Director stated that Patient C15 had been held on his current unit for safety reasons only and that if he [patient C15] were to be moved to either 2S1 or 3S1 (one of the two other forensic units) he would need to be placed on a 1:1 for safety reasons. He stated that in order for Patient C15 to be moved to either unit, steps would need to be taken to promote healing among the patients who blame Patient C15 for their loss of campus activities, which were all discontinued following Patient C15's elopement in September, 2009. No explanation was given as to why such healing activities had not been completed in the five months following the elopement and during which time Patient C15 had been on Unit 1S1.

II. Failure to provide alternative active treatment for patients who refused to attend scheduled treatment activities

A. Record/document review

The facility's plan of correction for the Centers for Medicare and Medicaid Services (CMS) survey completed on 12/10/09 stated "A process will be developed for treatment teams to follow when a patient consistently refuses to go to assigned groups or is not able to attend a full group schedule. A specific treatment plan identifying alternative treatment/interventions will be developed by the team."

B. Specific Patient Findings

1.) Active Sample Patient A67

a. Observations

(1) During an observation on 2/23/10 at 9:50 a.m. on Ward D, active sample patient A67 was seen in his room in bed. According to the "GPU [Geropsychiatric Unit] Program Referral" Form, he was scheduled to attend the "Problem Solving Group" at 9:30 a.m.

(2) During observation at a Treatment Planning Meeting on 2/23/10 from 11:30 a.m. to 12:10 p.m., while reporting how patient A67 was doing with his schedule, MHT2 stated "He likes to sleep in and we let him."

(3) During an observation on 2/24/10 at 9:30 a.m. on Ward D, patient A67 was seen in his room in bed. He was scheduled to attend a "Problem Solving Group" at 9:30 a.m. He was observed again at 10:30 am, in his room in bed. At this time, he was scheduled to attend a "Sensory Connections Group." The "GPU [Geropsychiatric Unit] Program Referral" Form revealed that the patient was scheduled for the "Problem Solving" and "Sensory Connections" groups on Wednesdays.

b. Record review

(1) Patient A67's "Annual Clinical Profile- Psychiatric Evaluation" dated 11/30/09 noted that this 55 year-old male was admitted on 11/25/09 and diagnosed with "Schizophrenia, Chronic, Paranoid type; Dementia, secondary to Traumatic Brain Injury and Cerebral Vascular Accident."

(2) The Patient's "Admission Clinical Profile - Psychosocial Assessment" dated 12/2/09 stated "...[Patient] has lived in [center] for over a year but due to his recent increasing assaultive behavior it is unknown if they are willing to take him back."

(3) Review of the "GPU [Geropsychiatric Unit] Program Referral" form revealed that the patient was assigned to the following Ward groups: "Problem Solving" (assigned Monday, Tuesday, Wednesday & Friday at 9:30 a.m.); Sensory Connections" (assigned Monday & Wednesday); "Event Exercise" (assigned Thursday at 10:30 a.m.); and "Karaoke" (assigned Thursday at 9:30 a.m.) No date for the initiation of these activities was documented.

(4) A review of the patient's treatment plan update of 12/23/09 revealed no alternative interventions such as individual sessions provided by staff to assist the patient to meet the treatment goals.

(5) The "Patient Refusal Report by Ward" for the dates 2/8/10 to 2/19/10 revealed that Patient A67 had 5 refusals of scheduled groups during this period and noted "no pattern."

c. Interviews

(1) In an interview on 2/23/10 at 9:35 a.m., RN6 stated that Patient A67 was in bed sleeping. She noted he was difficult to get out of bed and sometimes became agitated when disturbed.

(2) During a discussion in the nursing station on 2/24/10 at 9:35 a.m., when asked about patient A67 being in bed, MHT3 stated "We allowed him to stay in bed because of being up during the night." Subsequent review of progress notes in the medical record revealed the following note dated 2/24/10 at 4:55 a.m.: "Pt [patient] has been in his room in bed all of this NOC [night]. Pt has had good positive sleep-restorative sleep all of this NOC." RN4 said that they might be able get him up later during the morning.

2. Non-sample Patients

a. Record Review

(1) Patient A1

(a) The "GPU [Geropsychiatric Unit] Program Referral form attached to the quarterly treatment plan review revealed that the patient was assigned to the following groups held on the Ward: "Sensory Connections" (Monday and Wednesday at 9:30 a.m.); "Building Bridges" (Monday, Tuesday, Wednesday, Thursday and Friday at 10:30 a.m.); "Sing along" (Tuesday at 9:30 a.m.); "Reminiscing" (Thursday at 9:30 a.m.) and "Gentle Care Relaxation" (Friday at 9:30 a.m.)."

(b) The "Patient Refusal Report by Ward" from 2/8/10 to 2/19/10 revealed that Patient A1 had 8 refusals of scheduled groups during this period. The report said "needs assessment from Treatment Team."

(c) A review of the patient's medical record and treatment plan (2/22/09) revealed no alternative interventions such as individual sessions provided by staff to assist the patient to meet treatment goals.

(2) Patient A5

(a) The "GPU [Geri-psychiatric Unit] Program Referral form attached the patient's quarterly treatment plan update dated 12/16/09 and partially updated on 1/10/10 and 2/8/10 revealed that the patient was assigned to the following groups held off Ward: "How to Win Friends & Influence People (changed 2/23/10) held off Ward on Monday at 9:30 a.m.; "How to cope with Institutional Living" held on Monday at 10:30 a.m.; "CSI" [sic] held on Tuesday at 9:30 a.m.; "Sensory Modulation" held off ward on Wednesday and Thursday at 9:30 a.m. changed (2/23/10); "Seasonal, Cultural Crafts" held on Tuesday at 10:30 a.m.; "Discharge Planning" held on Wednesday at 10:30 a.m.; Gentle Relaxation at 9:30 a.m. (on Ward); and "Life Skill" held on Friday at 9:30 a.m.

(b) The "Patient Refusal Report by Ward" from 2/8/10 to 2/19/10 revealed that Patient A5 had a 6 refusals of scheduled groups during this period. The report said "needs assessment from Treatment Team."

(c) A review of the patient's medical record and treatment plan (12/16/09) revealed no alternative interventions such as individual sessions provided by staff to assist the patient to meet treatment goals.

(3) Patient A32

(a) The GPU [Geri-psychiatric Unit] Program Referral form attached to the patient's treatment plan revealed that the patient was assigned to the following groups held on the Ward: "What's Up" held on Monday-Friday at 9:30 a.m.; "Relaxation" held on Tuesday at 10:30 a.m.; "Sensory Connections" held on Tuesday and Thursday at 10:30 a.m.; "Substance Abuse" held on Wednesday at 10:15 a.m.; and "Discharge Planning" held on Friday at 10:30 a.m.

(b) The "Patient Refusal Report by Ward" from 2/8/10 to 2/19/10 revealed that Patient A32 had 11 refusals of scheduled groups during this period. The report said "needs assessment from Treatment Team."

(c) A review of the patient's medical record and treatment plan (2/11/10) revealed no alternative interventions such as individual sessions provided by staff to assist the patient to meet treatment goals.

(4) Patient A35

(a) The GPU [Geropsychiatric Unit] Program Referral form attached to the patient's treatment plan revealed that the patient was assigned to the following groups held on the Ward: "What's Up" held on Monday-Friday at 9:30 a.m.; "Relaxation" held on Tuesday at 10:30 a.m.; "Sensory Connections" held on Tuesday and Thursday at 10:30 a.m.; "Music Appreciation" held on Wednesday and Friday at 10:15 a.m.; and "Discharge Planning" held on Fridays at 10:30 a.m.

(b) The "Patient Refusal Report by Ward" from 2/8/10 to 2/19/10 revealed that Patient A35 had 15 refusals of scheduled groups during this period. The report said "needs assessment from Treatment Team."

(c) A review of the patient's medical record and treatment plan (1/5/10) revealed no alternative interventions such as individual sessions provided by staff to assist the patient to meet treatment goals.

(5) Patient A57

(a) The patient's treatment plan revealed that he was assigned to the following groups held on the Ward on the evening shift: "Movies and popcorn" held on Monday; "All about me/trivia" held on Tuesday; "Community meeting/current events" held on Wednesday; "Use it or lose it" held on Thursday; and Beach ball bonanza held on Friday. The following groups were schedule on the day shift: "Sensory connection" and "Problem solving" held on Monday, Tuesday, Wednesday and Friday; "Event exercise" held on Tuesday and Thursday; "Sensory Connections" held on Wednesday; and "Karaoke" held on Thursday.

(b) The "Patient Refusal Report by Ward" from 2/8/10 to 2/19/10 revealed that Patient A57 had 17 refusals of scheduled groups during this period. The report said "needs assessment from Treatment Team."

(c). A review of the patient's medical record and treatment plan (12/2/09) revealed no alternative interventions such as individual sessions provided by staff to assist the patient to meet treatment goals.

(6) Patient A60

(a) There was no GPU [Geropsychiatric Unit] Program Referral form attached to this patient's treatment plan and no groups were listed on the treatment plan. The "Treatment Plan Review Note" dated 2/16/10 stated "She has been unwilling to engage in on-ward groups and refusing."

(b) The "Patient Refusal Report by Ward" from 2/8/10 to 2/19/10 revealed that Patient A60 had 15 refusals of scheduled groups during this period. The report said "needs assessment from Treatment Team."

(c) A review of the patient's medical record and treatment plan (2/16/10) revealed no alternative interventions such as individual sessions provided by staff to assist the patient to meet treatment goals.

(7) Patient A63

(a) There was no GPU [Geropsychiatric Unit] Program Referral form attached to the patient's treatment plan and no groups were listed on the treatment plan.

(b) The "Patient Refusal Report by Ward" from 2/8/10 to 2/19/10 revealed that Patient A63 had 15 refusals of scheduled groups during this period. The report stated "needs assessment from Treatment Team."

(c) A review of the patient's medical record and treatment plan (2/5/09) revealed no specific treatment plan that identified alternative treatment/interventions such as individual sessions provided by staff to assist the patient to meet treatment goals.

(8) Patient A64

(a) Review of the patient's treatment plan revealed that he was assigned to the following groups held off the Ward: "Sensory Connections" and "How to cope in Institutional setting" held on Monday; "Seasonal Crafts" and "My Strengths" held on Tuesday; "Leisure Education" held on Wednesday; "Sensory Modulation" held on Wednesday and Thursday; "Management of Emotions" held on Thursday; and "Drinks and Dialogue" held on Friday.

(b) The "Patient Refusal Report by Ward" from 2/8/10 to 2/19/10 revealed that Patient A64 had 15 refusals of scheduled groups during this period and "needs assessment from Treatment Team."

(c) A review of the patient's medical record and treatment plan (2/10/10) revealed no alternative interventions such as individual sessions provided by staff to assist the patient to meet treatment goals.

b. Interviews

(1) In an interview on 2/25/10 at 10:10 a.m., the need for alternative treatment interventions for Patients A57, A60, A63, and A64 was discussed. RN4 confirmed that there were no specific alternative treatment/interventions for these patients.

(2) In an interview on 2/25/10 at 10:20 a.m., the need for alternative treatment interventions for Patient A32 and A35 was discussed. RN3 confirmed that there were no specific alternative treatment/interventions for these patients.

(3) In an interview on 2/25/10 at 10:30 a.m., the need for alternative treatment interventions for Patient A1 and A5 was discussed. RN3 confirmed that there were no specific alternative treatment/interventions for these patients.

III. Lack of active treatment for patients with cognitive impairments and behavioral problems

A. Sample Patient

1.) Patient A28

a. Observation

(1) During an observation on 2/23/10 from 10:00 a.m. to 10:35 a.m., Patient A28 was seen in a hallway of the treatment unit where a "Reminiscing Group" was being held. During this period, the patient sat with his arms folded, head bowed, and eyes closed. When the staff conducting the group asked a question, the patient did not respond.

(2) During an observation on 2/24/10 from 10:45 a.m. to 11:15 a.m., the patient was observed in the Solarium of the treatment unit where a "Sensory Connections Group" was being held. During this period, the patient sat with his arms folded and eyes closed. Staff approached him 3 times to get him to participate. When the staff left him, he would fold his arms, bow his head, and close his eyes.

(3) During an observation on 2/24/10 from 10:35 a.m. to 11:15 a.m., the patient was observed in the Solarium of the treatment unit where a "Music Appreciation Group" was being held. During this period, the patient sat with his arms folded and eyes closed. The staff conducting the group asked Patient A28 if he was awake. There was no response from the patient.

b. Record Review

(1) Patient A28's "Annual Clinical Profile- Psychiatric Evaluation" dated 10/10/09 noted that this 64 year old Hispanic male was admitted to Eastern State Hospital on 10/18/00. His Axis I Diagnosis was "Dementia, Vascular Type, secondary to Cerebral Vascular Accident with Behavior Disturbance." The evaluation stated "The patient seems to have shown more deterioration of his cognitive functioning...The interpreter indicated that the patient talks in a gibberish way and that it is not Spanish or English."

(2) The Patient's "Annual Clinical Profile - Psychosocial Assessment" dated 10/6/09 stated "He received a 180 day civil commitment in January of 2003....[Patient's name] is Spanish speaking and will require an interpreter most of the time. His communication skills in Spanish are also very poor and at times it is very difficult for the interpreter to interpret what [Patient's name] is saying whether it is in English or Spanish "... "He requires total care with his ADL's...He remains incontinent." "Because of [Patient's name] inappropriate sexual behavior, it is impossible at this time to proceed with a discharge plan. There is no facility that is willing to accept him with the inappropriate sexual behaviors."

(3) The quarterly "Treatment Plan Review Note" dated 11/24/09 stated "Pt has severe cognitive impairment - he remains confused and disoriented, needs total care. He requires an interpreter for Tx [Treatment] Plans...He attends What's Up. Does not attend any other groups."

(4) The quarterly "Treatment Plan Review Note" dated 1/23/10 said that Recreational therapy would obtain sensory tools for the patient. The note stated "Patient appears not to understand where he is at, why he is hospitalized, he appears to have severe cognitive impairment, but he presented as quiet, calm."

(5) The "GPU Program Referral" form revealed that the patient was assigned to the following groups: "What's Up" held on Monday 9:30 a.m.; "Relaxation" held on Monday at 10:30 a.m.; "Reminiscing " held on Tuesday, Wednesday, Thursday and Friday at 9:30 a.m.; "Sensory Connections" held on Tuesday at 10:30 a.m. and "Music appreciation" held on Wednesday at 10:30 a.m.

(6) The "Group Attendance Details" data for the patient's assigned treatment groups revealed that Patient A28 "attended 89% of 59 groups held" and "participated 69%" of the time. This report revealed that patient was mostly non-verbal, and it contained comments that included but were not limited to: "slept, did open eyes to his name when called"; "limited participation, required physical assistance;" and "continues to require physical assistance to engage in activity."

c. Interview

(1) In an interview on 2/23/10 at 10:40 a.m., when asked if Patient A28 understood what she was reading in the group, MHT1 stated "I don't know if he understands or not."

(2) In an interview on 2/23/10 at 11:50 a.m., RT1 stated the patient did not communicate with staff and that it was difficult to communicate with the patient. She noted that staff needed to do demonstrations in order for him to follow instructions.

(3) In a joint interview on 2/23/10 at 3:40 p.m., RN2 and the Geropsychiatric Services Director said that patient A28 had been sexually inappropriate with the interpreter and that he sat and slept during group sessions.

(4) During an interview on 2/24/10 at 9:00 a.m., the Psychiatric Surveyor informed the Medical Director that after reviewing patient A28's care, it was determined that he had not received active psychiatric treatment. The Director confirmed that the hospital had not developed an alternative treatment plan and acknowledged the patient was not receiving active psychiatric treatment.

B. Non-Sample Patients

1.) Patient A22

a. Record Review

(1) The patient's "Admission Clinical Profile - Psychiatric Evaluation" dated 10/6/09 stated "This is the first admission for this 89 year-old male...admitted on 10/6/09 due to substantial deteriorating of his functioning... It has been further indicated that the patient has been 'very angry, irritable, and confused,' yelling at staff, and being unable to articulate his locations and where he is residing." The evaluation noted a provisional diagnosis of "Dementia, NOS, with Aggression/Delusions: Rule out Vascular Dementia with Delusions/Aggression."

(2) The last quarterly "Treatment Plan Review Note" dated 11/23/09 stated "Patient is currently on end of life care. Not oriented to time or place." The "Interdisciplinary Clinical Formulation (undated) noted "[Patient's name] is still having outbursts during which he will strike out. Some days he is alert and cooperative - he also will sleep or catnap most of the day. Due to his physical decline, he has been placed on End of life/comfort care..." The Current Discharge Plan section of the Treatment Plan Review Note stated "End of life care - possible Hospice Services if appropriate."

(3) The "GPU Program Referral" form revealed that the patient had no assigned groups. The short-term goals on the referral form stated "Will show passive participation in groups offered."

(4) The individual program sheet dated 2/25/10 showed that for the week of 2/21/10 - 2/27/10, the patient was to attend the following groups: "Sensory connections, Building Bridges, Drumming, and Gentle Care Relaxation." The "Group Attendance Details" from 1/23/10 to 2/23/10 revealed that the patient attended "75% of 37 groups held" and "participated 67%" of the time. This report contained comments that included but were not limited to: "Quiet and polite, sleepy, passive, and slept."

(5) A review of the patient's medical record and treatment plan (12/30/09) revealed no specific treatment plan identifying alternative treatment/interventions.

b. Interview

In an interview on 2/25/10, RN6 stated that the patient was on end of life care and noted that he [patient] sometimes attends groups. When asked about hospice care, she said "Sometimes this is considered for patients."

2.) Patient A39

a. Record Review

(1) The patient's "Annual Clinical Profile - Psychiatric Evaluation" dated 9/18/09 noted that the patient was a 64 year old male admitted...with a diagnosis of "Dementia, secondary to Traumatic Brain Injury with Mood Lability and Psychosis." The evaluation stated "He also has become increasingly seclusive and generally stays in his room and sleeps. He only comes out of his room when he has to go out for fresh air, smoking, and mealtimes...He has been resistive in attending groups and actually refused to attend discharge preparation."

(2) The patient's "Annual Clinical Profile - Psychosocial Assessment" stated "Since the surgery [Patient's name] has presented as more agitated, irritable, aggressive and assaultive toward peers. [Patient's name] has become increasingly seclusive to himself; he usually stays in his room, comes out for meals, but is usually resistive to attending groups...[Patient] will need four weeks of non aggressive/non assaultive behavior before a facility will accept a referral for placement."

(3) The last quarterly "Treatment Plan Review Note" dated 1/5/10 stated "Patient is seclusive to his room except for meals and smoking. He refuses all groups and activities, he remains irritable, easily angered, aggressive, agitated. He requires help with his ADL's."

(4) The "GPU Program Referral" form revealed that the patient was assigned to the following groups: "What's up" held Monday-Friday at 9:30 a.m.; "Relaxation" held Monday at 10:30 a.m.; Sensory Connections held Tuesday at 10:30 a.m.; "Music Group" held Wednesday at 10:30 a.m.; and "Music Appreciation" held Friday at 10:30 a.m.

(5) Review of the "Group Attendance Details" data from 1/23/10 to 2/23/10 revealed that the patient attended 69% of 65 groups assigned and participated 49%. This report contained comments that included but were not limited to: "no response, head on table, no aggressive bx's [behaviors], pt refused, said going to bed, slept, slept in wc [wheelchair], and slept most of time."

(6) Review of the patient's medical record and treatment plan review note (dated 1/5/10) revealed no specific treatment plan identifying alternative treatment/interventions.

b. Interview

In an interview on 2/24/10 at 10:25 a.m., RN #3 stated that Patient A39 was not attending many groups. She stated that it was difficult to get him out of bed and that he was cognitively impaired.

3.) Patient A47

a. Record Review

(1) The patient's "Annual Clinical Profile - Psychiatric Evaluation" dated 6/8/09 stated that he was a 57 year-old man readmitted on 5/18/05 with a diagnosis of "Dementia, Vascular type, secondary to Cerebral Vascular Accident and Traumatic Brain Injury, Alcohol-Induced." The evaluation noted that "He is unable to maintain meaningful interaction. He has difficulty focusing and does not make sense. His behavior appears essentially the same - he still shows aggressive, assaultive behavior, displays anger and agitation...Oftentimes he is very difficult to redirect and will become angry - yelling and threatening the staff."

(2) The patient's Psychosocial Assessment dated 6/4/09 stated "[Patient's name] continues to be a very difficult patient to coordinate with on discharge planning. This is in regards to the severity of his psychiatric problems, his aggressive/assaultive behaviors, and his medical problems... [Patient's name] will need to be free of assaultive/aggressive behavior for a least one month prior to discharge."

(3) The last quarterly "Treatment Plan Review Note" dated 1/22/10 stated "Pt [Patient] continues to present as irritable, angry, confused. Pt was assaultive on 1-8-10 ...Progress towards STG's [short-term goal] Impairment cognitive functioning with mood lability, active... LTG's [long-term goal] not met...Progress towards meeting discharge criteria - None, Due to pt's [patient's] assaultive, aggressive behavior no facility will accept pt at this time."

(4) The treatment plan update of 1/22/10 noted that short-term goal #2 was "When offered groups, [patient's name] will focus on maintaining or improving his functional skills through recreational/leisure involvement."

(5) The "GPU Program Referral" form revealed that the patient was assigned to the following groups: "What's Up" held Monday at 9:30 a.m.; "Relaxation" held Monday at 9:30 a.m.; "Reminiscing" held Tuesday-Friday at 9:30 a.m.; "Sensory Connection" held Tuesday at 10:30 a.m.; "Music Appreciation" held Wednesday at 10:30 a.m.; and "Drinks & Dialogue" held Friday at 10:30 a.m."

(6) Review of the "Group Attendance Details" data from 1/23/10 to 2/23/10 revealed that he "attended 69% of 71 groups held" and "participated 54%" of the time. This report contained comments that included but were not limited to the following: "no response, able to briefly add relevant comment, patient sleeping, left early, some arguing with peer, listening to group outside the door, refused to sit in group."

b. Interview

In an interview on 2/24/10 at 2:15 p.m., RN3 noted that Patient A47 consistently refused groups and alternative activities and that "he does not understand what's going in group because his cognitive functioning is poor."

Based on medical record review and interview, the Medical Director failed to:

I. Monitor Master Treatment Plans to assure that interventions were individualized treatment measures for 1 of 15 sample patients (Patient C15) and 3 non-sample patients (A37, A43, and A56). Interventions on the MTPs did not specify when they would be delivered (day and time) or were routine generic discipline functions. This failure results in a lack of guidance to staff in providing consistent and focused treatment to patients. (Refer to B122).

II. Provide housing for one of 15 active sample patients (Patient C15) on a treatment unit that was appropriate to his treatment needs. The patient was housed on a high security forensic unit that did not have a treatment program appropriate for his needs. This deficient practice results in patients being hospitalized without all receiving all interventions for recovery, potentially delaying their improvement and discharge (Refer to B125-I).

III. Ensure that alternative active treatment measures were provided for 1 of 15 sample patients (A67) and 8 non-sample patients (A1, A5, A32, A35, A57, A60, A63 and A64 who were housed on Geropsychiatric units and refused to participate in regularly scheduled treatment activities. (Refer to B125-II)

IV. Assure appropriate treatment for 1 of 15 sample patients (A28) and 3 non-sample Geropsychiatric patients (A22, A39 and A47) who had severe cognitive impairments and behavioral problems. (Refer to B125-III).

These failures result in patients being hospitalized without all interventions for their recovery being provided, potentially delaying discharge to appropriate settings.

Based on medical record review and interview, the Director of Nursing failed to monitor the Master Treatment Plans of 3 of 5 sample patients (A37, A43 and A56) to ensure that nursing interventions clearly specified what the nursing staff was to do (in individual or group sessions) to assist patients to achieve their short and long-term goals. The listed nursing interventions were generic nursing functions instead of individualized interventions, based on patient assessments.

Findings are:

A. Record Review

1.) Patient A37 was a 55 year-old male admitted 1/12/10 with a diagnosis of Chronic, Paranoid Schizophrenia. His treatment plan update of 2/10/10, listed the following generic nursing function for the short-term goal: "[Patient's name] will voluntarily accept medications five of five times when offered for two weeks": [RN] will "Redirect to a reality based topic as needed."

2.) Patient A43 was a 32 year-old male admitted 1/9/10 with a diagnosis of Schizoaffective Disorder. His treatment plan update of 2/8/10 listed the following generic nursing function for the short term goal "[Patient's name] will take meds 100% of the time": "[Nursing] Staff will monitor patient for increasing anxiety and frustration, jumping up and down (upper body)."

3.) Patient A56 was a 51 year-old male admitted 2/4/10 with a diagnosis of Chronic, Paranoid Schizophrenia. His treatment plan update of 2/16/10 listed the following generic routine nursing functions for the following short-term goal, "[Patient's name] will comply with treatment and medications every time offered." RN Intervention: "Approach [Patient's name] in a calm and unhurried manner; Provide reassurance that ESH is a safe place and staff are here to help; Provide a quiet place as necessary to decease stimuli."

B. Interview

In an interview on 2/24/10 at 11:00 a.m., the Master Treatment Plans for Patients A37, A43 and A56 were reviewed. The Director of Nursing acknowledged that these plans contained generic routine nursing functions and did not specify what nursing staff was to do in individual and/or group sessions to assist patients achieve their short-term goals.