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Based on medical record review, document review and interview, in two (2) of seven (7) medical record reviewed, the facility did not follow it's policy to ensure that (a) patients are placed in seclusion when ordered by a physician and (b) verbal order for restraint/seclusion is signed by the physician in a timely manner. (Patient #14, #16, #21).


Findings include:

Review of medical record for patient #14 noted the patient was admitted on 1/26/2019. On 2/15/2019 at
12:30 PM, the nurse noted the patient became agitated, patient postured at staff aggressively. Patient was asked to walk to the quiet room and instead ran to his room closing himself in. Staff open the door and escorted patient to the seclusion room. Seclusion room door was locked at 12:50 PM. Closed seclusion was discontinued at 2:30 PM.
There was no physician's order for the patient to be placed in seclusion, documented in the medical record..

On 2/16/19 it was documented that the patient was aggressive and threatening staff. The patient was placed in seclusion. The seclusion order form dated 2/16/19 at 12:20 PM, did not specify the duration of the seclusion, as the section on the form for "up to hours ( maximum 3 hours)" was not completed.

On 2/20/2019 it was documented that the patient became irritable and agitated. The physician's note, dated 2/20/2019 at 7:01 PM, indicated that the patient was taken to the seclusion room to give IM ( intramuscular ) medications. There was no physician's order for seclusion. There was no documentation stating how long the patient was in the seclusion room.



Review of medical record for patient # 16 noted the patient was admitted to the facility on 1/18/19. On 1/26/19 it was documented that the patient displayed aggressive behavior. The patient began hitting hand against wall in the hallway at 12:49 PM and at 12:55 PM, the patient was escorted to the seclusion room by the staff doing constant observation. The staff documented the seclusion room door was opened.

On 2/4/19, it was documented that the patient went into a verbal altercation with another female patient. The patient was medicated on 2/4/19 at 11:50 PM and the patient was escorted to the seclusion, door open. There was no physician order for the seclusion. The documentation did not state how long the patient remained in the seclusion room.

On 2/15/19, it was documented that the patient was trying to bite her hands and bang head, de-escalation and redirector provided with no success. The patient was escorted to the seclusion room (door open). The patient was medicated in the seclusion room on 2/15/19 at 1:50 PM. The patient was escorted back to room.
There was no documentation stating when the patient was escorted back to her room.

This patient was escorted to the seclusion room on multiple occasions without a physician's order for seclusion (1/26, 2/3, 2/10 and 2/15)

During interview on 3/15/18 at approximately 11:30 AM, Staff K, Chief Nursing and Quality Officer, acknowledged the findings. Staff K stated patients in seclusion room or on restraint, are placed on constant observation. He stated an order was not necessary as the seclusion door was open. When asked by the surveyor, Staff K was unable to state if the patient was aware that she was not in seclusion and could leave the seclusion room.

Review of facility's policy Titled "Seclusion," states: Except in an emergency situation seclusion may only be employed when ordered by a physician." The facility was not following this policy.



Review of the medical record for patient # 21 identified: patient was admitted on 1/12/2019. On 2/14/19 at
2:54 AM, due to patient's aggressive violent behavior, the patient was placed in seclusion. The nurse noted the verbal order and indicated the seclusion was initiated 2/14/19 at 2:54 AM, and the order expired 2/14/19 at 3:00 AM. The verbal telephone order for seclusion, was authenticated by the physician on 2/14/19 at 7:00 AM. The order form indicated that the order was not to exceed 30 minutes from the time of initiation.

The policy titled "Verbal/telephone Orders," revised 1/20/2017 states, verbal orders for emergency initiation of restraint/seclusion used must be cosigned by the physician within thirty (30) minutes of the application of restraint or seclusion.

Based on medical record review and interview, in two (2) of seven (7) medical records reviewed, the facility failed to ensure orders for restraints are written as determined by hospital policy. (Patient #13, Patient #18)

Review of medical record for patient #13 identified: the patient was admitted on 1/24/2019. On 1/30/19, It was documented that the patient was a danger to self (banging head on the wall). The physician ordered for the patient to be placed on 4 points restraint. The physician's order for 4 points restraint, dated 1/30/2019 at 9:26 AM, did not include the duration (time expired) the patient should be in restraint.


Review of medical record for patient #18 identified: the patient was admitted on 1/14/2019. On 1/16/2019, it was documented that the patient became abusive to staff and other patients. The patient was placed in 4 points restraint on 1/16/2019 at 4:45 PM. The physician's order for restraint, dated 1/16/2019 at 4:45, did not specify the type of restraints.


During interview with Staff K, Chief Nursing & Quality Officer, on 3/15/19 at 11:30 AM, Staff K acknowledged the findings. Staff K stated the facility's plan to implement MD electronic orders, will eliminate the MD order deficiencies identified during the survey.

Based on medical record review and interview, in one (1) of 15 medical records reviewed, the medical staff did not ensure that the patient received an intensive assessment and treatment, as per facility's policy. (Patient #9).

Findings include:

Review of medical record for patient # 9 identified: 52 year old patient admitted on 3/1/19. The record indicated the patient with distorted lower extremity (right and left) and foot. The patient had unsteady gait and used a wheel chair for mobility.
On 3/7/2019, the physician approached the patient to inquire about the mobility. The patient informed the physician that she has been using the wheelchair for years, at home, can walk to the bathroom and kitchen. Physical therapy evaluation was offered. The patient was very emotional and informed the physician that further discussions should be conducted with her dad.
There was no documentation evidence that the physician followed up with the patient's mobility.

On 3/8/19 the physician documented that the patient had a blood test and this test was positive (abnormal) for Tuberculosis (TB). A chest x ray was negative for active TB, the patient needed Infectious Disease (ID) referral for treatment of latent TB.
There was no documented evidence that there was a follow-up with ID while the patient was hospitalized.

On 3/13/19 10:32, the physician documented "the patient was planned for discharge and PPD was positive (abnormal). A subsequent CxR did not reveal evidence for active TB. A quantiferon (blood test) was sent for confirmation and is pending at the time of discharge." There was no documentation evidence this medical issue was resolved prior to discharge.
The Discharge Summary did not include the PPD information.

Review of facility's policy titled "Assessment and Reassessment," states, "Assessment: an intensive process aimed at identifying and addressing a patient's presenting problems." This policy was not implemented to address patient's problems before discharge.

During interview with Staff K, Chief Nursing & Quality Officer on 3/15/19 at approximately 11:45 AM, Staff K acknowledged the findings.

Based on medical record review, document review and staff interview, in three (3) of six (6) medical records reviewed, the nursing staff did not ensure that (a) patients received appropriate fall risk screening to determine their fall risk and (b) nursing care plans were appropriately updated after patient falls. (Patients #1, #2 and #3).

Findings Include:

Review of medical record for patient #1 revealed: a 63 year-old female patient was admitted on 3/5/19 for Bipolar Disorder. Upon admission a nurse assessed the patient as a no risk for falls and documented the patient's score as 15. (Fall Risk Assessment scores 0-24 = No Risk for falls: Scores 25-50 = Low Risk: Score 51 and above = High Risk for falls). On 3/5/19 the psychiatrist ordered Klonopin (sedative/hypnotic), Effexor (anti-depressant), Zyprexa (antipsychotic) and Neurontin (anti-seizure). These medications are noted to have side effects that include dizziness, clumsiness while walking and lightheadedness.

On 3/11/19 at 6:37 PM, the nurse noted that the patient fell in the hallway and the patient's fall risk score was changed to 40 (Low Risk).
On 3/12/19 at 5:00 AM, the nurse noted that the patient fell (second fall) while using the bathroom in her room. The nurse noted that the patient was bleeding from the left side of the head and had sustained a laceration and she notified the physician. The nurse noted that the patient reported that the she felt lightheaded before she fell in the bathroom. The nurse documented that the patient was transported by ambulance at 5:42 AM to another hospital where three (3) staples were applied to the wound.
On 3/13/19 1:24 AM, the nurse noted that the patient's fall risk was 25 (No risk) and at 3:33 PM the nurse noted the fall risk was 40 (Low Risk).
On 3/15/19 at 2:18 AM, a nurse noted that the patient's fall risk was 15 (No Risk).


Review of medical record for patient #2 revealed: a 25 year- old male was admitted on 10/15/18 for Schizoaffective Disorder. The nurse admitting fall risk assessment score was 0. The physician ordered Clozaril (anti-psychotic) on 10/15/18, a medication noted to have side effects of seizures and that the blood pressure could drop upon standing. On 10/21/18 at 4:00 PM, the nurse observed the patient placing himself on the floor. A nurse noted that the patient complained of body twitching and documented the fall risk at 25. A nurse noted on 10/23/18 at 10:10 PM that the patient was observed twitching and that he fell and hit his head. A nurse documented at 11:52 PM the patient's fall risk score as 25 (Low risk).

Similar findings of inappropriate fall risk assessment of a patient who fell was noted in medical record #3.

During interview with the Staff A, Patient Care Director on 3/13/19 at 2:00 PM, she stated the patients should have been scored as high risks for fall upon admission, especially with the anti-psychotic and sedative drugs that the patients were receiving.

The facility policy titled "Fall Assessment and Prevention" last revised on 10/24/17 states, "a fall in the hospital always indicates the need to increase the patient to High Fall Risk."
The policy does not address fall risk assessment for the patients who are receiving anti-psychotic and sedative medication.

Based on observation, document review and staff interview, it was determined that the Food Service Director did not ensure that the menu planning and emergency food supplies for the Food Service Department is maintained.

Findings include:

A tour of the hospital kitchen was conducted on 3/11/19 at approximately 11:00 AM, identified the following:

The hospital Master Menu posted in the kitchen consisted of a two (2) week cycle menu, with only one diet listed(Regular diet). The hospital has approximately 35 diets on their Physician diet formulary, and 34 of these diets were missing from the posted Master Menu. Therefore, all approved hospital diets for meals were not contained in the menu cycle.

The hospital provides Asian food items, however, Asian menus with diet restrictions are not included as part of the Master Menu.

Physicians Diet Orders were abbreviated on the meal ticket. Example: Prescribed "Heart Health diet" was noted on the meal ticket as "HH Diet." Review of the hospital policy titled "Tray Identification," does not direct the Food Service Department to abbreviate physician prescribed diet orders.



A review of the Food Service Department Emergency Preparedness Manual identified that the manual was not comprehensive. Examples are as follows:

- The manual did not state the manner the food would be delivered to the units.
- There was no direction given for the location of menu items, water, paper goods or utensils.
- The manual contained a five (5) day menu. This menu was not modified to include therapeutic diets and did not meet the nutritional needs of all patients.

All findings were shared with Staff B, Director of Quality and Patient Safety and Staff C, Staff Dietitian, who accompanied the surveyor during the tour.

Based on document review and staff interview, it was determined that the facility did not ensure that hospital menus with nutrient analysis were approved by a qualified Dietitian.

Findings include:

Review of the Master Menu attached to the nutrient analysis showed that the menus were not reviewed or approved by a qualified Dietitian. Name of a qualified Dietitian and date of review were missing on the menus.

Staff C, Dietitian and Staff B, Director of Quality and Patient Safety, were present during review. Staff C acknowledged the finding and stated he did not know who or when the menus were reviewed and approved.

Based on document review and interview, it was determined that the Food and Nutrition Department failed to ensure that hospital diets and menus are nutritionally balanced and meet the needs of patients.

Findings include:

A review of hospital menus and nutrient analysis identified:
- The hospital menu attached to the nutrient analysis contained 15 diets. Seven (7) of 15 diets did not specify the amount of the diet restriction, therefore, the nutrient analysis of these diets was invalid.

- The Hospital Master Menu has 15 diets listed with nutrient analysis. The Physician diet formulary has 35 diets. Therefore, 20 diets on the Physician diet formulary are without a menus or nutrient analysis.

A review of the physician diet formulary identified:
- The Physician Diet Formulary did not match the hospital diet manual. For example: Bland and BRAT diets listed on the Physician Diet formulary were removed from the hospital diet manual. There were no menus for these diets.

- The Physician diet formulary has Consistent Carbohydrate diet with amount of carbohydrate per meal and not by total amount of carbohydrate per day, as per the diet manual.

- All diets on the Physician Diet Formulary does not specify the amount of the restriction. Examples: Heart Healthy, High Fiber, Low Fiber, Low Fat, Low Cholesterol and Renal diets.

- There was no evidence that the Physician Diet Formulary was updated according to the hospital diet manual (2018 National Academy of Nutrition).

Present during the review were Staff C, Staff Dietitian and Staff B, Director of Quality and Patient Safety. The findings were acknowledged, and Staff was unable to tell the surveyor when the Physician Diet Formulary was last updated. There is no Nutrition Committee at the hospital.


A review of the hospital Nutrition Screen, revised 6/4/15, identified: The Nutrition Screen consisted of data that pertained to a diet history that would be required when a nutritional assessment is necessary. A nutrition screen is not a nutrition assessment.
- The screening tool should measure data to assess if a nutrition assessment is warranted by defining if a patient is at high risk nutritional risk or not at nutritional risk.
- There is no determining factor at the end of the screen to identify if the patient is at nutritional risk.
- This screen is missing this outcome.

Present during review were Staff B, Director of Quality and Patient Safety and Staff C, Staff Dietitian. Staff C acknowledged the findings.

Based on document review and staff interview, it was determined that the hospital therapeutic diets were not current with the hospital diet manual.

Findings include:

A review of the hospital therapeutic diets routinely ordered by the physicians, identified the diets were not current with the hospital diet manual.

During interview on 3/12/19 at approximately 2:00 PM, Staff B, Director of Quality and Patient Safety informed the surveyor that their Clinical Nutrition Manager had resigned, and the staff dietitians cannot respond to administrative questions. The Clinical Nutrition Manager is responsible for updating the Physician Diet Formulary with the hospital diet manual. The hospital diet manual was updated in 2018 when the Clinical Nutrition Manager was still employed.

Based on observation, document review and staff interview, the facility did not ensure that the condition of the physical plant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

During tours of the four (4) Psychiatric units on 3/11/2019 at 11:00 AM, the following were identified in the presence of the facility's Director of Engineering and Assistant Director of Engineering:

On the 2nd floor:
- The male bathrooms and showers "three stalls and two shower areas" were closed and not available for use by the patients. Upon interview, the facility's Director of Engineering stated that there was a leak of water at the male bathrooms and they were being fixed. It was observed that the facility has used one bathroom that was inside a patient room as a male bathroom which is not sufficient to substitute for the unavailable male bathrooms.

- The wiring of the microwave was not secured and is a potential for looping hazard.
- There was a cell phone being charged and connected through the charger wiring to the electric outlet on the counter of the pantry next to the refrigerator, and was not attended by any staff.


On the 4th floor:
- The air supply at the anteroom of the seclusion room was observed to have a wire mesh covering with openings > 1/2-inch-wide, which is a potential for looping hazard.
- The latch plate of Room GS-04-426 was observed to be loose and not secured and is protruding outside the door frame, which is potential for self-harm.
- The wire mesh covering the air supply in the anteroom of Seclusion Room 427, as well as on all the other floors, had openings that are approximately 1/2 - inch wide and are potential for looping hazard.
- The ceiling access door of Room 440 was found to be rusty and the paint is peeled off.
- The phone cord in the pantry room was noted to be too long, >6 ft long and is a potential of looping hazard.
- The door handle of a cabinet within the Therapeutic Activity (TA) Room, was noted to be not an OMH approved type of handle and is a potential for looping.
- The light fixtures of all the patient rooms were observed being mounted to the walls at approximately 5- feet from the floor and they had sharp edges and presented risk for self-harm.


On the 5th floor:
- There was a medical bed placed in the Seclusion Room #517. The use of medical bed in the seclusion room is a potential for looping hazard.
- The tracks of the shower curtain can be used for looping by patients.
- The electric wiring and cords of the coffee machine in the pantry room were long and not secured and presented looping hazard.


On the 3rd floor:
- The wardrobe of Room GS-03-302 had sharp edges which is a potential of self -harm.
- The computer drop down station on the anterooms of the seclusion rooms were found to have sharp edges and small openings between the stations and their frames, which makes them unsafe and a potential for self-harm and a looping hazard.
- There was an opening which is 1 ½ x 2 ½ feet in diameter on the wall below the drop down computer station of Room 302.
- The panic bar button in the pantry rooms and treatment rooms are boxes which were mounted at about 4 ½ ft from the floor and presents a looping hazard.
- The clean utility room was found to have a negative air pressure instead of the positive air pressure that is required for this type of room.
- The hinges of the storage cabinet, towel dispenser and the panic bar in the Therapeutic Activity (TA) Room of the 3rd floor, presents a looping hazard.
- There was no exit sign provided at the medical record area to direct the staff to the exit door in the event of a fire or emergency.

Based on medical record review, document review and interview, in four (4) of 11 medical records reviewed, the facility did not ensure that each patient's discharge planning evaluation includes an assessment of the patient's post-discharge environment for its appropriateness. (Patient #4, #7, #8 & # 9).

Findings include:

During a tour of the 4th floor, on 3/11/2019 at approximately 12:00 PM, patient # 4 was interviewed. The patient stated prior to admission she resided with two roommates. The patient stated that she will be discharged tomorrow to reside with her boyfriend.

Review of medical record for patient # 4 identified: 31 year old with history of mental illness, was transferred from another hospital as an involuntary status due to suicidal ideation. The patient was admitted to this facility on 2/20/2019. The Social Services Progress note, dated 2/28/2019, documented that prior to hospitalization the patient was living with two roommates. The patient was to be discharged on 3/12/19 to reside with her boyfriend.
The discharge evaluation did not include the reasons the patient did not return to pre -hospitalization residence. The discharge planning evaluation did not include if the patient's boyfriend had the ability to care for the patient, post discharge.

Staff G, Social Worker, assigned to patient #4 , was interviewed, on 3/13/19 at 1:36 PM. She stated the arrangement was made prior to hospitalization.


Review of medical record for patient # 7 identified: 33 year old with multiple psychiatric hospitalization, was admitted on 12/9/2018. On 12/17/2018, the social worker note indicated that referrals were sent to three inpatient rehab facilities.
There was no documented evidence that the placement process and bed availability was discussed with the patient.

On 12/31/18, the social worker stated the patient was willing to be discharged to only one inpatient rehab.

Social work discharge note dated 1/2/2019, indicated that the patient was to return to mother's home. It was noted that the discharge planner connected the patient with an outpatient treatment program. Patient and family agreed with discharge plan.
The discharge planning evaluation did not include if the patient no longer required inpatient rehab services or the reason the discharge plan was changed. The discharge planning evaluation did not include if returning to pre-hospitalization environment was appropriate for this patient.
During interview with Staff F, Director of Social Worker on 3//13/19 at 1:00 PM, Staff F acknowledge the findings.


Review of the medical record for patient # 8 identified: 70 year old who was admitted on 2/14/19. Prior to admission, the patient lived in a supportive adult residence. The psychosocial assessment dated 2/15/19 indicated, as per patient's resident case manager, patient lived in a roach infected room, non compliance with out-patient care services, poor ADLs and hoarding.

On 2/21/19, the behavior health notes indicated that due to thought and memory impairments, the patient was not able to care for himself independently in the community.

The patient was discharged on 3/11/19 back to residence, with out-patient mental services. The patient was referred for home health, home attendant and skilled nursing services. The date for implementation of home services was not documented
During interview with Staff F, Director of Social worker, Staff F acknowledged the findings.


Review of medical record for patient #9 identified: 52 year old patient with history of multiple admissions, was admitted on 3/1/19. The chief complaint, the patient stopped taking her medications and became paranoid towards her home attendant. The patient hit the home attendant. Prior to admission, the patient had case management services and home attendant. The patient was discharged on 3/13/19 to home with same outpatient services.

On 3/13/19, the discharge planner documented "I called VNS ( visiting nursing services) your home care services is resumed on 3/13/19."
The discharge planning assessment did not document the current home care service hours and if this was adequate to meet the patient's discharge needs.

Review of the Facility's Policy titled, "Discharge Planning and Continuum of Care," states: "Social Work documentation in the medical record includes the following: a) patient/caregiver involvement, b) active discharge planning efforts, c) referrals to agencies/or facilities and the outcome of application for serves, d) collaboration with the interdisciplinary team and e) coordination of care."
This policy does not include an assessment of the patient's post-hospitalization environment and/or appropriateness of post discharge plan.

Based on record review and interview in one (1) of 11 medical records reviewed, the hospital did not ensure that all assessments are completed timely so that post- hospital care services can be implemented, as planned ( Patient #6) .

Findings include:

Review of medical record for patient # 6 identified: The patient was admitted on 1/24/19. On 1/25/19, the discharge planning notes indicated that the patient will likely be discharged back home with outpatient mental health services.
On 1/28/19, the patient had a physical therapy (PT) evaluation. PT recommended physical therapy in a sub acute rehab. The discharge plan was changed to subacute rehab.
On 1/31/19, MD noted patient was still in agreement with the plan to transfer him directly to a subacute or acute rehab, arrangements were made with a specific facility, which has reviewed preliminary information and looks favorably towards his application.
The discharge note dated 2/1/2019 indicated that "PT recommended for discharge to subacute rehab due to patient's mobility and inability to navigate stairs in home." The patient was accepted at a skilled nursing facility (SNF), however, the patient could not be transferred to the SNF directly from the hospital as there was no staff member available to certify the screen. (The assessment to determine the level of care and type of facility needed). The patient was discharged home and the patient was referred for outpatient mental health treatment. Patient schedule to have nurse in the community to complete the screen for the referral to the skilled nursing facility. There was no documented follow-up that the patient was screened and accepted to the SNF.

There was a delay in the discharge and the patient remained in the hospital until 2/1/19. The patient was then discharged to home and not to the SNF. There was no documented follow-up that the patient was screened and accepted to the SNF.

During interview with Staff F, Director Social Worker, on 3/14/2019 at approximately 2:00 PM, he stated the patient's discharge plan was to skilled nursing facility and the patient was accepted to that facility. He stated due to extraordinary circumstances, currently there was only one screen-certified social worker on staff, the patient was discharged home. Staff F stated the patient was discharged home with the necessary durable medical equipment and arrangement was made for a registered nurse to screen the patient at home. Staff F stated the patient entered the skilled facility as scheduled.

Review of the Facility's Policy titled," Discharge Planning and Continuum of Care," states: Social Wok Staff is responsible for follow-up to implementation of the discharge. There was no documented evidence that this policy was followed.

Based on medical record review and interview, in one (1) of 11 medical records reviewed, the facility did not ensure the correct discharge plan was documentation in the patient's medical record. (Patient# 5)

Findings include:

Review of medical record for patient #5 identified: 53 year old homeless was admitted to the facility on 2/21/2019. On 3/1/2019 the discharge planning documentation indicated the discharge plan was inpatient rehab vs. shelter, with outpatient treatment. On 3/8/2019, the Social Services note indicated that the patient expressed interest in inpatient rehab treatment. Referral was made to inpatient treatment center and the patient was accepted, with 3/12/2019 admission date. The patient agreed with the plan.

On 3/12/2019 at 10:53 AM, the RN discharge note indicated the patient was discharged to private residence. He was picked up by cab service. Patient left the facility at 9:00 AM.

Social Work Discharge Summary dated 3/13/2019 at 1:26 PM, documented: After care options and recommendations were reviewed with the patient and he expressed preference being discharged to an inpatient. Patient was discharge to inpatient rehab with 30 day supply of medications, on 3/12/2019 at 9:00 AM . The record indicated the Social worker made arrangement for transportation to the inpatient rehab.

During interview with Staff F, Director of Social Work, on 3/14/19 at approximately 1:45 PM, Staff F acknowledged the findings.

Based document review and interview, in two (2) of 11 medical records reviewed, the facility did not inform patients the freedom of choice in post-hospitalization providers (Patient #6 & # 8).

Findings include:

Review of medical record for patient # 6 identified:72 year old patient was admitted on 1/24/19. Prior to hospitalization, the patient resided at home with family. The discharge plan was changed to a skilled nursing facility. There was no documented evidence that the patient/patient representative was informed the patient had a choice in selection of skilled nursing facility, and that the patient/patient representative was not given a list of facility to choose from.


Review of medical record for patient # 8 identified: 70 year old was admitted on 2/14/19 and discharged on 3/11/18. The patient was discharged to home with home care services. The patient was instructed that he was referred to a Home Care Agency and the patient will be contacted by a nurse to set up an initial visit. There was no documented evidence the patient was given a choice of home care agency.

Review of the Facility's Policy titled, "Discharge Planning and Continuum of Care," states: Aftercare Plans may include skilled nursing, assisted living placement and home care."

This policy did not include the regulatory requirement that, as part of the discharge planning process, the patient or the patient's family must be informed of their freedom to choose post-hospital care service providers.

During interview with Staff F, Director of Social Worker, on 3/15/19 at approximately 11:00 AM, Staff F acknowledged the findings.

Based on record review and staff interview it was determined that for 7 of 10 active sample patients (Patients 1,2,4,5,6,8 and 10) the Psychiatric Evaluations failed to include an assessment of patient assets in descriptive, not interpretive, fashion. These failures resulted in no information being present that might help engage these patients in therapeutic endeavors.

The findings include----

I. Record Review:

1. Patient 1: The Psychiatric Evaluation dated 2/20/19 had as the Psychosocial Strengths: "Cooperative" as the sole patient asset identified.

2. Patient 2: The Psychiatric Evaluation dated 2/22/19 had as the Psychosocial Strengths: "Cooperative. No physical impairments."

3. Patient 4: The Psychiatric Evaluation dated 3/4/19 had as the Psychosocial Strengths: "Cooperative" as the sole patient asset identified.

4. Patient 5: The Psychiatric Evaluation dated 2/6/19 had as the Psychosocial Strengths: "Cooperative, Positive attitude."

5. Patient 6: The Psychiatric Evaluation dated 1/14/19 had as the Psychosocial Strengths: "Communication skills, Cooperative."

6. Patient 8: The Psychiatric Evaluation dated 2/27/19 had as the Psychosocial Strengths: "Cooperative, Motivation for treatment."

7. Patient 10: The Psychiatric Evaluation dated 11/03/18 had as the Psychosocial Strengths: "Support system." No information about inherent patient assets that might be utilized in selecting therapeutic interventions was present.

II. Staff Interview:

On 3/12/19 at 10:00 a.m. the Clinical Director was interviewed. The director was shown several of the examples cited in Section 1, above. The director agreed they were problematic and stated, "They could be more individualized."

Based on record review and interview, the facility failed to formulate treatment goals that were relevant to the patient's psychiatric condition for 8 of 10 active sample patients (1, 2, 4, 5, 6, 7, 9 and 10). The goals were not measurable. Without a set of defined goals against which to measure progress, it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in case of lack of progress.

Findings include:

A. Record Review

1. In patient 1's Master Treatment Plan (MTP), dated 3/10/19, the difficult to measure short-term goal for the identified problem "anxiety, delusional, depressed mood, impulsive, paranoia, suicidal, thought disturbance" was "pt [patient] will have decrease in psychotic sx's [symptoms], no longer be suicidal and able to participate in a dc [discharge] plan."

2. In patient 2's MTP, dated 3/4/19, the difficulty to measure short-term goal for the identified problem "aggressive, anxiety, impulsive paranoia, thought disturbance" was "pt. will have improved [sic] thought disorganization."

3. In patient 4's MTP, dated 3/4/19, the difficult to measure short-term goal for the identified problem "anxiety, depressed mood, manic symptoms, mood swings, suicidal, thought disturbance" was "pt will be free from suicidal ideation."

4. In patient 5's MTP, dated 3/1/19, the difficult to measure short-term goal for the problem "agitated, depressed mood, impaired concentration, paranoia, worthlessness" was "pt will present with improved mood, more reality-based thinking."

5. In patient 6's MTP, dated 3/6/19, the difficult to measure short-term goal for the identified problem "AH/VH/SI [Audio Hallucination, Visual Hallucination, Suicidal Ideation]" was "pt will stabilize on medications and thinking will be grounded in reality."

6. In patient 7's MTP, dated 3/1/19, the difficult to measure short-term goal for the problem "anxiety, depressed mood, impaired concentration, worthlessness" was "s/w [social work] will collaborate with the pt on a mutually agreed upon aftercare plan that will address pt's plan with new appropriate medication, treatment plan."

7. In patient 9's MTP, dated 2/27/19, the difficult to measure short-term goal for the problem "depressed mood, thought disturbance" was "improvement of depression in the context of bipolar illness."

8. In patient10's MTP, dated 3/5/19, the difficult to measure short-term goal for the problem "aggressive, agitated, impulsive, manic symptoms, thoughts disturbance, other S/P [Suicide Precaution], seclusion" was "pt. will demonstrate ability to have linear conversation in a calm and appropriate manner."

B. Interview

In an interview with the Clinical Director on 3/12/19 at 2:30 p.m., the difficult to measure short-term goals were discussed. She did not dispute the findings.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) for 8 of 10 active sample patients (1, 2, 3, 4, 5, 7, 9 and 10) that individualized treatment interventions with a specific purpose and focus. Many of the interventions on the Treatment Plans were listed as generic discipline functions/tasks. Failure to clearly describe specific modalities on patients' MTPs can hamper staff's ability to provide treatment based on individual patient needs.

Findings include:

I. Record Review

Dates of MTPs in parenthesis--

1. Patient 1 [MTP 3/10/19]:
For the problem identified as "anxiety, delusional, depressed mood, impulsive, paranoia, suicidal, thought disturbance," the generic MD [doctor] intervention was "MD will see pt 5x a week for 20 min [minutes] per day for medication management and will monitor for NC SE [Negative Side Effect] to medication [sic] and draw appropriate bw [blood work]."

2. Patient 2 [MTP 3/04/19]:
For the problem identified as "aggressive, anxiety, impulsive, paranoia, thought disturbance," the generic intervention was "pt will be encouraged to attend groups such as mental health education, anger management and social skills to verbalize feelings with improved insight behavioral control."

3. Patient 3 [ MTP 3/04/19]:
For the problem identified as "agitated, depressed mood, hopelessness, impaired concentration, impulsive paranoia, sleep disturbance (decrease), suicidal, worthlessness," the generic MD intervention was "MD will meet with [Patient 3] for 20 - 30 mins [minutes] daily to review the efficacy and tolerability of the prescribed mood-stabilizing and antipsychotic regimen and to work on problem solving and coping skills to handle distressing emotional states, life circumstances. The SW will meet with pt during daily clinical rounds, make collateral contact as necessary, engage in discharge and safety planning and provide psychoeducation, and counseling to encourage pt's insight and mental health condition."

4. Patient 4 [MTP 3/04/19]:
For the problem "anxiety, dressed [sic] or typo? mood, manic symptoms, mood swings, suicidal, thought disturbance," the generic social work intervention was "s/w will meet pt 1x daily rounding 3x per week to provide psychoeducation, emotional support, nursing will observe patient's behavior frequently, will assess pt's mood and thought."

5. Patient 5 [MTP 3/01/19]:
For the problem "agitated, depressed mood, impaired concentration, paranoia, worthlessness," the generic social work intervention was "s/w will meet with pt during daily clinical rounds, make collateral contacts as necessary, engage in discharge planning and provide psychoeducation and counseling to encourage pt insight into mental health condition."

6. Patient 7 [MTP 3/01/19]:
For the problem "anxiety, depressed mood, impaired concentration, worthlessness," the generic intervention was "pt will be seen 3 times per week to discuss an appropriate aftercare plan, encourage pt to engage in groups and provide psychoeducation regarding treatment adherence."

7. Patient 9 [MTP 2/27/19]:
For the problem "depressed mood, thought disturbance," the generic intervention was "psychiatrist will prescribe psychotic [sic] or typo? medications, describe the risks and benefits of these medications and provide supportive psychotherapy 5 days a week for 15 minutes per day."

8. Patient 10 [MTP 3/05/19]:
For the problem "aggressive, agitated, impulsive, manic symptoms, thought disturbance," the generic intervention was "administer medications as ordered, educate on medication, effects, and monitor adherence."

B. Interview

In an interview with the clinical director on 3/12/19 at 2:40 p.m., the generic interventions were discussed. She did not dispute the findings.

Based on medical record review and staff interview it was determined that the clinical director failed to:

1.Ensure Psychiatric Evaluations contained an assessment of patient assets in descriptive, not interpretive fashion. For details, see B117.

2.Ensure Master Treatment Plans had goals that were behaviorally measurable. For details, see B121.

3.Ensure Master Treatment Plans contained interventions that were more than a listing of generic discipline tasks and were reflective of individualized patient care to meet specific patient needs. For details, see B122.

These failures resulted in absent information that might be utilized in treatment planning. These failures also resulted in Master Treatment Plans that did not reflect an individualized approach by staff when treating each patient.