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Based on observations and interview, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients on a geriatric psychiatric unit. There were currently 14 patients receiving treatment at the time of the observations.

Findings:

On 12/07/15 at 10:00 a.m., the following observations were made in patients' rooms:

a. Room entry door and bathroom doors with 3 hinges with an area between the hinges that were a ligature risk,
b. Crank beds with 3 cranks attached to the front of all the beds on the unit,
c. Goose neck faucets in the patients' bathroom sinks (non-anti-ligature).
d. The patient beds contained springs which had sharp points and could potentially be
removed and the springs and the frame of the beds presented an area for ligature risk.
e. Mattresses with a plastic cover with a zipper down the backside center of the mattress, which could serve as an area to hide contraband for 15 out of 16 beds observed.
f. Exposed plumbing under the toilets in the patients' bathroom.
g. Doors to the bathroom in the patient rooms were noted to be locked at all times limiting the patients ability to utilize the toilet and/or lavortory when needed. Patients were required to search for a staff member to unlock the bathroom door in order to utilize the bathroom. Patient #3 complained about not having access to his bathroom when he needed to go the bathroom on 12/07/15 at 11:00 a.m.


An interview was conducted with S3RDQ on 12/07/15 at 2:30 p.m. She confirmed the above observations were safety risks for the patients in the hospital.

Based on record review and interview, the hospital failed to set priorities for its performance improvement activities that focused on high risk/high volume areas that had the potential to affect health outcomes, patient safety and quality of care. This deficient practice is evidenced by failure to identify deficient practices related to a. mental health technicians not documenting observation of patients as prescribed by the physician and directed in hospital policy, b. treatment plans not individualized with long/short term goals and all identified problems, and c. psychiatric evaluations not identifying patient strengths.
Findings:

Review of the QAPI plan presented as current by S4IC/PI and S24 VP PI revealed no documented evidence that observation by the mental health technicians, treatment plans, or psychiatric evaluations were identified as problem areas in need of performance improvement.

An interview was conducted with S4IC/PI and S24 VP PI on 12/09/15 at 8:50 a.m. They confirmed the problems with the mental health technicians not documenting the patient observations as prescribed and directed in the policy had not been identified as a problem in the need of performance improvement. S24VP PI stated they had a quality indicator for every 15 minute observations but it had not been implemented at this hospital. S4IC/PI confirmed the only current PI monitoring related to psychiatric evaluations was for the time frame for completion of the psychiatric evaluation. S4IC/PI and S24VP PI confirmed the deficient practices related to treatment plans had not been identified by the QAPI process.

Based on observation, record review and interview, the hospital failed to ensure the QAPI program established clear expectations of patient safety as evidenced by failing to analyze an adverse patient event in accordance with hospital policy for 1 of 1 (Patient #12) adverse patient events.

Findings:

Review of the hospital's policy titled, Unexpected Death of a Patient, policy number TX SPEC-19 with a revised date of 9/2015 revealed in part the following:
Performance Review:
Will establish a committee of the Performance Improvement Committee and review the need for a Root Cause Analysis on all in house death. The committee shall consist of at least one physician who is not the attending physician, Infection Control nurse and the Director of Nursing. Cases will be reviewed at the next Committee of the Whole as part of the ongoing Professional Practice Evaluation.

Patient #12
Review of the medical record for Patient #12 revealed the patient was a 75 year old male admitted to the hospital on 05/17/15 with a diagnosis of Dementia with Behavior Disturbance. Review of the record revealed the patient was found slumped over in the wheelchair at 3:05 a.m. on 05/19/15. The record revealed CPR was initiated and 911 was called. The record revealed CPR was discontinued by EMS at 3:26 a.m. The record revealed, "4:54 a.m. Coroner arrived at this time. Questions were asked about events leading up to incident and also requested to see medical diagnoses. All questions answered. Coroner stated the patient had a lot going on." There was no documented evidence in the patient's record of the pronouncement of death.


In an interview on 12/09/15 at 9:45 a.m., S3RDQ provided an incident report and a document titled Medical Record Review for Patient #12 for review. Review of the documents revealed a review of the events of the patient's resuscitation and death. The reports were signed by S2DON.

In an interview on 12/10/15 at 8:50 a.m., S2DON confirmed she had done the incident report and medical record review for Patient #12. She stated she talked about the incident with S21MD on rounds and she stated they discussed the incident at the Committee of the Whole.

On 12/10/15 at 10:40 a.m., S3RDQ confirmed the hospital had no documentation that a physician had reviewed the patient's death and they had no documentation that the Committee of the Whole had reviewed the incident. S3RDQ confirmed the hospital's policy for performance review of the incident had not been followed.

Based on record review and staff interview, the hospital's governing body failed to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all contracted services in the QAPI program. Findings:

Review of the QAPI plan, provided as current by S4IC/PI revealed the following: Contract Services providing direct patient care or services affecting the health and safety of patients are also included in the continuous monitoring activities.

Review of the current quality indicators being monitored in the QAPI program revealed no documented evidence of quality indicators for the contracted services of Radiology, patient linens, and biohazardous waste.

In an interview on 12/10/15 at 11:20 a.m., S4IC/PI confirmed the contracted services of Radiology, patient linens, and biohazardous waste were not currently included in the QAPI monitoring.

Based on record review and staff interview, the hospital's governing body failed to ensure the number of distinct performance improvement projects that were to be conducted annually was determined. Findings:

Review of the QAPI plan, provided as current by S4IC/PI revealed no documented provisions related to performance improvement projects.

Review of the Governing Body meeting minutes dated 01/16/15 revealed no documented evidence that the number of performance improvement projects was determined. There was no documented evidence that the Governing Body had approved the current project of Response to Deterioration in Patient's Condition.

In an interview on 12/10/15 at 11:10 p.m., S3RDQ confirmed there was no documentation in the Governing Body minutes that the governing body had determined the number of performance improvement projects the hospital would conduct and there was no documentation that the governing body had approved the current project.

Based on record reviews, observations and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

The hospital failed to ensure a RN supervised and evaluated the care of each patient as evidenced by:

1) failing to ensure the MHTs were performing the prescribed level of observation for 1 (#3) of 1 patient on 1:1 observation (see findings in A-0395), and;

2) failing to ensure the MHTs were performing/documenting safety observation rounds in real time for 9 (#1, #2, #3, #4, #5, #7, #R1, #R3, #R4) of 9 current patients reviewed for close observation out of a total sample of 12 patients, and failing to ensure the RN assessed and documented patient rounds every 2 hours on Close Observation Check Sheets for 2 (#3, #4) of 9 current patients reviewed for documentation of close observations out of a total sample of 12 patients (see findings in A-0395).

26351

Based on record reviews, observations and interviews the hospital failed to ensure a RN supervised and evaluated the care of each patient as evidenced by:

1) failing to ensure the MHTs were performing the prescribed level of observation for 1 (#3) of 1 patient on 1:1 observation;

2) failing to ensure the MHTs were performing/documenting safety observation rounds in real time for 9 (#1, #2, #3, #4, #5, #7, #R1, #R3, #R4) of 9 current patients reviewed for close observation out of a total sample of 12 patients, and failing to ensure the RN assessed and documented patient rounds every 2 hours on Close Observation Check Sheets for 2 of (#3, #4) of 9 current patients reviewed for documentation of close observations out of a total sample of 12 patients;

3) failing to ensure patients had a yellow fall risk indicator armband on their wrist for 4 (#1, #2, #3, #4) of 4 patients assessed as a moderate and/or high fall risk as indicated on the facilities Fall Risk Assessment score sheet and failing to ensure 2 (#1- #2) of 2 patients had a "spoon" picture on their room door for patients assessed to be at a moderate and/or high risk for choking as indicated on the facilities Choking Screen score sheet.

4) failing to ensure the MHTs included documentation of the patient's behaviors on the Close Observation Check Sheet as directed in the hospital policy for 2 (#3, #4) of 2 current patients observed for demonstrating disruptive or inappropriate behavior, and;

Findings:

1) failing to ensure the MHTs were performing the prescribed level of observation for 1 (#3) of 1 patient on 1:1 observation;

Review of the hospital policy titled TX-SPEC-05: Level of Observations, revealed in part: One to one observation - The staff should ensure the patient is visually within sight and within arms reach of a staff member at all times and in all circumstances.

On 12/07/15 at 11: 15 a.m., 11:25 a.m., 11:35 a.m., 12:00 p.m., 2:40 p.m., and 2:50 p.m., Patient #3 was observed to repeatedly stand up and sit down from his wheel chair and to be unsteady. The patient was also observed at this time to attempt to grab, touch, and hug staff members.

Review of the clinical record for Patient #3 revealed the patient was admitted to the hospital from a skilled nursing facilty on 12/02/15 with a diagnosis of Schizoaffective Disorder. The patient was referred from the skilled nursing facility for sexually inappropriate behavior, going into other patient's rooms, trying to touch females inappropriately, and groping staff. The record also indicated the patient had been psychotic, combative, exit seeking, and hitting since admission to the hospital, and he could not sit still and kept trying to stand up unassisted.

Review of the physician's orders dated 12/07/15 at 4:00 p.m. revealed an order for 1:1 observation for safety. Further review of the physician's orders on 12/08/15 revealed no documented evidence of an order to discontinue the 1:1 observation.

On 12/08/15 from 2:10 p.m. to 2:30 p.m. an observation was made of Patient #3 in a Recreation Group Therapy. Patient #3 was observed seated in a chair in the middle of the room. S16MHT providing 1:1 observation for Patient #3 was observed to be seated on a couch approximately 6 feet from the patient. S16MHT was observed to be out of arms reach of Patient #3. There was no other staff member within arms reach of Patient #3 in the group therapy at this time.

In an interview and observation of Patient #3 on 12/08/15 at 2:20 p.m., S4IC/QA confirmed S16MHT was assigned to provide 1:1 observation for Patient #3 and the MHT was not in arms reach of the patient as required in the hospital's policy. S4IC/QA confirmed the MHT could not get to the patient from where she was sitting in a timely manner to prevent a fall and/or to prevent the patient groping and/or striking out at another patient.


2) failing to ensure the MHTs were performing/documenting safety observation rounds in real time for 9 (#1, #2, #3, #4, #5, #7, #R1, #R3, #R4) of 9 current patients reviewed for close observation out of a total sample of 12 patients, and failing to ensure the RN assessed and documented patient rounds every 2 hours on Close Observation Check Sheets for 2 of (#3, #4) of 9 current patients reviewed for documentation of close observations out of a total sample of 12 patients:

Review of the hospital policy titled TX-SPEC-05: Level of Observations, revealed in part the following: Close Observation Form: The staff member utilizes the close observation form to document the location of the patient. Additional information regarding, activities are included on the form when relevant....The form is initialized with the observing staff's initial to indicate the patient was observed. Assignment Duties: Staff assigned to perform observations does not stop their duties without formally handing over the assignment of the observations to another staff.

On 12/07/15 at 12:00 p.m., an observation was made of the patients in the dining room, awaiting meal service. S16MHT was observed to have a clip board with Close Observation Check Sheets noted on the clip board. She was not observed to be transcribing information from another document or note. S16MHT provided her clip board for review as requested. Review of the Close Observation Check Sheets for Patients #1, #7, #R1, #R3, and #R4 revealed multiple blanks for the every 15 minute observation checks for the time period prior to 12:00 p.m. S16MHT stated she was trying to "catch up" her documentation of the 15 minute checks from 10:30 a.m. and 10:45 a.m. She stated she went on break from 11:00 a.m. to 11:30 a.m. and no one documented the 15 minute observations. S16MHT stated all the MHTs watch all the patients but each MHT is assigned certain patients to document the 15 minute checks on. S16MHT stated she was assigned to Patients #1, #7, #R1, #R3, and #R4 today.

On 12/07/15 at 12:10 p.m., S17MHT was observed in the dining room, documenting on a clip board. S17MHT provided her clip board of Close Observation Check Sheets as requested. Review of the Close Observation Check Sheets revealed Patient #2 had no documentation of 15 minute checks since 9:45 a.m., and Patient #3 and Patient #5 had multiple blanks prior to 12:15 p.m. Review of the Close Observation Check Sheet for Patient #4 revealed no documented evidence of every 15 minute observations since 6:30 a.m. Review of the Close Observation Check Sheets for Patient #3 and #4 revealed no documented evidence that the RN had documented every 2 hour checks as directed on the form. S17MHT confirmed the every 15 minute observations had not been documented. S17MHT stated the morning had been rough. She confirmed she had not completed the every 15 minute observation checks and stated she would fill out what she knew later. S17MHT was not observed to transcribe information from another document or note. S17MHT was asked to provide a copy of the Close Observation Check Sheets for Patient #3 and #4. S17MHT provided a copy of Patient #3 that now had all 15 minute checks completed. S17MHT confirmed she had not documented the 15 minute checks at the time of the observations.

In an interview on 12/07/15 at 3:30 p.m. S3RDQ reviewed the observation sheets for Patient #3 and #4 and confirmed that Patient #4 had no documentation of every 15 minute observation since 6:30 a.m. She confirmed the every 2 hour RN checks had not been documented. S3RDQ confirmed the observations should be documented at the time the observation was made.

On 12/08/15, the clinical records for Patient #3 and #4 were reviewed and revealed the Close Observation Check Sheets dated 12/07/15 had now been documented every 15 minutes by the MHT and every 2 hours by the RN.

In an interview on 12/09/15 at 11:50 a.m., S3RDQ confirmed the MHT and RN should not have gone back and documented the every 15 minute and every 2 hour observations later in the day.

3) failing to ensure patients had a yellow fall risk indicator armband on their wrist for 4 (#1, #2, #3, #4) of 4 patients assessed as a moderate and/or high fall risk as indicated on the facilities Fall Risk Assessment score sheet and failing to ensure 2 (#1- #2) of 2 patients had a "spoon" picture on their room door for patients assessed to be at a moderate and/or high risk for choking as indicated on the facilities Choking Screen score sheet.

A review of the Fall Risk Assessment score sheet revealed that patients assessed as a moderate and/or high risk for Falls will have a yellow armband placed on their wrist.

A review of the Choking Screen score sheet revealed that patients assessed as a moderate and/or high risk for Choking will have a "spoon" picture on their room door.

Patient #1
A review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 12/01/15 with an admit diagnosis of Dementia with Psychosis. A further review of the patient's medical record revealed he was assessed to be at a high risk for falls and at a moderate risk for choking.

An observation of Patient #1 on 12/07/15 at 11:30 p.m. revealed no yellow fall risk armband. An observation of Patient #1's room door revealed no "spoon" picture on his room door indicating a choking risk.


Patient #2
Patient #2 was a 78 year old admitted to the hospital on 11/27/15 for Alzheimer's Disease with behavioral disturbances.

Review of Patient #2 medical record revealed she was considered a moderate risk for choking related to her choking score sheet. According to the key at the bottom of the page of the choking score sheet, Patient #2 should have a "spoon" picture on her room door for indication of her risk.

An observation was conducted with S14LPN on 12/07/15 at 2:30 p.m. of Patient #2 not having an armband on her arm indicating she was also a high risk for falls.

Review of Patient #1- #4's medical record revealed all 4 patients were assessed at risk for falls. Patient #1 and Patient #2 were assessed at risk for choking.

An observation/interview was conducted on 12/07/15 at 2:50 p.m. of no signage located on Patient #1 and #2's doors indicating they were at risk for choking. This observation was confirmed by S3RDQ. She further indicated that patients assessed as moderate and/or high risk for Falls were not wearing yellow armbands.


4) failing to ensure the MHTs included documentation of the patient's behaviors on the Close Observation Check Sheet as directed in the hospital policy for 2 (#3, #4) of 2 current patients observed for demonstrating disruptive or inappropriate behavior:


Review of the hospital policy titled TX-SPEC-05: Level of Observations, revealed in part the following: Observation Levels: Every 15 minutes - the staff member should visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities.


Patient #3
On 12/07/15 at 11: 15 a.m., 11:25 a.m., 11:35 a.m., 12:00 p.m., 2:40 p.m., and
2:50 p.m., Patient #3 was observed to repeatedly stand up and sit down from his wheel chair and to be unsteady. The patient was also observed at these times to attempt to grab, touch, and hug staff members.

Review of the Close Observation Check Sheet dated 12/07/15 from 11:15 a.m. to 3:00 p.m. revealed no documentation of any of the above behaviors and only included the location of the patient.


Patient #4
On 12/07/15 at 11:10 a.m., Patient #4 was observed to be agitated, walking in the hall, stating Patient #R1 cannot get into bathroom because the door is locked.
On 12/07/15 at 11:30 a.m., Patient #4 was observed to be walking in the hallway, yelling at times and cursing.
On 12/07/15 at 12:00 p.m., Patient #4 was observed sitting in the dining room at a table with Patient #5 and Patient #11. Patient #11 was observed to grab Patient #5's blanket and remove it from around her. Patient #4 became agitated, began yelling and threatening Patient #5.
On 12/07/15 at 12:40 p.m., Patient #4 was observed to be walking up and down the hallway, demanding to be allowed to smoke. The patient was talking loudly and was agitated.
On 12/07/15 at 3:15 p.m., Patient #4 entered his room where observations of the bathroom were being made with S3RDQ. The patient was agitated and stated his bathroom was locked and he cannot get the staff to come open the door in time for him to use the bathroom. The patient complained he had urinated on himself.
On 12/07/15 at 3:45 p.m., Patient #4 was observed outside the nurse's station in the hallway demanding antibiotics and threatening to sue the hospital. Patient was agitated and talking loudly.

Review of the Close Observation Check Sheet dated 12/07/15 from 11:10 a.m. to 4:00 p.m. revealed no documentation of any of the above behaviors and only included the location of the patient.

An interview was conducted on 12/09/15 at 11:50 a.m. with S1ADM, S2DON, and S3RDQ. After review of the observation sheets of Patient #3 and #4, S3RDQ confirmed the MHT had only documented the location of the patients. She stated the RN documents the patients' behaviors in the daily nurse note. S3RDQ confirmed the daily nurse note was only a summary of the patient's behaviors. S3RDQ confirmed the hospital's policy indicated behaviors would be documented on the observation sheets.



30172

Based on record review, observation and interview the hospital failed to be able to promptly retrieve in a timely manner the complete medical record of patients who were treated in the hospital within the last 5 years as evidenced by the hospital maintaining closed medical records only for a period of 3 (three) months prior to storage at another location.

Findings:
A review of the hospital policy titled, "Health Information Management" as provided by S3DRQ as the most current, revealed in part: The HIM Department will maintain 1 (one) year of closed medical records in the hospital. Medical records older than one year will be maintained at an off-site storage and archiving facility.

An observation of the Medical Record Department revealed a small room (approximately 6 feet by 6 feet) with a small filing cabinet area against one wall.

In an interview on 12/09/15 at 2:50 p.m. with S9MR, she indicated that she was the HIM Coordinator. S9MD was asked about the location of the closed patient medical records. S9MR indicated that the hospital only kept 3 (three) months of closed (discharged) patient medical records on-site. Closed (discharged) patient medical records more than 3 (three) months are moved to an off-site storage facility after 3 (three) months. She indicated that discharged patient's complete medical records more than 3 (three) months ago would have to be requested from the storage facilty and it would take 24- 48 hours to arrive at the hospital. S9MR indicated that a discharged patient's complete medical record could be a "stat" request by the physician and it could take a few hours (up to 12 hours) to arrive.

Based on observation and staff interview, the hospital failed to ensure drugs were stored in accordance with manufacturer's recommendations as evidenced by drugs stored in the medication refrigerator at a temperature below the manufacturer's recommended range of temperature storage. Findings:

On 12/08/15 at 11:50 a.m. an observation of the medication refrigerator was conducted with S2DON. Upon opening the refrigerator, the temperature of the refrigerator was observed to be 26 degrees Fahrenheit on the only thermometer found in the refrigerator. The temperature of the refrigerator was confirmed by S2DON at the time of the observation.
Review of the contents of the refrigerator revealed the following medications were stored in the refrigerator and the recommended storage temperature on the labels was 36-46 degrees Fahrenheit:
Risperdal Consta (1 )
Humulin 70/30 Insulin (1)
Humulin Regular Insulin (2)
Humalog Insulin (1)
Humalog Insulin Pen (1)
Levemir Insulin (2)
1 Plastic box with 15 bottles of insulin
Brovana Inhalant (5-6)
Latanoprost Opthalmic (3)
Influenza Vaccine (2 boxes).
Review of the temperature log revealed the temperature of the refrigerator had not been logged for 12/08/15.

On 12/08/15 at 11:50 a.m., S2DON confirmed the the above medications were stored in the refrigerator at a temperature below the manufacturer's recommended range of 36-46 degrees Fahrenheit.

Based on record review and interview, the hospital failed to ensure errors in medication administration were documented in the medical record for 1 (#R2) of 2 patients (#R2, #23) reviewed for known medication errors out of a sample of 12 patients. Findings:

Review of the hospital's policy titled TX Med-08: Medication Variance Corrective Action revealed when a medication variance occurred the occurrence was to be documented in the patient's chart and documented on an incident report.

Review of the hospital's medication variances revealed a medication error had been identified for Patient #R2 on 08/13/15. Review of the Medication Variance Report dated 08/13/15 revealed the lab report was previously reviewed on 08/12/15 by S10APRN. A duplicate call to S10APRN was made on 08/13/15 regarding the same lab results of a potassium level and the patient was administered a potassium supplement twice for the same lab report.

Review of the patient's medical record revealed no documented evidence of a medication variance related to the administration of the potassium supplement.

In an interview on 12/09/15 at 2:20 p.m., S2DON reviewed the clinical record for Patient #R2 and confirmed the medication variance on 08/13/15 regarding the potassium supplement was not documented in the patient's record.

Based on record review and interviews, the hospital failed ensure the Utilization Committee had two or more practitioners who were not involved in the patient's care to carry out the Utilization Review (UR) functions. Findings:

Review of the hospital's "Plan for Utilization Review" by S1ADM as the current Utilization Review Plan, revealed in part the following: "The UR Committee must consist of two or more practitioners, the UR Coordinator (Committee Chairman), and member representatives from nursing, administration, admissions, business office, clinical services, and discharge planning. At least two of the members of the committee must be doctors of medicine or osteopathy." There was no documented evidence of a provision that the reviews may not be conducted by an individual who was professionally involved in the care of the patient whose case is being reviewed.

Review of the Utilization Review Committee meeting minutes for the past 11 months (2015) revealed multiple meetings where no physician was involved in the meetings. Further review of the meetings revealed the only physicians attending were S20MD and S21MD (Current psychiatrist and medical physician for all current inpatients).

In an interview on 12/10/15 at 11:50 a.m. S3RDQ confirmed the Utilization Review Committee meeting minutes for the past 11 months (2015) revealed multiple meetings where no physician was involved in the meetings and only S20MD and S21MD were in attendance at the other meetings. S3RDQ confirmed S20MD and S21MD were the physicians for most of the hospital's patients. S3RDQ confirmed the Utilization Review Plan needed to be revised and stated the UR Committee needed to be revised.

Based on record review, observation and interview, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by:

1) failing to ensure patients with orders for Contact Isolation had correct signage indicating contact precautions on their room door for 1 out of 1 patient (Patient #2)observed in isolation.

2) failing to ensure hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring for 2 out of 3 fingersticks observed. This deficient practice is evidenced by improper hand hygiene after glove usage.

1. Failing to ensures patients with orders for Contact Isolation had correct signage indicating contact isolation on their doors.

Review of the hospital policy and procedure titled IC-04: Transmission Based Precautions: Contact; Droplet; Airborne Precautions Protocol to Identify Pathogen/Organism/Infection, revealed in part:
Protocol instructions for Contact Precautions:
3. A sign will be posted outside of the patient's door indicating contact precautions.

Patient #2 was a 78 year old admitted to the hospital on 11/27/15 for Alzheimer's Dementia with behavioral disturbances.

Review of her Physician's Orders for 11/28/15 revealed an order for Contact precautions per hospital protocol for Herpes Simplex.

An observation was conducted on 12/7/15 at 11:00 a.m. of Patient #2's door which had no signage indicating Patient #2 was on Contact Isolation Precautions.

An interview was conducted with S4IC/QA (Infection Control/Quality Assurance) on 12/07/15 at 3:00 p.m. She confirmed Patient #2 had no signage on her door indicating Patient #2 was in contact isolation. She further reported the patient was incorrectly placed on contact isolation and should have not been on contact isolation for a fever blister.


2. Failing to ensure hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring.

Review of the hospital policy titled IC-09: Hand Hygiene revealed in part:
Purpose:
Inadequate hand hygiene is the leading cause of infectious outbreaks in healthcare facilities. Scrupulous hand hygiene practices clearly reduce the spread of infectious microorganisms.
Glove removal:
How to perform hand washing:
Thoroughly wet hands with warm-never hot-running water. Apply soap and lather. Vigorously rub lathered hands together for 20 to 30 seconds, including all parts of hands and wrists.

An observation was conducted on 12/7/14 at 11:45 a.m. Patient #3 was observed having a fingerstick performed by S14LPN in the nurses' station. S14LPN washed her hands, put on a pair of gloves, cleaned the glucometer, removed her gloves and she failed to wash her hands after removing the gloves. S14LPN put on new gloves, wipe the patient's finger with alcohol, performed the finger stick, touched the trash can, removed her gloves, she failed to wash her hands. S14LPN put on a new pair of gloves. Cleaned the glucometer, took off her gloves and failed to wash her hands again.

An observation was conducted on 12/7/15 at 12:00 p.m. of Patient #R3 having a fingerstick performed by S14LPN. S14LPN washed her hands, put on gloves, wipe the patient's finger with alcohol and performed the fingerstick, S14LPN touched the disinfectant wipes container, obtained wipes out of the container, removed her gloves, didn't wash her hands and returned the patient to his room.

An interview was conducted with S14LPN on 12/7/15 at 12:30 p.m. She confirmed she had forgotten to wash her hands after removing her gloves.

Based on record review and interview, the hospital failed to have a process in place for ongoing reassessment of its discharge planning process that identified preventable readmissions by failing to conduct an indepth review of its discharge planning process that included a review of discharge plans in closed patient medical records in order to revise their discharge planning and/or related processes that addressed preventable readmissions.

Findings:
A review of the hospital policy titled, "Discharge Planning", provided by S3RDQ as the most current, and a review of the Discharge Planning Quality Assurance indicators, provided by S4IC/QA, as the complete QA indicators, revealed no documented evidence of a mechanism utilized by the hospital to review their discharge planning process in an ongoing manner through any QA activities.

In an interview on 12/10/15 at 12:00 p.m. with S4IC/QA she was asked for the hospital's QA indicators/activities used to review their discharge planning process that included tracking and trending of readmission in order to identify potential factors to prevent readmissions. S4IC/QA indicated that the hospital had no process in place for an ongoing reassessment of its discharge planning process that identified preventable readmissions factors. S3IC/QA further indicated that the hospital was not conducting any indepth review of its discharge planning process in order to revise/modify their discharge planning and/or related processes.

Based on record reviews, observations and interviews, the hospital failed to meet the requirements of the Condition of Participation of the Special Medical Record Requirements for Psychiatric Hospitals as evidenced by:

1) the hospital failed ensure treatment received by patients was documented and all active therapeutic efforts were included as evidenced by:
a) failing to ensure treatment interventions were identified and implemented for identified problems for 1 of 1 (#3) current patients observed with inappropriate sexual behavior/fall risk behavior out of a total sample of 12 patients, and;
b) failing to ensure effective treatment plans were available for patients who were unable to benefit from group therapy to assure that each patient achieved their optimal level of functioning for 2 of 2 (#1, #2) current patients reviewed for active therapeutic treatment plans out of a total sample of 12 patients (see B-0125)

2) the hospital failed to ensure that each patient received a psychiatric evaluation that included an inventory of the patient's assets in a descriptive manner and not an interpretive fashion for 3 of 3 (#1, #2, #6) current patients reviewed for strengths/assets in the psychiatric evaluation out of a total of 12 sampled patient medical records. (see B-0117)

3) the hospital failed to ensure the treatment plan was based on an inventory of the patient's strengths and disabilities for 3 of 3 (#1, #3, #4) current sampled patients reviewed for treatment plans based on strengths and disabilities out of a total of 12 sampled patient medical records. (see B-0119)

4) the hospital failed to have measurable and relevant short term and long term goals identified on the active treatment plans for 3 of 3 (#1, #2, #3) current patient medical records reviewed for treatment plans out of a total of 12 sampled patient medical records.
(see B-0121)

Based on record review and interview, the hospital failed to ensure each patient received a psychiatric evaluation that included an inventory of the patient's assets in a descriptive manner and not an interpretive fashion for 3 of 3 (#1, #2, #6) current patients reviewed for strengths/assets in the psychiatric evaluation out of a total of 12 sampled patient medical records.
Findings:

Review of the hospital policy titled AS-03: Psychiatric Evaluation dated 2013, revealed in part the following: Psychiatrist/LIP: Identifies specific patient strengths and assets to enable the multidisciplinary treatment team to choose treatment modalities that best utilize these strengths and assets in the patient's treatment.

Patient #1
A review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 12/01/15 with an admit diagnosis of Dementia with Psychosis.

A review of the psychiatric evaluation dated 12/02/15 by S11APRN revealed the only strengths and assets identified and documented for Patient #1 were, " Support of children" and "Able to return to same nursing home". There was no documented evidence of any personal attributes identified that could be utilized in the development of Patient #1's treatment plan

Patient #2
Review of the clinical record for Patient #2 revealed the patient was admitted to the hospital on 11/27/15 with a diagnosis of Alzheimer's Dementia with behavioral disturbances.

Review of the psychiatric evaluation dated 11/28/15 and documented by S11APRN revealed the only strengths and assets identified for Patient #2 were, "Good family support, adequate finances, and community support." There was no documented evidence of any personal attributes identified that could assist with developing an effective treatment plan.


Patient #6
Review of the clinical record for Patient #6 revealed the patient was admitted to the hospital on 12/02/15 with a diagnosis of Chronic Paranoid Schizophrenia and Impulse Control Disorder.

Review of the psychiatric evaluation dated 12/02/15 and documented by S11APRN revealed the only strengths and assets identified for Patient #6 were," Family supportive and on disability income." There was no documented evidence of any personal attributes identified that could assist in developing an effective treatment plan.

In an interview on 12/09/15 at 11:20 a.m. S11APRN confirmed she had conducted the psychiatric evaluation for the above patients (#1, #2, #6). S11APRN indicated she goes by the template on the chart for the psychiatric evaluation. After reviewing the template for Patient #1 with S11APRN, she confirmed the strengths and assets section was left blank. She confirmed the only strengths identified on the dictated psychiatric evaluation were the patient was able to return to the nursing home and his children were involved in his care. S11APRN confirmed these were not a patient's personal attributes. S11APRN further indicated that she utilized the psychiatric evaluation template for all patients and did not identify personal strengths and weaknesses unless it "stood out" in the patient's medical record.



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Based on record review and interview, the hospital failed to ensure the treatment plan was based on an inventory of the patient's strengths and disabilities for 3 of 3 (#1, #3, #4) current sampled patients reviewed for treatment plans based on strengths and disabilities out of a total of 12 sampled patient medical records.
Findings:

Review of the hospital policy titled, TX-GEN-02: Treatment Planning; Integrated/Multidisciplinary, revealed in part the following: The treatment plan includes defined problems and needs, measurable goals, and objectives based on assessed needs, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care.

Patient #1
A review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 12/01/15 with an admit diagnosis of Dementia with Psychosis.

A review of the psychiatric evaluation dated 12/02/15 by S11APRN revealed the only strengths and assets identified and documented for Patient #1 were, " Support of children" and "Able to return to same nursing home". There was no documented evidence of any personal attributes identified that could be utilized in the development of Patient #1's treatment plan

A review of the Multidisciplinary Integrated Treatment Plan initiated on 12/02/15 revealed no documented evidence of any liabilities/special needs or patient strengths/assets identified for Patient #1. A review of the Treatment Plan after the treatment team meeting conducted on 12/07/15 revealed no documented evidence of any liabilities/special needs or patient strengths/assets added to the treatment plan.


Patient #3
Review of the clinical record for Patient #3 revealed the patient was admitted to the hospital on 12/03/15 with a diagnosis of Schizoaffective Disorder.

Review of the psychiatric evaluation dated 12/04/15 and documented by S11APRN revealed the only strengths and assets identified for Patient #3 were, "Able to return to same nursing home and Children involved in his care." There was no documented evidence of any personal attributes identified that could be useful in developing a meaningful treatment plan.

Review of the Multidisciplinary Integrated Treatment Plan initiated on 12/03/15 revealed no documented evidence of any liabilities/special needs or patient strengths/assets identified for Patient #3. Review of the Treatment Plan after the treatment team meeting conducted on 12/08/15 revealed no documented evidence of any liabilities/special needs or patient strengths/assets added to the treatment plan.

In an interview on 12/09/15 at 11:50 a.m. with S3RDQ, in the presence of S1ADM and S2DON, Patient #1 and Patient #3's Treatment Plans were reviewed. S3RDQ confirmed there were no patient liabilities or strengths identified on the treatment plans.


Patient #4
Review of the clinical record for Patient #4 revealed the patient was admitted to the hospital on 12/02/15 with a diagnosis of Paranoid Schizophrenia.

Review of the psychiatric evaluation dated 12/03/15 and documented by S20MD revealed the only strengths and assets identified for Patient #4 were, "Articulative, adequate finances, community support, lives in a nursing home, and has family support." There was no documented evidence of any other personal attributes identified that could be useful in developing a meaningful treatment plan.

Review of the Multidisciplinary Integrated Treatment Plan initiated on 12/02/15 revealed only the following:
Liabilities: Language preference - English.
Patient Strengths and Assets - Support of family and friends, adequate finances.
There was no documented evidence of any patient strengths based on personal attributes identified other than the patient was articulate.

In an interview on 12/09/15 at 11:50 a.m. with S3RDQ, in the presence of S1ADM and S2DON, Patient #4's Treatment Plan was reviewed. S3RDQ confirmed the patient strengths were not based on personal attributes, and confirmed the English language was not a liability or special need.






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Based on record reviews and interviews, the hospital failed to have measurable and relevant short term and long term goals identified on the active treatment plans for 3 of 3 (#1, #2, #3) current patient medical records reviewed for treatment plans out of a total of 12 sampled patient medical records.
Findings:

Review of the hospital's policy titled, "Treatment Planning; Integrated/Multidisciplinary", provided by S3RDQ as the most current, revealed in part: The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs, strength and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower level of care.

Patient #1
A review of the medical record for Patient #1 revealed he was a 78 year old male admitted to the hospital on 12/01/15 with an admit diagnosis of Dementia with Psychosis.

A review of the patient's Psychiatric Evaluation dated 12/02/15 revealed in part: the patient has vascular dementia with impaired memory, poor insight, poor judgement, and attention and concentration impairment.

A review of his short and long term goals related to his admit diagnosis and identified problem of Dementia with Psychosis, revealed in part: Patient will have an improvement in thought process within 14 days, patient will demonstrate increased ability to function with reality based thought processes within 14 days, patient will think more clearly within 7 days, and patient will explore options and interests and verbalize those which are realistic and attainable within 7 days.


Patient #2
Patient #2 was a 78 year old admitted to the hospital on 11/27/15 with a diagnosis of Alzheimer Dementia with behavioral disturbances.

Review of her Psychiatric Evaluation dated 11/28/15 revealed in part, Patient #2 was not cooperative, affect was bizarre, speech is loud and bizarre. Patient #2 exhibited flight of ideas and talking to herself. She is orientated to person only. Her memory was impaired, her insight and judgement poor, her attention and concentration impaired. She was unable to do abstract thinking.

Review of the her nursing short term goal related to the problem of High Risk for Falls revealed the following goals that were not measurable; Will demonstrate an increase in judgement in 7 days. Patient #2's Alteration in Perception problem revealed a short term goal of; Will experience an increase in reality orientation within 7 days.


In an interview on 12/08/15 at 1:25 p.m. with S13RN she was asked how the IDT (interdisciplinary team) measured the above short and long term goal interventions for Patient #1. S13RN indicated that the patient has vascular dementia and any goals that required improved thought processes/memory or verbalization would not be realistic for this patient or any other patient with impaired memory and/or Dementia.

In an interview on 12/09/15 at 11:50 a.m. with S3RDQ, in the presence of S1ADM and S2DON, Patient #1's Treatment Plan was reviewed. S3RDQ indicated that the treatment plan goal interventions for all patients should be measurable and realistic for each patient. S3RDQ indicated that many of Patient #1's treatment plan goals were not measurable and/or realistic. S3DRQ further indicated that staff will have to be re-educated on treatment plan interventions and goals being measurable, relevant and attainable for all patients.


Patient #3
Review of the clinical record for Patient #3 revealed the patient was admitted to the hospital on 12/03/15 with a diagnosis of Schizoaffective Disorder.

Review of the psychiatric evaluation dated 12/04/15 and documented by S11APRN revealed the patient was a resident of a skilled nursing facility and had been demonstrating inappropriate sexual behaviors, was impulsive, pacing, going into other residents' rooms, and trying to touch females inappropriately. The psychiatric evaluation also revealed the patient's behavior in the hospital had been psychotic, combative, hitting, and exit seeking.

Review of the Multidisciplinary Integrated Treatment Plan initiated on 12/03/15 revealed sexually inappropriate behavior, increased agitation, and increase impulse control trying to climb out of chair were identified as problems for Patient #3. Review of the Treatment Plan revealed no documented evidence of a short term goal or interventions to address the patient's sexually inappropriate behaviors. There was no documented evidence of any Short or long term goals that were observable or measurable that addressed any of the patient's identified behaviors.

In an interview on 12/08/15 at 2:05 p.m., S13RN reviewed the Multidisciplinary Integrated Treatment Plan for Patient #3 and confirmed there were no goals or interventions to address the identified patient problem of sexually inappropriate behavior. S13RN stated the goals/interventions should have been addressed by the RN when she initiated the Treatment Plan. S13RN confirmed the patient's Treatment Plan was incomplete and did not address all the patient's behaviors with measurable goals and specific interventions.


In an interview on 12/09/15 at 11:50 a.m. with S3RDQ, in the presence of S1ADM and S2DON, Patient #3's Treatment Plan was reviewed. S3RDQ indicated that the treatment plan goal interventions for all patients should be measurable and realistic for each patient. S3RDQ confirmed the Treatment Plan did not include any Short Term goals and interventions that addressed the patient's sexually inappropriate behaviors. S3RDQ confirmed the treatment plan goals were not measurable or individualized to address the patient's identified behaviors. S3DRQ further indicated that staff will have to be re-educated on treatment plan interventions and goals being measurable, relevant and attainable for patients.

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Based on record reviews, observations and interviews, the hospital failed ensure treatment received by patients was documented and all active therapeutic efforts were included as evidenced by:
1) failing to ensure treatment interventions were identified and implemented for identified problems for 1 of 1 (#3) current patients observed with inappropriate sexual behavior/fall risk behavior out of a total sample of 12 patients, and;
2) failing to ensure effective treatment plans were available for patients who were unable to benefit from group therapy to assure that each patient achieved their optimal level of functioning for 2 of 2 (#1, #2) current patients reviewed for active therapeutic treatment plans out of a total sample of 12 patients
Findings:

1) failing to ensure treatment interventions were identified and implemented for identified problems for 1 of 1 (#3) current patients observed with inappropriate sexual behavior/fall risk behavior:

Review of the hospital policy titled, "Treatment Planning: Integrated/ Multidisciplinary", provided by S3RDQ as the most current, revealed in part: The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits identified in the assessment process....Admitting Nurse: Implements immediate treatment interventions for safety and stabilization of the patient.

On 12/07/15 the following observations were made of Patient #3:
11:15 a.m. - Patient #3 was observed to be seated in a wheel chair in the activity room with Patient #2 and Patient #11. S18Liaison was observed to be seated in a chair across from Patient #3, holding the patient's hands and singing. Patient #3 was observed to stand up quickly from the wheel chair and attempt to grab S18Liaison around her waist. S18Liaison assisted the patient back into the wheel chair, and the patient repeatedly stood up and tried to grab S18Liaison. S18Liaison continued to hold the patient's hands when he was seated, and the patient continued to stand up and try to grab S18Liaison around her waist.
11:24 a.m. - S18Liaison was observed to tell S8EOC that the patient needed to use the bathroom. S4IC/QA was observed to be walking down the hall and assisted the patient to the bathroom.
11:27 a.m. - Patient #3 was returned to the activity room. S23MHT was present and stated Patient #3, "liked to hug." Patient #3 was observed to continue to repeatedly stand up from his wheel chair and he was observed to be unsteady. Patient #3 was also observed to put his arms around the waist of S16MHT.
11:35 a.m. - Patient #3 was wheeled into the nurse's station by S14LPN to obtain a blood glucose test. Patient #3 was observed to repeatedly stand up and attempt to touch/grab the nurse and a surveyor. The patient was assisted to sit back down each time.
12:00 p.m. - Patient #3 was observed sitting in a wheel chair at a dining room table. The patient was observed to repeatedly stand up quickly and was observed to be unsteady. S16MHT was observed to be standing near the patient's wheel chair. Patient #3 was observed to grab S16MHT. S16MHT assisted the patient to sit back down.
2:41 p.m. - S2DON was observed to be in the hallway outside the nurse's station, applying a gait belt to Patient #3. Patient #3 was observed to attempt to grab/touch S2DON.
2:50 p.m. - Patient #3 was observed to be seated in a wheel chair with a lab buddy across his lap in the dining room. An MHT was observed to be standing near the patient. Patient #3 stood up suddenly and the lap buddy was dislodged from the wheel chair and fell on the floor. The patient was observed to ambulate unsteadily to another chair in the corner of the dining room and sit down.

In an interview on 12/07/15 at 3:05 p.m., S2DON confirmed the patient was unsteady and had repeatedly gotten up from his wheel chair. She confirmed the patient had repeatedly grabbed or tried to hug the nursing staff and confirmed the patient was referred to the hospital for inappropriate sexual behavior at the skilled nursing facilty. When asked how the staff determined 1:1 observation was needed, S2DON stated Patient #3 needed 1:1 observation today and she was going to talk to the physician about increasing the level of observation.

Review of the clinical record for Patient #3 revealed the patient was admitted to the hospital on 12/03/15 with a diagnosis of Schizoaffective Disorder.

Review of the psychiatric evaluation dated 12/04/15 and documented by S11APRN revealed the patient was a resident of a skilled nursing facility and had been demonstrating inappropriate sexual behaviors, was impulsive, pacing, going into other residents' rooms, and trying to touch females inappropriately. The psychiatric evaluation also revealed the patient's behavior in the hospital had been psychotic, combative, hitting, and exit seeking.

Review of the Multidisciplinary Integrated Treatment Plan initiated on 12/03/15 revealed sexually inappropriate behavior, increased agitation, and increase impulse control trying to climb out of chair were identified as problems for Patient #3. Review of the Treatment Plan revealed no documented evidence of a short term goal or interventions to address the patient's sexually inappropriate behaviors, or the patient's fall risk behavior of repeatedly getting up from the wheel chair.

Review of the Daily Nurse Note dated 12/07/15 at 2:30 p.m. revealed the following: Sexually inappropriate-attempting to grab staff's breasts-anxious and unable to remain seated in wheelchair-repeatedly stands unassisted-difficulty expressing thoughts/feelings into words-frequent reassurance/support provided. There was no documented evidence of any other interventions provided to address the patient's behavior.

Review of the Group Documentation revealed the following:
12/04/15 - The problem list and the benefit/progress related to treatment goals sections were left blank. Review of the Psychotherapy Group section revealed Patient #3 attended the group and his participation was fair. The topic of the group was a discussion of 1950's and memory. The note revealed the patient remembered Elvis Presley.
12/05/15 - The problem list and the benefit/progress related to treatment goals sections were left blank. Review of the Nursing Group section revealed Patient #3 attended the group with good participation. The topic of the group was listed as Prozac (Review of the patient's record revealed the patient was not prescribed the drug Prozac).
12/06/15 - The problem list and the benefit/progress related to treatment goals sections were left blank. Review of the Psychotherapy Group section revealed Patient #3 attended the group and his participation was fair. The topic of the group was a discussion of 1980's and memory.
12/07/15 - Review of the note revealed the benefit/progress section was completed, but the patient did not attend the group, "secondary to nursing intervention."

In an interview on 12/08/15 at 2:05 p.m., S13RN reviewed the Multidisciplinary Integrated Treatment Plan for Patient #3 and confirmed there were no goals or interventions to address the identified patient problem of sexually inappropriate behavior or the patient's fall risk behavior of standing from the wheelchair. S13RN stated the goals/interventions should have been addressed by the RN when she initiated the Treatment Plan. S13RN confirmed the patient's Treatment Plan was incomplete and did not address all the patient's behaviors with measurable goals and specific interventions.

In a telephone interview on 12/09/15 at 11:10 a.m., S18Liaison confirmed she was singing with the patient on 12/07/15. She stated she walked through the unit and stayed in the activity room because she did not want the patient's to be left alone. She stated there was no other staff immediately available to stay with the patient. S18Liaison stated she was holding the patient's hands to keep the patient from grabbing her. S18Liaison confirmed she was not aware of the patient's treatment interventions.

In an interview on 12/09/15 at 11:50 a.m. with S3RDQ, in the presence of S1ADM and S2DON, Patient #3's Treatment Plan, group notes, and nursing documentation was reviewed. S3RDQ indicated that the treatment plan goal interventions for all patients should be measurable and realistic for each patient. S3RDQ confirmed the Treatment Plan did not include goals and interventions that addressed the patient's sexually inappropriate behaviors, or the patient's fall-risk behaviors. S3RDQ confirmed the group notes were incomplete, and indicated the benefit/progress section should be completed since it indicated the progress the patient was making. S3RDQ confirmed the psychotherapy group had not addressed the patient's sexually inappropriate behavior. She also indicated the nursing group should have addressed medication compliance and not a specific medication. S3RDQ confirmed the documentation did not include therapeutic interventions to address the patient's sexually inappropriate behaviors.


2) failing to ensure effective treatment plans were available for patients who were unable to benefit from group therapy to assure that each patient achieved their optimal level of functioning for 2 of 2 (#1, #2) current patients reviewed for active therapeutic treatment plans

Review of the hospital policy titled, "Treatment Planning: Integrated/ Multidisciplinary", provided by S3RDQ as the most current, revealed in part: The purpose is to document and implement treatment objective/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided.

A review of the hospital policy titled, "Group Therapy", provided by S3RDQ as the most current, revealed in part: All group therapy shall have a specific purpose and structure which nurtures the therapeutic milieu and attempts to advance patient toward treatment goals.

Patient #1
A review of the medical record for Patient #1 revealed he was a 78 year old male admitted to the hospital on 12/01/15 with an admit diagnosis of Dementia with Psychosis.

A review of the patient's Psychiatric Evaluation dated 12/02/15 revealed in part: the patient has vascular dementia with impaired memory, poor insight, poor judgement, and attention and concentration impairment. A review of the patient's treatment plan indicated that the patient will attend group therapy daily to decrease threatening behavior, improve mood and understand medication compliance.

A review of the patient's group therapy notes revealed the following documentation:
12/02/15 - Patient slept throughout the group therapy.
12/03/15 - Patient did not participate in group therapy after several prompts.
12/04/15 - Patient slept throughout the group therapy
12/05/15 - Good participation (group therapy was a discussion of a medication currently not prescribed for the patient).
12/06/15 - Patient did not attend group therapy.
12/07/15 - An observation of the group therapy on 12/07/15 revealed that the patient did not participate in the group therapy. The group therapy progress notes from 12/07/15 further revealed that the patient did not participate in group therapy after several prompts and that the patient was withdrawn.
A further review of the group therapy progress notes revealed no documentation of any patient barriers to the current treatment plan that indicated that the patient could benefit from group therapy and the progress notes did not reflect any insight into the patient's ability and/or inability to participate meaningfully in group therapy.


Patient #2
Patient #2 was a 78 year old admitted to the hospital on 11/27/15 with the diagnosis of Alzheimer Dementia with behavioral disturbances.

Review of her Psychiatric Evaluation dated 11/28/15 revealed in part, Patient #2 was not cooperative, affect was bizarre, speech is loud and bizarre. Patient #2 exhibited flight of ideas and talking to herself. She is orientated to person only. Her memory was impaired, her insight and judgement poor, her attention and concentration impaired. She was unable to do abstract thinking.

Review of the Inpatient Group Doumentation from 11/29/15 revealed Patient #2 did not attend 2 groups on that date, no documentation of what time the groups were held, only documentation was she did not attend. No documentation of alternative treatment.

Review of the Inpatient Group Documentation from 11/30/15 at 10:15 a.m. revealed the intervention was painting and music. The documentation recorded indicated the patient slept on and off during the group and didn't participate.

Review of the Inpatient Group Documentation from 12/01/15 at 10:00 a.m. revealed the topic was Family/Patient and social work discussion. Patient #2's response was patient did not attend group, was singing. The 2:00 p.m. recreational group consisted of chair yoga, space ball with questions and music. The patient's response was the patient did not participate in group. Patient sang off and on then fell asleep.

Review of the Daily Nursing Group notes for 12/01/15 at 7:30 p.m. revealed the topic was Increase social interaction, patient response was singing gospel music and she doesn't openly initiate conversation with others

Review of the Inpatient Group Documentation from 12/2/15 at 10:00 a.m. revealed the topic was Honesty. Patient's response was head down and singing. The 11:00 a.m. group topic of focus was awareness of positive recreation activities, music and goal setting. Patient #2's response was patient was loud and disruptive talking, singing, patient needs several redirects and prompt to respond.

An observation was conducted on 12/08/15 of Patient #2 sleeping through Inpatient group at 10:00 a.m. and 2:00 p.m.

In an interview on 12/08/15 at 3:00 p.m. with S3RDQ, the group therapy observations and group therapy notes for Patient #1 and Patient #2 were reviewed. S3RDQ indicated that some of the therapy groups did not address the needs of the patients with dementia. S3RDQ further indicated that some patients were unable to participate meaningfully in some of the scheduled group therapies.