HospitalInspections.org

2019-3-021
Based on observation, record review, document review and staff interview it was determined the hospital failed to protect and promote patient rights as evidenced by failure to provide care in a safe setting; failure to provide treatment based on a physician's orders; and, failure to establish a behavior plan for a patient with aggressive, destructive behavior (See tags A 144 and A 145).

Based on observation, record review, document review and staff interview it was determined the hospital failed to provide care in accordance with physician's orders for behavior plans in one (1) out of fourteen (14) patients (patient #1). This failure has the potential to place patients and staff at risk for harm or injury due to possible aggressive, threatening or violent behavior and/or destruction of property.

Findings include:

1. During a tour of unit 1 Central (C) on 3/11/19 at 10:20 a.m. paper was noted to be torn from the wall in several places in the hallway and door latches were noted to be jammed.

2. During observations on unit 1 C on 3/11/19 at 1:29 p.m. Patient #1 was noted to exit his room and loudly pound on the community bathroom door. Registered nurse (RN) #1 stated he had broken the lock on the door, and it was not an uncommon occurrence.

3. A review of documents revealed Patient #1 was moved between units 1 C (a "low-stimulus" environment) and 2 West on five (5) occasions with the last move being on 2/19/19 when he was moved to 1 C. Each move to 1 C occurred after he exhibited aggressive, threatening, and violent behavior with property destruction. There was no physician order found in the medical record relative to the moves between units. During an interview conducted on 3/11/19 at 1:29 p.m. with the House Nursing Supervisor, she stated the expectation is a physician order would be written to move patients between units.

4. A review of documents relating to Patient #1 revealed three (3) behavior health plans were developed sequentially during his hospitalization beginning 12/17/18 and ending 3/8/19. Two (2) out of three (3) documents were not signed either by the therapist or the patient. Refusals to sign were not noted on the documents. None of the documents were signed by the physician, nor were there physicians' orders for the behavior health plans. There was no behavior health plan after 3/8/19 found in the patient's record.

5. A review of an untitled, undated, document (which was placed on a clipboard turned over in the corner of the nurses' station) provided by registered nurse (RN) #1 working on 1 C on 3/11/19 at 1:29 p.m. revealed it stated in part, "Following a rigid schedule or behavior plan is not in the best interest for [Patient #1] or staff at this time." The document was signed by the Director of Social Services, Director of Therapy, Director of Therapeutic Recreation, and Director of Patient Care services. There were no signatures from the physician or nursing on the document.

6. An interview was conducted with the Chief Medical Officer on 3/12/19 at 10:35 a.m. When asked if she was involved in the creation of the document concerning the discontinuation of Patient #1's behavior health plan as of 3/8/19, she did not answer the question but stated she was aware of the document. She then concurred she did not sign the document.

7. A review of the medical record for Patient #1 revealed a progress note written on 3/12/19 and signed by the Chief Medical Officer which stated in part, "Continue Structured unit programming-encourage appropriate behaviors with rewards for good behavior." There was no documentation in the medical record to indicate nursing was following the physician's plan as there was no treatment plan developed for the patient.

8. An interview was conducted with RN #1 assigned to unit 1 C on 3/11/19 at 1:29 p.m. When asked about Patient #1's activity schedule, she stated, "He does whatever he wants." When questioned about Patient #1's treatment plan, she stated in part, "I don't think he has one."

9. An interview was conducted with Patient #1 on 3/11/19 at 1:29 p.m. He stated in part there was "nothing to do on the unit" and that he slept and did nothing. He revealed he had a schedule but had no copy of it and he did not know what was included in his treatment or behavior plan.

10. A review of the policy and procedure titled "Patient Rights and Responsibilities of the Individual" last reviewed 7/7/18 revealed it states in part, "You have the right to quality care that is suited to your needs, delivered promptly and safely by well-trained staff."

Based on observation, record review, document review and staff interview it was determined the facility failed to ensure one (1) out of fourteen (14) patients were free from neglect (Patient #1). Patient #1 did not have a current behavior plan and had no orders for activity programming. This failure has the potential to place all patients at risk for neglect.

Findings include:

1. Observations on unit 1 Central (C) on 3/11/19 at 10:00 a.m. and 1:29 p.m. revealed Patient #1 was resting quietly on blankets on the floor beside the bed in his room with his eyes closed. No programming schedule was displayed on the unit.

2. A review of documents revealed Patient #1 was moved between units 1 C (a "low-stimulus" environment) and 2 West on five (5) occasions with the last move being on 2/19/19 when he was moved to 1 C. Each move to 1 C occurred after he exhibited aggressive, threatening, and violent behavior with property destruction. There was no physician order found in the medical record relative to the moves between units. During an interview conducted on 3/12/19 at 2:27 p.m. with the House Nursing Supervisor, she stated the expectation is a physician order would be written to move patients between units.

3. A review of documents relating to Patient #1 revealed three (3) behavior health plans were developed sequentially during his hospitalization beginning 12/17/18 and ending 3/8/19. Two (2) out of three (3) documents were not signed either by the therapist or the patient. Refusals to sign were not noted on the documents. None of the documents were signed by the physician. There were no physician orders for the behavior health plans in the medical record.

4. A review of Physician's orders revealed there were no orders for programming or activities. Review of the daily Physician's Progress Notes from 2/24/19 through 3/11/19 included group therapy in Patient #1's plan.

5. A review of Patient #1's medical record revealed a physician's progress noted dated 3/12/19, signed by the Chief Medical Officer, which stated in part, "Continue structured unit programming--encourage appropriate behaviors with rewards for good behavior."

6. A review of an untitled, undated, document provided by registered nurse (RN) #1 working on 1 C on 3/11/19 at 1:29 p.m. (which was placed on a clipboard turned over in the corner of the nurses' station) revealed it stated in part, "Following a rigid schedule or behavior plan is not in the best interest for [Patient #1] or staff at this time." The document was signed by the Director of Social Services, Director of Therapy, Director of Therapeutic Recreation and Director of Patient Care services. There were no nursing or physician signatures on the document.

7. A review of Patient #1's medical record documents titled "BHT Observation Record" from 3/1/19 through 3/12/19 revealed he slept between nine (9) and ten (10) hours on average each twenty-four (24) hours. Most of his sleep occurred during the day time hours as there was no structure regarding a bed time.

8. A review of Patient #1's medical record documents titled "Group Attendance Log-- BHT" revealed of the eighteen (18) activities provided on the unit from 2/27/19 through 3/6/19 he participated in music one (1) time. The document did not reflect activities offered that were refused the patient.

9. A review of a document titled "Medical Staff Bylaws" revealed it states in part, "The duties of the Medical Staff Executive Committee shall be to...7. fulfill the Medical Staff's accountability for the quality of medical care rendered to patients in the Hospital."

10. An interview was conducted with the Chief Medical Officer on 3/12/19 at 10:35 a.m. When asked if she was involved in the creation of the document concerning the discontinuation of Patient #1's behavior health plan as of 3/8/19, she stated she was aware of the document but had not signed it.

11. An interview was conducted with RN #1 assigned to unit 1 C on 3/11/19 at 1:29 p.m. When asked about Patient #1's activity schedule, she stated, "He does whatever he wants." When questioned about Patient #1's treatment plan, she stated in part, "I don't think he has one."

12. An interview was conducted with Patient #1 on 3/11/19 at 1:29 p.m. He stated in part there was "nothing to do on the unit" and that he slept and did nothing. He stated he had a schedule but had no copy of it and he did not know what was included in his treatment or behavior plan.

13. An interview was conducted with the Chief Nursing Officer on 3/12/19 at 11:20 a.m., she stated for Patient #1's care the staff was operating from a position of fear. She stated in part, "It is not in his best interest and we recognize this."

14. A review of policy and procedure titled "Patient Rights and Responsibilities of the Individual" last reviewed 7/7/18 revealed it states in part, "You have the right to quality care that is suited to your needs, delivered promptly and safely by well-trained staff."

Based on record review, document review, staff interview and observations it was determined the governing body failed to ensure care of a psychiatric problem that developed during hospitalization in one (1) out of fourteen (14) patients (Patient #1). This failure has the potential to place all patients at risk for inadequate psychiatric care.

Findings include:

1. A review of Patient #1's medical record revealed he was assigned to units 2 West and 1 Central (C) at various times during his hospitalization. He had been moved between units 1 C and 2 West a total of five (5) times. Prior to the moves, there were episodes of aggression, threatening, violence, and destruction of property. There were no physician orders found in the medical record regarding the unit moves. During an interview with the House Nursing Supervisor on 3/12/19 at 2:27 p.m., she stated the expectation is to have a physician order to move patients from one unit to another.

2. A review of documents relating to Patient #1 revealed three (3) behavior health plans were developed sequentially during his hospitalization beginning 12/17/18 and ending on 3/8/19. Two (2) out of three (3) documents were not signed either by the therapist or the patient. Refusals to sign were not noted on the documents. None of the documents were signed by the physician. There were no physician orders for the behavior health plans. These findings were verified by registered nurse (RN) #1 on 3/11/19 at 1:29 p.m.

3. A review of an untitled, undated, document (which was placed on a clipboard turned over in the corner of the nurses' station) provided by the RN #1 working on 1 C on 3/11/19 at 1:29 p.m. revealed it stated in part, "Following a rigid schedule or behavior plan is not in the best interest for [Patient #1] or staff at this time." The document was signed by the Director of Social Services, Director of Therapy, Director of Therapeutic Recreation and Director of Patient Care services. There were no nursing or physician signatures on the document.

4. Observations on unit 1 C on 3/11/19 at 10:00 a.m. and 1:29 p.m. revealed Patient #1 was resting quietly on blankets on the floor beside the bed in his room with his eyes closed. There was no programming schedule displayed on the unit.

5. A review of Patient #1's medical record revealed a physician's progress note dated 3/12/19, signed by the Chief Medical Officer (CMO), revealed it stated in part, "Continue structured unit programming--encourage appropriate behaviors with rewards for good behavior." This was verified with the CMO on 3/12/19 at 10:35 a.m. during an interview.

6. A review of a document titled "Medical Staff Bylaws" revealed it states in part, "The duties of the Medical Staff Executive Committee shall be to...7. fulfill the Medical Staff's accountability for the quality of medical care rendered to patients in the Hospital."

7. An interview was conducted with the CMO on 3/12/19 at 10:35 a.m. When asked if she was involved in the creation of the document concerning the discontinuation of Patient #1's behavior health plan on 3/8/19, she stated she was aware of the document but had not signed it.

8. An interview was conducted with RN #1 assigned to unit one (1) center on 3/11/19 at 1:29 p.m. When asked about Patient #1's activity schedule, she stated, "He does whatever he wants." When questioned about Patient #1's treatment plan, she stated in part, "I don't think he has one."

9. An interview was conducted with Patient #1 on 3/11/19 at 1:29 p.m. He stated in part there was "nothing to do on the unit" and that he slept and did nothing. He revealed he had a schedule but had no copy of it and he did not know what was included in his treatment or behavior plan.

10. A review of policy and procedure titled "Patient Rights and Responsibilities of the Individual" last reviewed 7/7/18 revealed it states in part, "You have the right to quality care that is suited to your needs, delivered promptly and safely by well-trained staff."

Based on record review, document review and staff interview it was determined the Nurse Manager of 4 South failed to ensure one (1) of twelve (12) patients who were ordered Close Constant Observation (CCO), had CCO if the staffing of Behavior Health Technicians (BHT) was four (4) or below (patient #11). This failure has the potential for all patients with an order for CCO to have the ability to cause harm to themselves or others.

Findings include:

1. Review of the medical record for patient #11 revealed an order on 10/09/18 at 2:41 p.m. for CCO due to polydipsia, water seeking behavior. Review of CCO safety checks and hallway checks documents revealed the same BHT's signed both documents on 01/16, 01/20, 01/22, 01/30, 02/04, 02/06, 02/09, 02/14, 03/03 and 03/06/19, from 7:00 p.m. through 7:00 a.m.

2. Review of the policy titled "Levels of Observation" last reviewed 08/27/18 revealed it states in part: "CCO is continual observation of patients (who have been identified as risk to themselves or others) while maintaining both direct visual contact and auditory range at all times, with no objects or obstacles between the assigned staff and the patient."

3. An interview was conducted on 3/12/19 at 2:30 p.m. with an anonymous source who wished to be interviewed and presented an email that stated in part: "[Physician] #1 believes that both the patients on 4 south warrant CCO's 24/7. [Director of Nursing] discussed the strain this places on staff, especially at night when we are down to 4 BHT's on that unit. We both agree that as long as [patient #11] is asleep, and the BHT sitting CCO has a radio that they can use to call for a replacement if he gets up, that person can be monitoring the hallway, allowing the other 2 BHT's to be mobile." The email was sent from the previous 4 South nurse manager who is now the Director of Patient Services.

4. An interview was conducted with the Director of Patient Services on 3/13/19 at 10:40 a.m. and a request was made for the above noted email. The email was presented and when asked to explain the email, she stated in part, "When we fall below four (4) BHT's due to staffing, we allow the person watching [patient #11] to also be hall monitor because he's only to ensure he isn't drinking water and there is no water source in his room. The physician knows we are doing this; we have discussed it in treatment." When asked if monitoring the hallway while on CCO for patient #11 was the hospital policy being followed for CCO, she stated in part, "No, but, he only needs to be monitored when outside of the room." When asked if an order had been written to change CCO to when the patient leaves his room, she was unsure but would look at the orders.

5. An interview was conducted on 03/13/19 at 9:00 a.m. with physician #1. When asked to explain the CCO with patient #11, she stated in part, "He is on CCO because he has polydipsia and seeks water so we have him monitored to ensure he doesn't have the ability to have that behavior. So someone sits with him 24/7." When asked if she was aware the CCO is also acting as a hallway monitor, and if so, had she changed her order accordingly, she stated in part, "I am aware they are allowing the CCO for him to monitor the hallway; he only needs monitored outside of his room. We have discussed it in his treatment plans. I have not changed the order to reflect that."

6. An interview was conducted with the Director of Patient Services on 3/13/19 at 10:40 a.m. She concurred the BHT's assigned to patient #11 on 01/16, 01/20, 01/22, 01/30, 02/04, 02/06, 02/09, 02/14, 03/03 and 03/06/19 also acted as hall monitor and therefore could not have eyes on the patient at all times.

A. Based on record review, document review and staff interview it was determined the Nurse Manager of 4 South failed to ensure one (1) of twelve (12) patients who were ordered Close Constant Observation (CCO), had CCO if the staffing of the Behavior Health Technicians (BHT) was four (4) or below (patient #11). This failure has the potential for all patients with an order for CCO to have the ability to cause harm to themselves or others.

Findings include:

1. Review of the medical record for patient #11 revealed an order on 10/09/18 at 2:41 p.m. for CCO due to polydipsia, water seeking behavior. Review of CCO safety checks and hallway checks documents revealed the same BHT's signed both documents on 01/16, 01/20, 01/22, 01/30, 02/04, 02/06, 02/09, 02/14, 03/03 and 03/06/19 from 7:00 p.m. through 7:00 a.m.

2. Review of the policy titled "Levels of Observation" last reviewed 08/27/18 revealed it states in part, "CCO is continual observation of patients (who have been identified as risk to themselves or others) while maintaining both direct visual contact and auditory range at all times, with no objects or obstacles between the assigned staff and the patient."

3. An interview was conducted on 3/12/19 at 2:30 p.m. with an anonymous source who wished to be interviewed and presented an email that stated in part: "[Physician #1] believes that both the patients on 4 south warrant CCO's 24/7. [Director of Nursing discussed the strain this places on staff, especially at night when we are down to 4 BHT's on that unit. We both agree that as long as [patient #11] is asleep, and the BHT sitting CCO has a radio that they can use to call for a replacement if he gets up, that person can be monitoring the hallway, allowing the other 2 BHT's to be mobile." The email was sent from the previous 4 South nurse manager who is now the Director of Patient Services.

4. An interview was conducted with the Director of Patient Services on 3/13/19 at 10:40 a.m. and a request was made for the above noted email. The email was presented and when asked to explain the email, she stated in part, "When we fall below four (4) BHT's due to staffing we allow the person watching [patient #11] to also be hall monitor because he's only to ensure he isn't drinking water and there is no water source in his room. The physician knows we are doing this; we have discussed it in treatment." When asked if monitoring the hallway while on CCO for patient #11 was the hospital policy being followed for CCO, she stated in part, "No, but, he only needs to be monitored when outside of the room." When asked if an order had been written to change CCO to when the patient leaves his room she was unsure but would look at the orders.

5. An interview was conducted on 03/13/19 at 9:00 a.m. with physician #1. When asked to explain the CCO with patient #11, she stated in part, "He is on CCO because he has polydipsia and seeks water so we have him monitored to ensure he doesn't have the ability to have that behavior. So someone sits with him 24/7." When asked if she was aware the CCO is also acting as a hallway monitor, and if so, had she changed her order accordingly, she stated in part, "I am aware they are allowing the CCO for him to monitor the hallway; he only needs monitored outside of his room. We have discussed it in his treatment plans. I have not changed the order to reflect that."

6. An interview was conducted with the Director of Patient Services on 3/13/19 at 10:40 a.m. She concurred the BHT's assigned to patient #11 on 01/16, 01/20, 01/22, 01/30, 02/04, 02/06, 02/09, 02/14, 03/03 and 03/06/19 also acted as hall monitor and could not have eyes on the patient at all times.



38531

B. Based on record review, document review, observation and staff interview it was determined the hospital failed to provide supervision and evaluation of patient care under the supervision of a registered nurse (RN). The facility failed to provide care according to physician orders and failed to document discontinuation of a behavior health plan for one (1) out of fourteen (14) patients (Patient #1). This failure has the potential to place all patients at risk for receiving care that is not supervised in accordance with accepted nursing practice.

Findings include:

1. A review of Patient #1's medical record revealed he was assigned to units 2 West and 1 Central (C) at various times during his hospitalization. He had been moved between unit 1 C and 2 West a total of five (5) times. Prior to the moves, there were episodes of aggression, threatening, violence, and destruction of property. There were no physician orders found regarding the moves.

2. A review of documents relating to Patient #1 revealed three (3) behavior health plans were developed sequentially during his hospitalization beginning 12/17/18 and ending 3/8/19. Two (2) out of three (3) documents were not signed either by the therapist or the patient. Refusals to sign were not on the documents. None of the documents were signed by the physician. There were no physicians' orders for the behavior health plans and no behavior health plan after 3/8/19.

3. A review of documents titled "Behavior Tracking Log" revealed from 3/4/19 through 3/7/19 (just prior to the date the behavior health plan was stopped) Patient #1 had no occurrences of physical aggression or destruction of property.

4. A review of an untitled, undated, document (which was placed on a clipboard turned over in the corner of the nurses' station) provided by RN #1 working on 1 C on 3/11/19 at 1:29 p.m. revealed it stated in part: "Following a rigid schedule or behavior plan is not in the best interest for [Patient #1] or staff at this time." The document was signed by the Director of Social Services, Director of Therapy, Director of Therapeutic Recreation and Director of Patient Care Services. There were no nursing or physician signatures on the document.

5. A review of Patient #1's medical record revealed a physician's progress noted dated 3/12/19, signed by the Chief Medical Officer, which stated in part: "Continue structured unit programming--encourage appropriate behaviors with rewards for good behavior."

6. An interview was conducted with the Chief Medical Officer on 3/12/19 at 10:35 a.m. When asked if she was involved in the creation of the document concerning the discontinuation of the behavior plan of Patient #1 as of 3/8/19, she stated she was aware of the document and concurred she had not signed it.

7. An interview was conducted with the Chief Nursing Officer on 3/12/19 at 11:40 a.m. When asked if she was aware Patient #1 had no incidents of aggression or destruction of behavior recorded on documents titled "Behavior Tracking Log" from 3/4/19 to 3/7/19 (the four (4) days immediately prior to the discontinuation of the behavior plan), she replied she was not aware and stated she felt Patient #1 would benefit from structure.

8. An interview was conducted with RN #1 assigned to unit 1 C on 3/11/19 at 1:29 p.m. When asked about Patient #1's activity schedule, she stated, "He does whatever he wants." When questioned about Patient #1's treatment plan, she stated in part, "I don't think he has one."

9. An interview was conducted with Patient #1 on 3/11/19 at 1:29 p.m. He stated in part there was "nothing to do on the unit" and that he slept and did nothing else. He also said he knew he had a schedule but had no copy of it and he did not know what was included in his treatment or behavior plan.

10. A review of the policy and procedure titled "Patient Rights and Responsibilities of the Individual" last reviewed 7/7/18 revealed it states in part, "You have the right to quality care that is suited to your needs, delivered promptly and safely by well-trained staff."

Based on observation, interview and record documentation, the facility failed to provide and document ongoing active treatment in a manner that assured appropriateness, correctness and completeness of therapeutic efforts. Specifically, there was failure to:

I. Develop and document comprehensive treatment plans based on the individual needs of eight (8) of eight (8) active sample patients (A2, A4, B1, C1, C2, D12, E1 and E2). There was failure to document individualized patient problems, goals and specific modalities/ interventions based on the patient's needs. For all active sample patients there were few additions or changes to the plans (pre-printed forms) based on the individual patient findings. This treatment plan format results in "sameness" from one plan to another and absence of comprehensive treatment plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

II. Ensure that active individualized psychiatric treatment was provided for three (3) of 8 (eight) active sample patients (A2, C1, and C2) and 1 non-sample patient (C3) added for review of active treatment. Failure to ensure active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely manner, delaying improvement. (Refer to B125, Section I.)

III. Provide sufficient numbers of structured treatment modalities to meet the needs of the patient population in all three programs, especially on Saturdays and Sundays. The majority of scheduled groups/activities offered on Saturdays and Sundays were leisure-oriented, rather than therapeutic treatment modalities based on individualized needs of the patient population. Failure to provide sufficient hours of active treatment based on patients' needs preven

Based on record review and interview, there was failure to ensure that psychosocial assessments included recommendations for the anticipated social work role in treatment and discharge planning for six (6) of eight (8) active sample patients (A2, A4, B1, C1, C2, and E1). In addition, there was failure to document a psychosocial assessment
for two (2) of eight (8) active sample patients (D12 and E2). These failures hinder treatment and discharge planning for patients.

Findings include:

A. Record Review:

Review of the psychosocial assessments revealed that for six (6) of eight (8) active sample patients the specific role of the social worker in treatment was not stated, nor were the specific recommendations for discharge identified. Records were (assessment dates in parentheses): A2 (12/7/18); A4 (3/11/19); B1 (3/7/19); C1 (2/19/19); C2 (2/1/19); and E1 (7/12/18).

B. Absence of Psychosocial Assessments

A psychosocial assessment was not completed for Patient D12 (admitted on 4/11/14) and Patient E2 (admitted on 6/24/15). There were no annual updates.

C. Interview

During interview with review of psychosocial assessments, on 3/12/19 at 2:35 p.m., the Director of Social Work agreed that the documented recommendations for the social work role in treatment were not complete.

Based on record review and interview, there was failure to document memory functioning for four (4) of eight (8) active sample patients (A2, A4, C1 and C2) in the psychiatric evaluations. This failure hinders the treatment team's ability to determine stability or change in status in subsequent reassessment.

Findings include:

A. Review of the psychiatric evaluations revealed that for four (4) of eight (8) active sample patients (assessment dates in parenthesis): A2 (12/6/18); A4 (3/10/19); C1 (2/17/19); and C2 (2/2/19), memory functioning was not addressed.

B. During interview on 3/13/19 at 11:00 a.m., the Chief Medical Officer stated that psychiatric evaluations should address memory functioning.

Based on interview and record review it was determined that the facility failed to develop and document comprehensive treatment plans based on the individual needs of eight (8) of eight (8) active sample patients (A2, A4, B1, C1, C2, D12, E1 and E2). There was failure to document individualized patient problems, goals and specific modalities/ interventions based on the patient's needs. For all active sample patients there were few additions or changes to the plans, which were pre-printed forms, based on the individual patient findings. This treatment plan format resulted in uniformity from one plan to another and therefore absence of comprehensive individualized treatment plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings.

Findings include:

A. Review of Treatment Plans:

1) Eight active sample records were reviewed (dates in parentheses): A2 (12/6/18 with Treatment Plan review date of 3/8/19); A4 (3/8/19); C1 (2/16/19); C2 (1/31/19); D12 (9/12/18 with Treatment Plan review date of 3/7/19); E1 (7/2/18 with Treatment Plan review date of 1/2/19); and E2 (8/1/18 with Treatment Plan review date of 1/17/19). Review of treatment plans revealed that for the 8 of 8 active sample patients there was failure to document individualized patient problems, goals and specific modalities/ interventions based on the patient's needs. Treatment plans for each patient were based on pre-printed forms for general diagnostic categories (e.g. Depressive Symptoms, Anger Control Problems, and Cognitive Impairment) that included lists of goals and interventions from which choices were identified for each patient by a check mark. Many of the identified goals failed to directly correlate with the diagnostic problem/category chosen for the patient. Interventions for all disciplines we

Based on observation, interview and document review, it was determined that the facility failed to:

I. Ensure that active individualized psychiatric treatment was provided for three (3) of 8 (eight) active sample patients (A2, C1, and C2) and 1 non-sample patient (C3) added for review of active treatment. In the case of active sample Patient A2, there was failure to provide treatment due to his/her special treatment needs. This patient stayed in his/her room asleep for many hours daily with little structure or expectations for attending treatment. In the case of sample Patients C1 and C2, there was a failure to provide active treatment based on their presenting needs. These patients remained in their rooms in bed sleeping for many hours and refusing to attend scheduled groups. For non-sample Patient C3, there was failure to provide structured treatment for this patient's specialized treatment needs. This patient functioned at a low cognitive level, yet adequate modalities to address his/her problems were not provided. Failures to ensure active treatment resulted in patients being hospitalized without all interventions for recovery being provided in a timely manner, delaying improvement.

II. Provide sufficient structured therapeutic modalities to meet the needs of the patient population in all three programs, especially on Saturdays and Sundays. The majority of scheduled groups/activities offered on Saturdays and Sundays were leisure-oriented, rather than therapeutic treatment activities based on individualized needs of the patient population. In addition, patients were allowed to choose to watch television, talk on the phone or sit/lie around the unit, rather than attend structured groups that were offered. Failure to provide sufficient hours of active treatment based on patients' needs prevents patients from achieving

Based on observation, interview and document review, the facility failed to assure that the Medical Director, the Director of Nursing, the Director of Social Work, and The Director of Rehabilitation Services adequately monitored active treatment and took corrective action as required. Specifically:

I. The Medical Director failed to:

A. Ensure documentation of memory functioning for four (4) of eight (8) active sample patients (A2, A4, C1 and C2) in the psychiatric evaluation. This failure hinders the treatment team's ability to determine stability or change in status in subsequent reassessment. (Refer to B144, Section I)

B. Assure staff developed comprehensive treatment plans based on the individual needs of eight (8) of eight (8) active sample patients (A2, A4, B1, C1, C2, D12, E1 and E2). There was failure to document individualized patient problems, goals and specific modalities/ interventions based on the patient's needs. The treatment plan format results in "sameness" from one plan to another and absence of comprehensive treatment plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B144, Section II)

C. Ensure that individualized active treatment was provided for three (3) of 8 (eight) active sample patients (A2, C1, and C2) and 1 non-sample patient (C3) added for review of active treatment. Failure to ensure active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely manner, delaying improvement. (Refer to B144, Section III)

D. Assure there are sufficient structured therapeutic modalities to meet the needs of the patient population in all three programs, especially on Saturdays and Sundays. The majority of scheduled groups/activities offered on Saturdays an

Based on observation, interview and document review, it was determined that monitoring and evaluation by the Medical Director failed to include sufficient review and corrective measures to assure compliance with necessary practices, treatment of patients, and documentation of treatment in the facility. Specifically the Medical Director failed to:

I. Ensure documentation of memory functioning for four (4) of eight (8) active sample patients (A2, A4, C1 and C2) in the psychiatric evaluation. This failure hinders the treatment team's ability to determine stability or change in status in subsequent reassessment. (Refer to B116)

II. Assure that staff developed comprehensive treatment plans based on the individual needs of eight (8) of eight (8) active sample patients (A2, A4, B1, C1, C2, D12, E1 and E2). There was failure to document individualized patient problems, goals and specific modalities/ interventions based on the patient's needs. For all active sample patients there were few additions or changes to the plans' pre-printed forms based on the individual patient findings. This treatment plan format results in "sameness" from one plan to another and absence of comprehensive treatment plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

III. Ensure that individualized active treatment was provided for three (3) of 8 (eight) active sample patients (A2, C1, and C2) and 1 non-sample patient (C3) added for review of active treatment. Failure to ensure active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely manner, delaying improvement. (Refer to B125, Section I)

IV. Assure sufficient structured therapeutic modalities to meet the needs of the patient population in all

Based on observation, document review and interview the Director of Nursing (DON) failed to adequately monitor the care provided to patients by nursing staff at the facility. Specifically the DON failed to:

I. Assure that nursing staff consistently provided comprehensive treatment plans for eight (8) of eight (8) active sample patients (A2, A4, B1, C1, C2, D12, E1 and E2) that included nursing treatment interventions with specific focus. Nursing interventions were either generic monitoring or discipline functions to be performed by nursing staff. This failure results in treatment plans that do not reflect individualized nursing approach to treatment and fail to provide guidance to nursing staff regarding modalities needed. This failure potentially results in patient not receiving effective treatment prolonging the hospitalization. (Refer to B 118.)

II. Assure nursing staff provided active nursing treatment, including purposeful alternative nursing interventions for three (3) of 8 (eight) active sample patients (A2, C1, and C2) and 1 non-sample patient (C3) added for review of active treatment. These four patients regularly and repeatedly did not attend the daily RN groups on the unit schedule. As a result, they spent most of their time in bed sleeping. Despite documentation showing lack of attendance in RN groups, treatment plans were not updated to more individualized treatment sessions for these patients. Failure to provide active treatment results in patients being hospitalized without receiving all treatment necessary for recovery being delivered in a timely manner, potentially delaying their improvement and prolonging hospitalization. (Refer to B 125 I)


III. Provide sufficient numbers of structured nursing modalities to meet the needs of the patient population in all three programs, especially on Satu

Based on interview and record review the Director of Social Work failed to ensure adequate monitoring and evaluation of the social work services provided for the patients. Specifically there was failure to:

I. Ensure that the medical record included psychosocial assessments that documented recommendations for the anticipated social work role in treatment and discharge planning for six (6) of eight (8) active sample patients (A2, A4, B1, C1, C2, and E1). In addition, there was failure to document a psychosocial assessment for two (2) of eight (8) active sample patients (D12 and E2). This failure hinder treatment and discharge planning for patients. (Refer to B108)

II. Ensure that social work interventions based on patients presenting needs were identified in the comprehensive treatment plans of eight (8) of eight (8) active sample patients (A2, A4, B1, C1, C2, D12, E1 and E2). For all active sample patients there were few additions or changes to the plans (pre-printed forms) based on the individual patient findings. This treatment plan format resulted in "sameness" from one plan to another and absence of comprehensive treatment plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

Based on observation, interview and document review, there was failure to provide sufficient numbers of structured therapeutic activities to meet the needs of the patient population on four (4) of six (6) Units, especially on Saturdays and Sundays. The majority of these scheduled groups/activities were leisure-oriented, rather than therapeutic treatment activities based on individualized needs of the patient population and were held off-unit in a central location. Failure to provide sufficient hours of active treatment based on patients' needs prevents patients from achieving their optimal level of functioning, thereby potentially delaying a timely discharge.

Findings include:

A. Review of the treatment/activity schedules provided by administration revealed that on the majority of evening shifts for 4 of 6 units (5N, 3S, 4S and 5S) there was only 1 group/activity offered after 4:15-5:00 p.m. The schedule reflected that most weekend groups were offered in a central location off of the patient care Units. These schedules documented that the majority of these groups/activities were leisure oriented, and those off the units were not accessible to many of the patients.

B. During observation on Unit 3 South on 3/12/19 at 11:35 a.m., RN D4 reported in interview that all the patients were on the unit, except for 3 patients who had gone off the unit to attend a therapeutic recreation group. Therefore, only 3 of 16 patients on this unit had attended the group and the other 13 patients remained on the ward. These patients were watching television, in their bedrooms or roaming about the unit.

C. Interviews:

During interview, including review of therapeutic schedules, on 3/12/19 from 2:45- 3:40 p.m., the Director of Therapy and the Director of Patient Services verified that patients are allowed to watch tel