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Based on record review, policy review, and interview, the facility failed to develop Master Treatment Plans (MTPs), that identified patient-centered, short-term goals stated in observable, measurable, behavioral terms for six (6) of eight (8) active patients (G2, G3, G5, G6, G7, and G8). In addition, the goals were written in terms that required the patient to self-assess and report the assessment to the staff. Lack of measurable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs.

Findings include:

A. Medical Record Review

1. Patient G2's (MTP), dated 5/13/18, listed the problem, "Depressed Mood with Suicidal Ideation and Self-Harm Thoughts." The Short-Term Goals (STGs) for this problem included the non-measurable and patient self reporting goals, "Pt [Patient] will be able to no longer report thoughts of suicide and self-harm AEB [As Evidenced By] self report to staff. Pt will also report a 50% decrease in depressed mood three (3) days prior to discharge AEB self report to staff."

2. Patient G3's MTP, dated 5/11/18, listed the problem, "Depressed Mood with Suicide and Self Harm Thoughts." The STGs for this problem included the non-measurable goal, "Pt will not act on self-harm thoughts x [times] 2 days prior to discharge."

3. Patient G5's MTP, dated 5/13/18, listed the problem, "Depression with Suicidal Ideation and Self-Harm." The STGs for this problem included the patient self-reporting goal, "[Patient] will report to staff any suicidal or self harm thoughts as they occur."

4. Patient G6's MTP, dated 5/13/18, listed the problem, ". . . . struggles with chronic pain which leads to depression, anxiety, and SI [Suicidal Ideation]." The STGs for this problem included the patient self-reporting goal, "[Patient] will deny any suicidal ideation for the next 3 days."

5. Patient G7's MTP, dated 5/13/18, listed the problem, ". . . . suicide attempt, depression and suicidal thoughts as a result of a history of PTSD [Post-Traumatic Stress Disorder] and having SI and unnatural sexual thoughts." The STG for this problem included the patient self-reporting goal, "[Patient] will report to staff any SI, SA [Substance Abuse], and depression [sic] thoughts that occur."

6. Patient G8's MTP, dated 5/13/18, listed the problem, ". . . . SI and depression as a result of separation from wife and [his/her] legal issues. Pt also reports Audio [sic] Hallucinations [AH]." The STGs for this problem included the non-measurable and patient self-reporting goals, "[Patient] will verbalize a 50% improvement in mood ...," and "[Patient] will report to staff any SI/AH & depression thoughts."

B. Policy Review

Review of hospital policy titled, "Interdisciplinary Treatment Plan," hospital reviewed 2/2018, revealed that "Short-term goals are stated as stepping stones to the long-term goals and are stated in specific behavioral, observable and measurable terms."

C. Interview

1. During an interview on 5/15/18 at 9:30 a.m., the Clinical Director agreed that the short-term goals were not measurable.

2. During an interview on 5/15/18 at 11:00 a.m., the Chief Medical Officer agreed that the short-term goals were not measurable.

3. During an interview on 5/15/18 at 2:00 p.m., the Director of Nursing agreed that the short-term goals were not measurable and required the patients to self-assess and inform the staff when feeling unsafe.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that included individualized interventions to address specific treatment needs for five (5) of eight (8) sampled patients (G2, G5, G6, G7, and G8). Listed interventions were stated in vague terms and were routine, generic discipline functions rather than individualized patient specific interventions. This deficiency results in lack of guidance to treatment staff in providing individualized, coordinated treatment in the least restrictive environment.

Findings include:

A. Medical Record Review

1. Patient G2's Master Treatment Plan (MTP), dated 5/13/18, included the Short-Term Goals (STGs), "Pt [Patient] will be able to no longer report thoughts of suicide and self-harm AEB [As Evidenced By] self report to staff. Pt will also report a 50% decrease in depressed mood 3 days prior to discharge AEB self report to staff." The intervention listed for these goals included the physician intervention, "Order medications and tx [treatment] modalities."

2. Patient G5's MTP, dated 5/13/18, included the STG, "[Patient] will report to staff any suicidal or self harm thoughts as they occur." The interventions listed for this goal included the nursing intervention, "observe every 15 minutes for safety."

3. Patient G6's MTP, dated 5/13/18, included the STG, "[Patient] will deny any suicidal ideation for the next 3 days." The interventions listed for this goal included the nursing intervention, "Observe [patient] every 15 minutes for safety."

4. Patient G7's MTP, dated 5/13/18, included the STG, "[Patient] will report to staff any SI [Suicidal Ideation], SA [Substance Abuse], and depression thoughts that occur." The interventions listed for this goal included the nursing intervention, "MHT [Mental Health Technician] will observe pt [patient] Q (every) 15 minutes for safety."

5. Patient G8's MTP, dated 5/13/18, included the STGs, "[Patient] will verbalize a 50% improvement in mood ...," and "[Patient] will report to staff any SI/AH [Suicidal Ideation/Auditory Hallucinations] & depression [sic] thoughts." The interventions listed for this goal included, "MHT-observe pt Q 15 min [minutes] during hosp. [hospital] stay."

B. Policy Review

Review of hospital policy titled, "Interdisciplinary Treatment Plan," reviewed 2/2018, revealed that, "The treatment plan shall contain specific interventions that relate to goals, are written in behavioral, observable and measurable terms, and include expected achievement dates . . . ."

C Interview

1. During interview on 5/15/18 at 2:00 p.m., the Clinical Director and the Director of Nursing agreed that the interventions were generic, discipline functions and were not individualized patient specific interventions.

Based on medical record review, policy review, and interview, the Chief Medical Officer failed to ensure:

1. The development of Master Treatment Plans (MTPs), that identified patient-centered, short-term goals stated in observable, measurable, behavioral terms for six (6) of eight (8) active patients (G2, G3, G5, G6, G7, and G8). In addition, the goals were written in terms that required the patient to self-assess and report the assessment to the staff. Lack of measurable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs. (See B121)

2. The development of Master Treatment Plans (MTPs) that included individualized interventions to address specific treatment needs for five (5) of eight (8) sampled patients (G2, G5, G6, G7, and G8). Listed interventions were stated in vague terms and were routine generic discipline functions rather than individualized patient specific interventions. This deficiency results in lack of guidance to treatment staff in providing individualized, coordinated treatment in the least restrictive environment. (See B122)

Interview

In an interview on 5/15/18 at 11:00 a.m., the surveyor discussed with the Chief Medical Officer the findings regarding short and long-term goals and treatment interventions. She concurred with the findings.

Based on record review and interview, the Director of Nursing failed to ensure that nursing interventions listed on patients' MTPs addressed individualized patient needs for four (4) of eight (8) active patients (G5, G6, G7, and G8). Instead, the interventions were stated in vague terms and were non-individualized, generic discipline functions rather than individualized patient specific nursing interventions. This deficiency limits the therapeutic nursing interventions available to patients.

Findings include:

A. Medical Record Review

1. Patient G5's MTP, dated 5/13/18, included the STG, "[Patient] will report to staff any suicidal or self harm thoughts as they occur." The interventions listed for this goal included the nursing intervention, "observe every 15 minutes for safety."

2. Patient G6's MTP, dated 5/13/18, included the STG, "[Patient] will deny any suicidal ideation for the next 3 days." The interventions listed for this goal included the nursing intervention, "Observe [patient] every 15 minutes for safety."

3. Patient G7's MTP, dated 5/13/18, included the STG, "[Patient] will report to staff any SI [Suicidal Ideation], SA [Substance Abuse], and depression thoughts that occur." The interventions listed for this goal included the nursing intervention, "MHT [Mental Health Technician] will observe pt [patient] Q (every) 15 minutes for safety."

4. Patient G8's MTP, dated 5/13/18, included the STGs, "[Patient] will verbalize a 50% improvement in mood...," and "[Patient] will report to staff any SI/AH [Suicidal Ideation/Auditory Hallucinations] & depression [sic] thoughts." The interventions listed for this goal included, "MHT-observe pt Q 15 min [minutes] during hosp. [hospital stay]."

B. Policy Review

Review of hospital policy titled, "Interdisciplinary Treatment Plan," reviewed 2/2018, revealed that, "The treatment plan shall contain specific interventions that relate to goals, are written in behavioral, observable and measurable terms, and include expected achievement dates...."

C Interview

1. During interview on 5/15/18 at 2:00 p.m., the Clinical Director and the Director of Nursing agreed that the interventions were generic, discipline functions and were not individualized patient specific interventions.