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Based on record review, policy, and staff interview, for seven (7) of seven sample(7) patients, (A1 - A7) the facility failed to provide social work assessments that included a description of the patients' family of origin, siblings, childhood development, educational attainment, and vocational achievement; nor did these assessments describe the current adult interpersonal relationships of the patient.

In addition, in 3 of the 7 psychosocial assessments (A1, A2 and A5), there was the suggestion that the patient had been subject to past physical or sexual abuse. Yet, no further focus was given in these assessments to the import of this information.

The failure to include this information within the completed reports reduced the capacity of the treatment team to formulate meaningful treatment plans to support the future needs of the patient.

Findings are:

A Record Review

Patient A1: This 19 year-old single individual was admitted on January 28, 2010.
The patient's psychosocial assessment (completed January 29, 2010) stated that the patient's mother had died "two years ago," and that the patient had "lived with (the patient's) brother in an essentially homeless situation." There was no mention of the patient's family of origin, childhood development, educational or vocational achievement. In addition, the assessment stated the following: "It is suspected that (the patient) had to prostitute...self in order to survive but this has not been confirmed".

Patient A2: This 33 year-old single individual was admitted on January 26, 2010.
The patient's psychosocial assessment (completed January 27, 2010) stated that "(the patient) was released from jail (after serving 30 days in jail) the date of admission due to domestic violence". The assessment also stated that the patient has "a history of abuse as a child" and had "a nervous breakdown 3 years ago". Yet, this report provided no further information regarding the patient's described "history of abuse", nor did it provide any information regarding the patient's family or origin, siblings, childhood development, educational and vocational attainment, nor history of employment.

Patient A3: This 41 year-old single individual was admitted on January 28, 2010.
The patient's psychosocial assessment (completed January 29, 2010) provided virtually no information on the patient's family or origin, childhood development, educational and vocational achievement; nor was there a description of the patient's current interpersonal relationships. This report only stated that the patient was currently "homeless".

Patient A4: This 33 year-old single individual was admitted on January 20, 2010.
The patient's psychosocial assessment (completed January 22, 2010) contained no information regarding the patient's family of origin, childhood development, educational or vocational achievement, nor history of adult interpersonal relationships.

Patient A5: This 46 year-old single individual was admitted on January 22, 2010.
The patient's psychosocial assessment (completed January 25, 2010) stated that this patient's family "resided in Europe", and that the patient had been a victim of "torture" of an Eastern European civil war. However, within the report there was no information regarding this patient's family of origin, other siblings, childhood development, educational, or vocational achievement.

Patient A6: This 36 year-old single individual was admitted on January 28, 2010.
This patient's psychosocial assessment (completed January 29, 2010) provided only fragments of this individual's life: "divorced two years ago", and "moved back with (patient's) father". Otherwise, the report contained no information regarding the patient's family of origin, siblings, childhood development, educational and vocational achievements; nor did the report describe the patient's current interpersonal relationships".

Patient A7: This 25 year old divorced individual was admitted on January 31, 2010.
The patient's psychosocial assessment (completed February 1, 2010) provided only fragments of this person's life: "mother of 3 children...and raising 3 of (the patient's) brother's children". The report also stated that "(the patient) felt cheated by (the patient's) birth father leaving when (the patient) was 6 months of age". There was no additional description of the patient's family of origin, siblings (outside of the mention of a brother), childhood development, educational or vocational aspirations, or employment.

B. Policy Review:

The Windhaven Psychiatric Hospital Policy Number: WPH.CL420.124, (last reviewed 4/23/08), Social Services, states under lll. FUNCTIONS AND DUTIES, "B. Duties 1. Completion of Comprehensive Assessment by a C. M. S. W...."

C. Interview:

The Director of Social Work holds a Master's degree in Social Work and is a Licensed Clinical Social Worker (AZ - through 2011). In an interview on February 1, 2010 at 1PM the Director stated that "the Department of Social Work does not have a specific policy in terms of what components should be within the psychosocial assessment, but we use the components of the psychosocial assessment as outlined in the 'the interpreter guidelines' under B108 of the code of federal regulations for psychiatric hospitals."

On February 2, 2010 at 3pm, the Director stated that all seven (7) current psychosocial assessments "didn't describe the basic information necessary to meet professional social work standards for a comprehensive psychosocial assessment". The Director agreed that in virtually all the reports, there was no mention of the patient's family of origin, demographics, childhood development, educational and vocation achievement; and that failing to provide this written overview reduced the capacity of the treatment team to plan for the patient's future needs.

Based on record review and interview, the facility failed to adequately estimate intellectual and memory functioning or describe methods used for testing for 7 of 7 active sample patients (A1- A7). This deficient practice compromises the data base from which changes in a patient's condition can be measured throughout the course of treatment, and impedes the ability of the clinical team to develop treatment goals and interventions that are concordant with the patient's estimated cognitive functioning.

Findings are:

A. Record Review:

Patient A1

In the psychiatric evaluation, done on 1-29-10, i.e. the day after admission, this patient was given an Axis II diagnosis of mental retardation (ICD-CM 319.0, changed, on 1-30-10 in a doctor's progress note to "mental retardation, unspecified"). The mental status examination addresses cognitive functions by means of a checklist including immediate recall, recent memory, remote memory and fund of knowledge, as well as the option "check here if all [i.e. the previous listed functions] intact." In Record A1, "all impaired secondary to DDD" was written in. As intellectual disability was identified as the only diagnosis in the psychiatric evaluation, a more detailed outline of cognitive deficits and intellectual dysfunction would have been required in order to set goals and determine realistic expectations for functional recovery.

Patient A2

A psychiatric evaluation was done on 1-27-10, i.e. the day after admission. The mental status examination addresses cognitive functions by means of a checklist including immediate recall, recent memory, remote memory and fund of knowledge, as well as the option "check here if all [i.e. the previous listed functions] intact." In Record A2, the examiner had written in "adequate for exam." In a patient with alcohol abuse and polysubstance dependence as working diagnoses on Axis I, a more detailed assessment would have been useful to identify cognitive weaknesses which, in turn, would limit prognostic expectations.

Patient A3

A psychiatric evaluation was done on 1-29-10, i.e. the day after admission. The mental status examination addresses cognitive functions by means of a checklist including immediate recall, recent memory, remote memory and fund of knowledge, as well as the option "check here if all [i.e. the previous listed functions] intact." In Record A3, "check here if all intact" was checked. In view of diagnoses of depression NOS, alcohol and methamphetamine dependence, cognitive baseline assessment would have been especially relevant to identify cognitive weaknesses which, in turn, would limit prognostic expectations.

Patient A4

A psychiatric evaluation was done on 1-21-10, i.e. the day after admission. The mental status examination addresses cognitive functions by means of a checklist including immediate recall, recent memory, remote memory and fund of knowledge, as well as the option "check here if all [i.e. the previous listed functions] intact." In Record A4, concentration and attention were marked as "decreased" while "all others are OK" was written in.

Patient A5

A psychiatric evaluation was done on 1-22-10, i.e. the day of admission. The mental status examination addresses cognitive functions by means of a checklist including immediate recall, recent memory, remote memory and fund of knowledge, as well as the option "check here if all [i.e. the previous listed functions] intact." In Record A5, the admitting psychiatrist had written in "all appeared impaired." In a patient where, initially, anticholinergic toxicity and delirium were suspected, a more nuanced baseline assessment would have been important. A full Mini-mental State rating (MMSE=23) was added on 2-1-10 and this included an outline of methodology.

Patient A6

A psychiatric evaluation was done on 1-29-10, i.e. the day after admission. The mental status examination addresses cognitive functions by means of a checklist including immediate recall, recent memory, remote memory and fund of knowledge, as well as the option "check here if all [i.e. the previous listed functions] intact." In Record A6, "check here if all intact" was checked.

Patient A7

A psychiatric evaluation was done on 1-31-10, i.e. the day of admission. The mental status examination addresses cognitive functions by means of a checklist including immediate recall, recent memory, remote memory and fund of knowledge, as well as the option "check here if all [i.e. the previous listed functions] intact." In Record A7, "check here if all intact" was checked.

B. Interview

The Medical Director was interviewed in the Consultants' office from 13:45 to 14:15 on 2-2-10. She agreed that the cognitive status is not always fully documented. She explained that "last spring" the medical staff decided to eliminate the full Folstein Mini-mental State Examination (MMSE) from the Psychiatric Evaluation Form. The reason for this decision had been, she added, that "the Psych Eval is already fifteen pages long." "We'll just put it [i.e. the MMSE] back in," she suggested, but then agreed that what really was needed was a more detailed evaluation (and description of methodology) of memory function and an assessment of intellectual functioning.

I. Based on, record review and interviews the Director of Psychiatric Nursing failed to ensure ongoing training of nursing staff, and nursing documentation of adherence to restraint policy, which outlines specific sequences of events to be taken prior to administration of medications to patients at risk and prior to the use of physical restraints.

Findings are:

A. Record Review (Patient A1)

The Staff Progress Notes on 1/29/2010 at 0745 stated that, "Patient began hitting walls and windows of nurses' station. Removed Hospital issued scrubs and threw in trash. Let me out. Give me my stuff." "Patient is not redirectable" "Patient refused Seroquel 50 mg., p.o. b.i.d. prn for mood instability". 0800 "Patient agrees to take Seroquel". At 0810, "patient was yelling and screaming, banging on windows". "Pt. attempts to enter nurses' station by pushing past staff". Code green called. "Two staff guided him to his room with hands on his arms. Four staff helped hold him on his bed and Zyprexa 5 mg. IM given". There was no evidence of, "non-physical intervention skills" employed by nursing staff prior to the use of restraints in the nursing documentation on the Staff Progress Note.

B. Policy Review

Policy WPH.CL420.301, Restraint, Date if issue: 4/23/08, Revision Date: 8/26/09, states that, "non-physical intervention skills such as de-escalation, mediation, conflict resolution, active listening, and verbal and observational methods" must be utilized by staff members before, "participating in restraints". The policy states that restraint may be: "physical, mechanical or pharmacological".

C. Competency Review

Review of Restraint competency documentation in the personnel file of employee R5, registered nurse, who administered the medications during the above noted incident revealed the employee did not show completion of the element of "Seclusion and Restraint Education" as outlined in Hospital Policy, WPH.CL420.301, Restraint, date of issue: 4/23/08, revision date: 8/26/09., The policy states that, "initial education and on-going training must be taught before staff participation in restraint use".

D. Interviews

1. In an interview with R3, (registered nurse) on 2/2/10 at 9:15am. R3 acknowledged that de-escalation steps had not been documented.

2. In an interview with the Director of Nursing (DON), R1 and R2, (registered nurses), on 2/2/10 at 3:30pm, the DON confirmed that Policy WPH.CL 420.301, Restraint, had not been followed in terms documentation of the use of "non-physical skills such as de-escalation, mediation, conflict resolution, active listening, and verbal and observational methods" prior to the use of pharmaceutical or physical restraint.

II. Based on record review and interviews, the Director of Nursing failed to ensure that there was documentation in the Barriers to Learning section on the Initial Nursing Care Plan Assessment in 5 of 7 active sample patients, (A1,A3,A4,A5,A6). This omission reduced the capacity of the treatment team to plan for the patients' immediate and future learning needs.

Findings are:

A. Record Review

Patient A1:

There was nothing listed in the barriers to Learning section. The patient has a diagnosis of mental retardation, unspecified.

Patient A3:

There was nothing listed in the Barriers to Learning section. The patient has a diagnosis of depression, homelessness, methamphetamine and alcohol dependence and paranoia.

Patient A4:

Barriers of learning section states, "none". "Pt. reads a lot at home" was written. Patient has a history of Schizpohrenia, psychosis, anxiety and depression.

Patient A5:

Nothing was listed on the Barriers to Learning section. Patient has a history of morphine methamphetamine addiction.

Patient A6:

Nothing was listed on the Barriers to learning section. Patient has a history of polysubstance abuse and depression.

B. Interview

An interview with the Director of Nursing, R1 and R2, (registered nurses), was conducted on 2/2/10 at 3:30pm. They confirmed that patients with the diagnoses listed above would, indeed, have some barriers to learning which ought to have been identified in order to establish a comprehensive, indivualized treatment plan.

III. Based on record review and interviews, the Director of Nursing failed to ensure the quality and appropriateness of care provided by the nursing staff. Upon review of the Nursing Shift Assignment Sheet and staff interviews, it was determined that shift staff are not assigned to specific patients. This resulted in no one person being accountable for specific patient care. In addition, patients were either documented on during the day shift or the evening shift, not both. It was not clear as to what occured if a patient had specific care needs on the day shift but was scheduled to be documented on during the evening shift. No policy was available to explain a process.

Findings are:

A. Interviews

1. An interview with Charge Nurse R4 was conducted on 2/1/10 at 11:00am. He was asked who was assigned to patient A5. The nurse replied that all staff are responsible for all patients, that there is no one person assigned to each patient.

2. An interview with Director of Nursing, R1 and R2 was conducted on 2/2/10 at 3:30pm to review the process and policy re: the assignment of staff to patients. Both individuals confirmed that the process of assigning all staff to all patients was true. They were unable to determine if there was a policy regarding the assignment of staff to patients.

Based on record review, policy, and staff interview, the Director of Social Work failed to monitor the quality of the psychosocial assessments at the time of their completion in seven (7) of seven (7) patient records (A1; A2; A3; A4; A5; A6; and A7). As a result of this failure to monitor the quality of the psychosocial assessments, significant aspects of patients' psychosocial history were omitted from the report and thus reduced the capacity of the treatment team to plan for the patients' future needs.

Findings are:

A. Patient Record Review:

The seven (7) psychosocial assessments (A1; A2; A3; A4; A5; A6; and A7) were developed and completed by NSW #1, and NSW #2, staff within the social work department that do not have a degree(s) in social work. The Director of Social Work assigned NSW #1 and NSW #2 to develop and complete the psychosocial assessments.
The staff person NSW#1 completed the assessments for A1 on January 29th; and A5 January 25th. The staff person NW #2 completed the assessments for A2 on January 27th; A3 on January 29th; A4 on January 22nd; A6 on January 29th; and A7 on February 2nd.
Neither NSW #1 nor NSW #2 have a degree(s) in social work; yet the content of their assessments as well as the conclusions rendered by NSW #1 and NSW #2 were not reviewed by the Director of Social Work prior to these written reports going to the treatment planning team.

B. Policy Review:

The Windhaven Psychiatric Hospital Policy Number: WPH.CL420.124, (last reviewed 4/23/08), Social Services, states under lll. FUNCTIONS AND DUTIES, B. 6. "The Social Worker Supervisor is the direct supervisor of the...other social workers and interns".

C. Interview:

This surveyor met with the Director of Social Work on February 2, 2010 at 3PM. The Director stated that (the Director of Social Work) "had not monitored the quality" - both content and conclusions - of all seven psychosocial assessments (A1; A2; A3; A4; A5; A6; and A7) that were developed by non-social work staff within the social work department "at the time of the completion" of these reports and prior to the their being reviewed by the treatment planning team.