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Based on review of hospital policies and procedures, documents, medical records, and staff interviews, it was determined that the hospital failed to ensure that at the time of admission, 9 of 20 patients (Patients #5, #7, #9, #14, #15, #16, #17, #19, #20), or patient representatives were provided a copy of:

1. the patient rights and responsibilities. This deficient practice poses a high risk for the potential of patients or patient representatives not knowing the patient's rights and responsibilities; and

2. the advanced directives. This deficient practice poses the high potential that the patient's directives may not be implemented in the event of an adverse occurrence during hospitalization.

Findings include:

1. Policy and procedure titled "Patient Rights" revealed: "...h. every patient, or his designated representative, shall be given, at the time of admission, a copy of the patient's rights and responsibilities...PROCEDURE: Upon admission and throughout the hospital stay, each patient and as appropriate, the patient's family members...is informed about patients rights...and provided a copy of the patients rights...."

Facility document titled "Acknowledgement of Notices" revealed: "...Initial each line and sign below to indicate receipt of the information listed...Patient Rights...."

Medical record review revealed that 9 of 20 patient records (Patients #5, #7, #9, #14, #15, #16, #17, #19, #20) did not contain the "Acknowledgement of Notices" document or any other documentation that the patient's had received a copy of the patient rights and responsibilities.

RN's #2 and #3 confirmed during interview conducted 04/12/18, that the process of informing patients and/or patient's representatives about patient rights was not maintained.

2. Policy and procedure titled "Advanced Directives" revealed: "...PROCEDURE: Admitting staff will complete the Advance Directive form to determine if a patient has executed an Advance Directive and/or desires information related to the process of formulating an Advance Directive...The patient/legal representative shall be requested to sign the Advance Directive form to acknowledge receipt of information regarding Advance Directives...."

Medical record review revealed that 9 of 20 patient records (Patients #5, #7, #9, #14, #15, #16, #17, #19, #20) did not contain the "Advance Directives" form.

RN's #2 and #3 confirmed during interview conducted 04/12/18, that the Advanced Directives process was not maintained.

Based on record review and interview, the facility failed to assure that all assessments were in the chart in a timely manner in the areas of Social Work one (1) of eight (8) active sample records-- pt. M15) (refer to B108); History and Physical Exams for six (6) of eight(8) active sample patients--pts. M8, M15, P2, P5, J11 and J14) (refer to B109); and Psychiatric Assessments (for five (5)of eight (8)active sample patients-pts.M15, P2, P5, J11, J14) (refer to B110). In addition, Master Treatment Plans were missing significant elements, including measurable long and short term goals for eight (8) of eight (8) active sample patients (pts.M2, M8, M12, M15, P2, P5, J11 and J14) (refer to B121) and individualized treatment modalities to meet patient needs for eight (8) of eight (8) active sample patients (M2, M8, M12, M15, P2, P5, J11 and J14) (refer to B122). Social Work individual and group treatment notes were missing from records for seven (7) of eight (8) active sample patients (pts.M8, M12, M15, P2, P5, J11 and J14) (refer to B124) and physician notes were missing from records for two (2) of eight (8)active sample patients (pts.M2 and M12); or were illegible for two(2) of two(2) records of one psychiatrist's patients that were reviewed (pts.M8and M15) (refer to B126). These failures resulted in a lack of documentation to guide staff on all shifts and all disciplines in the effective treatment of patients and can hinder timely discharge.

Based on record review and staff interview the facility failed to have completed Psychosocial Assessments in the chart in a timely manner for one (1) of eight (8) active sample patients (M15). Failure to complete the Assessment in a timely manner can lead to discharge planning that fails to take into account the psychosocial needs of the patient that could impair successful discharge.

Findings include:

A. Record Review

Pt. M15 was admitted 4/26/18 with a diagnosis of dementia. On 4/27/18 the social worker did the 6 page assessment interview with the patient. No other informant was available at the time. The only information the social worker was able to put in the assessment was the reason for admission and present level of functioning, gleaned from admission papers.

The remainder of the sections of the 6 page assessment was either blank or contained the phrase "Information unavailable at this time-will be updated upon receipt." Further review of the social work notes in the record showed no additional information was added between admission and the survey, 5/7/18.

B. Staff Interview

In an interview with the Director of Social Services on 5/8/18 at 11 a.m., she did not dispute the findings.

Based on record review and staff interview the facility failed to have history and physical exams (H&P), including neurological exams, in the charts for six (6) of eight (8) active sample patients (M8, M15, P2, P5, J11 and J14) and for one (1) of eight (8) patients (M12) there was a brief H&P, but it did not contain a neurological exam. Failure to provide this information in the record prevents all staff from having this medical information available to use as a baseline to assess the patients' medical needs and possible changing medical status.

Findings include:

A. Record Review

1) Pt. M 8 was admitted 4/24/18. As of 5/7/18, the admission history and physical, including the neurological exam, was not in the record.

2) Pt. M12 was admitted 4/8/18. A brief H&P was in the record at the time of admission, but most of the physical exam, including the neurological was omitted at the time because the examiner noted the patient was "currently sleeping after receiving p.r.n. (as necessary) medication and becomes combative when attempting to wake [him/her]." Further review of the record does not show that a neurological exam was done at any time since then, in a patient with deteriorating mental status.

3) Pt. M15 was admitted 4/26/18. As of the first day of the survey 5/7/18, no H&P was in the record. This is an elderly patient with symptoms of dementia.

4) Pt. P2 was admitted 5/2/18. As of the first day of the survey 5/7/18, no H&P was in the record.

5) Pt. P5 was admitted 5/2/18). As of the first day of the survey 5/7/18, no H&P was in the record.

6) Pt. J11 was admitted 5/2/18. As of the first day of the survey 5/7/18, no H&P was in the record.

7) Pt. J14 was admitted 5/1/18. As of the first day of the survey 5/7/18, no H&P was in the record.

B. Policy Review:

Policy 4830110 retrieved 5/8/18, states "Within the first twenty-four (24) hours of the patient's admission, a physician will complete a history and physical."

C.Staff Interviews:

In an interview with the Risk Manager on 5/7/18 at approximately 2:00 p.m., she stated that the facility was currently without a medical records staff person and thought that was why the H&Ps were not in the chart.

In an interview with the Medical Director on 5/8/18 at 11:30 a.m., he was unaware that the H&Ps were not in the chart.

Based on record review and staff interview, the facility failed to have Psychiatric Assessments in the chart for five (5) of eight (8) active sample patients (M15, P2, P5, J11 and J14). Failure to ensure Psychiatric Assessments are in the chart in a timely manner prevents the staff from having access to baseline information on the patient's psychiatric status, as well as an understanding of any changes in patient status during the course of hospitalization.

Findings include:

Record Review

The Psychiatric Assessments of 5of 8 patients, with admission dates in parentheses, were missing from the records: M15 (4/26/18), P2 (5/2/18), P5 (5/2/18), J11(5/2/18) and J14 (5/1/18).

Policy Review:

Policy 4830110 retrieved 5/8/18, states "Within the first twenty-four (24) hours of the patient's admission, the practitioner will compete ...and dictate the Psychiatric Evaluation. The information which is required at this time is documented ...."

Staff Interview:

In an interview with the Risk Manager on 5/7/18 at approximately 2:00 p.m., she stated that the facility was currently without a medical records staff person and thought that was why the Psychiatric Assessments were not in the chart.

In an interview with the Medical Director on 5/7/18 at 11:30 a.m., he stated he was aware that the Psychiatric Assessments were not always in the chart, and that there were times he wanted to be able to look back at his own assessments and their absence was a problem.

Based on staff interview and record review, the absence of a Psychiatric Assessment for 5 of 8 active sample patients (M15, P2, P5, J11 and J14) resulted in no medical history in the record. Failure to ensure that the Psychiatric Assessment was in the chart in a timely manner prevents the staff from having access to baseline information on the patient's medical history, as well as an understanding of any changes in patient status during the course of hospitalization.

Findings include:

Record Review

The Psychiatric Assessments of the following patients, with admission dates in parentheses, were missing from the records: M15 (4/26/18), P2 (5/2/18), P5 (5/2/18), J11(5/2/18) and J14 (5/1/18).

Staff Interview:

In an interview with the Risk Manager on 5/7/18 at approximately 2:00 p.m., she stated that the facility was currently without a medical records staff person and thought that was why the Psychiatric Assessments were not in the chart.

In an interview with the Medical Director on 5/7/18 at 11:30 a.m., he stated he was aware that the Psychiatric Assessments were not always in the chart, and that there were times he wanted to be able to look back at his own assessments and their absence was a problem

Based on staff interview and record review, the absence of a Psychiatric Assessment for five (5) of eight (8) active sample patients (M15, P2, P5, J11 and J14) resulted in no record of the mental status. Failure to ensure that the Psychiatric Assessment was in the chart in a timely manner prevented the staff from having access to baseline information on the patient's mental status, as well as an understanding of any changes in patient status during the course of hospitalization.

Findings include:

A. Record Review

The Psychiatric Assessments of the following patients, with admission dates in parentheses, were missing from the records: M15 (4/26/18), P2 (5/2/18), P5 (5/2/18), J11(5/2/18) and J14 (5/1/18).

B. Staff Interviews

In an interview with the Risk Manager on 5/7/18 at approximately 2 p.m., she stated that the facility was currently without a medical records staff person and thought that was why the Psychiatric Assessments were not in the chart.

In an interview with the Medical Director on 5/7/18 at 11:30 a.m., he stated he was aware that the Psychiatric Assessments were not always in the chart, and that there were times he wanted to be able to look back at his own assessments and their absence was a problem.

Based on interview and record review, the absence of a Psychiatric Assessment for five (5) of eight (8) active sample patients (M15, P2, P5, J11and J14) resulted in no history of the onset of illness in the record. Failure to ensure that the Psychiatric Assessment was in the chart in a timely manner prevented the staff from having access to baseline information on the patient's psychiatric history, as well as an understanding of any changes in patient status during the course of hospitalization.

Findings include:

A. Record Review

The Psychiatric Assessments of the following patients, with admission dates in parentheses, were missing from the records: M15 (4/26/18), P2 (5/2/18), P5 (5/2/18), J11(5/2/18) and J14 (5/1/18).

B. Staff Interviews

In an interview with the Risk Manager on 5/7/18 at approximately 2;00 p.m., she stated that the facility was currently without a medical records staff person and thought that was why the Psychiatric Assessments were not in the chart.

In an interview with the Medical Director on 5/7/18 at 11:30 a.m., he stated he was aware that the Psychiatric Assessments were not always in the chart, and that there were times he wanted to be able to.

Based on staff interview and record review, the absence of a Psychiatric Assessment for 5 of 8 active sample patient (M15, P2, P5, J11 and J14) resulted in no description of the patient's behavior at the time of admission in the record. Failure to assure that the Psychiatric Assessment was in the chart in a timely manner prevented the staff from having access to baseline information on the patient's behavior, as well as an understanding of any changes in patient status during the course of hospitalization.
Findings include:

A. Record Review

The Psychiatric Assessments of the following patients, with admission dates in parentheses, were missing from the records: M15 (4/26/18), P2 (5/2/18), P5 (5/2/18), J11(5/2/18) and J14 (5/1/18).

B. Staff Interviews

In an interview with the Risk Manager on 5/7/18 at approximately 2:00 p.m., she stated that the facility was currently without a medical records staff person and thought that was why the Psychiatric Assessment was not in the chart.
In an interview with the Medical Director on 5/7/18 at 11:30 a.m., he stated he was aware that the Psychiatric Assessments were not always in the chart, and that there were times he wanted to be able to look back at his own assessments and their absence was a problem

Based on interview and record review, the facility failed to include an estimate of memory functioning for seven (7) of eight (8) active sample patients (M2, M8, M15, P2, P5, J11 and J14). Failure to provide the assessment of memory functioning meant that there was no baseline assessment for these patients. This failure prevents the staff from having access to baseline information on the patient's memory abilities, as well as an understanding of any changes in patient status during the course of hospitalization.

Findings include:

A. Record Review

1) Patient M2 had a Psychiatric Assessment dated 3/16/18 which stated "mod [sic] to severe deficits" without any objective information as to how the conclusion of the level of impairment was reached.

2) Patient M8 had a Psychiatric Assessment dated 4/24/18 with no information on memory functioning.

3) The Psychiatric Assessments of the following patients, with admission dates in parentheses, were missing from the records: M15 (4/26/18), P2 (5/2/18), P5 (5/2/18), J11(5/2/18) and J14 (5/1/18).

B. Staff Interviews

In an interview with the Risk Manager on 5/7/18 at approximately 2 p.m., she stated that the facility was currently without a medical records staff person and thought that was why the Psychiatric Assessment was not in the chart.

In an interview with the Medical Director on 5/7/18 at 11:30 a.m., he stated he was aware that the Psychiatric Assessments were not always in the chart, and that there were times he wanted to be able to look back at his own assessments and their absence was a problem.

Based on record review and staff interview the facility failed to ensure that Psychiatric Assessments contained an inventory of patient assets by the physician for eight (8) of eight (8) active sample patients. Five (5) of eight (8) records did not contain the assessments (M15, P2, P5, J11, J14); three (3) of eight (8) contained psychiatric assessments, but did not contain the identification of patient assets (M2, M8, M12). Failure to identify patient assets resulted in the team failing to identify treatment modalities tailored to the patient's abilities, resulting in delayed treatment and discharge.

Findings include:

A. Record Review

The Psychiatric Assessments of the following five (5) of eight (8) patients, with admission dates in parentheses, were missing from the records: M15 (4/26/18), P2 (5/2/18), P5 (5/2/18), J11(5/2/18) and J14 (5/1/18). The Psychiatric Assessments of the following 3 of 8 patients, with dates in parentheses, were in the record, but did not contain an inventory of assets: M2 (3/16/18), M8 (4/24/18) and M12 (4/8/18).

B. Staff Interview

During an interview on 5/8/18 at 1:00 p.m., Dr. #1 agreed that there was no inventory of assets
in the records of his patients (P2, P5, M2.)

Based on record review and staff interview the facility failed to ensure that the Master Treatment Plan was in the chart for one (1) of eight (8) active sample patients (M15). Failure to assure the Master Treatment Plan is present in the record prevented the staff from having access to the information which relates the individual patient goals and the staff treatment interventions to be implemented to enable the patient to progress towards discharge.

Findings include:

A. Record Review

Pt. M15 was admitted 4/26/18, but the chart did not contain the Master Treatment Plan as of the first day of the survey 5/7/18.

B. Policy Review

Review of the Treatment Plan policy ( http://Havenbehavioral-phoenix.policystat.com/policy/4648314) states that the patient will have a "written, comprehensive plan" "within72 hours of inpatient admission ...."

C. Staff Interview

In an interview with the Risk Manager on 5/7/18 at approximately 2:00 p.m., she stated that the facility was currently without a medical records staff person and thought that was why items like the treatment plan were not in the chart.

Based on record review and staff interview, the facility failed to provide Master Treatment Plans (MTPs) that utilized assessed patient strengths/assets for eight (8) of eight (8) active sample patients (treatment plan dates in parentheses): M2 (3/19/18); M8 (4/27/18); M12 (4/10/18); M15 (no MTP in the chart); P2 (5/4/18); P5 (5/4/18); J11(4/30/17) and J14(5/4/18). The MTPs included a short list of patient traits or external support resources labeled as "strengths." These were not based on assessments as there were no assessments in the record. Failure to use assessments to identify patient strengths can diminish the effectiveness of treatment.

Findings include:

A. Record Review

1. Patient M2 was admitted on 3/16/18. The MTP dated 3/19/18, in the section titled "Patient Strengths," noted the following: "Able to seek help, able to identify symptoms." There was no evidence in the record how the listed strengths were identified to be used to support the patient's treatment goal(s).

2. Patient M8 was admitted on 4/25/18. The MTP dated 4/27/18, in the section titled "Patient Strengths," noted the following: "Able to seek help, likes to joke." There was no evidence in the record how the listed strengths were identified to be used to support the patient's treatment goal(s).

3. Patient M12 was admitted on 4/8/18. The MTP dated 4/10/18 in the section titled "Patient Strengths," noted the following. "Family support, caring and protective." There was no evidence in the record how the listed strengths were identified and/or how they could be used to support the patient's treatment goal(s).

4. Patient M15 was admitted on 4/26/18. The MTP was not in the chart. This lack of information hinders the patient's hospitalized treatment.

5. Patient P2 admitted 5/2/18. The MTP dated 5/4/18, in the section titled "Patient Strengths," noted the following: "Strong-willed, and loyal." There was no evidence in the record how the listed strengths were identified and/or would be used to support the patient's treatment goal(s).

6. Patient P5 admitted on 5/2/18. The MTP dated 5/4/18, in the section titled "Patient Strengths," noted the following: "Listening, eager to learn, respectful." There was no evidence in the record how the listed strengths were identified and/or would be used to support the patient's treatment goal(s).

7. Patient J11 admitted 4/27/18. The MTP dated 4/30/18, in the section titled "Patient Strengths," noted the following: "I am a good grand-father, kind." There was no evidence in the record how the listed strengths were identified and/or would be used to support the patient's treatment goal(s).

8. Patient J14 admitted 5/1/18. The MTP dated 5/4/18, in the section titled "Patient Strengths," noted the following: "Generous, friendly." There was no evidence in the record how the listed strengths were identified and/or would be used to support the patient's treatment goal(s).

B. Policy Review

The facility policy titled, "Treatment Plan" "PolicyStat ID: 4648314" under "Policy" stipulated, "Each patient shall have a written, individual comprehensive treatment plan within 72 hours of inpatient admission .... The plan must be based on an inventory of patient's strengths and disabilities and must include Problem statement(s) that reflect the consensus of assessments."

C. Staff Interview

In a group interview with SW#1, SW #2 and Psychiatrist I#1on 5/8/18 at 1:00 p.m., the non-specific strengths/assets on the treatment plan were discussed. SW#1 and SW #2 both agreed with the findings.

Based on record review and staff interview, the facility failed to develop individualized Master Treatment Plans (MTPs) that identified patient-related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (M2, M8, M12, M15, P2, P5, J11 and J14). In many of the Master Treatment Plans, similarly worded short-term goals were listed which were not measurable outcome behaviors. This deficient practice hindered the treatment team's ability to measure behavioral changes in the patients and may contribute to failure of the team to modify the Master Treatment Plans and/or Updates in response to patient needs.

Findings include:

A. Record Review

1. Patient M2: MTP update 4/30/18, with identical update 5/7/18 listed the following short-term goals:

"[Pt.] will remain medication compliant, verbalize any side effects, and report ...daily mood, affect, and any symptoms of depression &any thoughts of SI & HI [sic]."

"[Pt.] will verbalize side effects of ...medication to RN staff ...and make daily attempts to work with staff to identify triggers and potential suicidal/homicidal risks."

"[Pt.] will work towards replacing negative thinking patterns that mediate feelings of hopelessness and helplessness by increasing the use of stress management and problem solving skills."

"[Pt.]" will cooperate with treatment by learning to recognize, accept, and cope with emotional, environmental, and/or interpersonal conflicts that underlie SI & HI [sic]."

2. Patient M8: MTP update 5/4/18 listed the following short-term goals:

"[Pt.] will take ...psychiatric medications prescribed to decrease ...bipolar and GAD[sic] symptoms."

"[Pt.] will work on communicating with RN staff in regards to ... needs, staring [sic] with reporting medication side effects and verbally expressing ...daily mood and affect."

"During group [pt.] will increase the ability to recognize and respectfully express frustration to resolve conflict related to ...emotional distress ...."

"[Pt.] will work towards being aware and oriented, if possible, by making an attempt to participate in group activates to improve ...thoughts processing and coping skills."

3. Patient M12: MTP update 5/2/18listed the following short-term goals:

"[Pt.] will take ...psychiatric medications as prescribed to decrease ...mood, irritability/agitation, and aggression."

"[Pt.] will report and medication side effects to RN staff and will also inform staff of ...mood state, energy level, sleep pattern, and any emotional distress ... experiencing. (Pt. is noted in psychiatric assessment and notes to be demented and verbally non-responsive).

"[Pt.] will attempt to attend at least 2 groups daily and demonstrate the ability to partake in groups for at least 45 minutes per group session."

"[Pt.] will work towards being aware and oriented if possible, by making an attempt to participate in group activities to improve ...thought processing and coping skills."

4. Pt. M15 (admitted 4/26/18) had no Master Treatment Plan in the chart.

5. Patient P2: MTP dated 5/4/18 listed the following short-term goals:

a. Short-term goal: "I need to develop self-regulation skills to stop myself from drinking when feeling anxious or depressed." Goal not stated in behavioral terms reflecting what the patient would be doing/learning to stop [himself/herself] "from drinking when feeling anxious or depressed."

b. Short-term goal: "I need to maintain a stable mood and manage my racing thoughts." Goal was stated as treatment compliance and not measurable.

6. Patient P5: MTP dated 5/4/18 listed the following short-term goals:

a. Short-term goal: "[Name of patient] will decrease SI [suicide] attempts at least 3 days prior discharge." Goal was not written in observable, measurable, behaviors to be achieved.

b. Short-term goal: "I need to learn how to cope with my anger." There were no identifiers how patient will learn "to cope with my anger," thus not a measurable goal.

7. Patient J11: MTP dated 4/30/18 listed the following short-term goals:

a. Short-term goal: "[Name of patient] will comply with [his/her] medication regimen by taking them as prescribed and as ordered." Goal was staff expectation/treatment compliance statement rather than a measurable goal.

b. Short-term goal: "[Name of patient] will improve mood and ability to cope and manage activities of daily living." Goal was stated as staff expectation and not measurable.

8. Patient J14: MTP dated 5/4/18 listed the following short-term goals:

a. Short-term goal: "[Name of patient] will comply with [his/her] inpatient treatment by taking [his/her] medication regimen as prescribed and as ordered." Goal was staff expectation/treatment compliance statement rather than a patient goal.

b. Short-term goal: "[Name of patient] will work towards reestablishing a sense of hope for self and the future by recognizing, accepting, and coping with emotional conflicts that are the cause of [his/her] underlying factors of depression." Goal not observable, measurable, nor stated in behavioral terms identifying what/how the patient would "work towards reestablishing a sense of hope for self ..... underlying factors of depression."

B. Staff Interviews

1. In an interview on 5/8/18 at 1:00 p.m., with SW #1, SW #2 and Physician #1, they concurred with the above findings that the goals needed to be individualized and written in observable, measurable patient behaviors to be achieved.

2. In an interview on 5/8/18 at 10:45 a.m., with the Nursing Director, the Treatment Plans were reviewed. The Nursing Director acknowledged that the Treatment Plan goals needed to be more individualized and written in observable and measurable terminology.

Based on record review and staff interview the facility failed to develop Master Treatment Plans (MTPs) that evidenced individualized treatment interventions/modalities with specific focus based on individual needs and abilities for seven (7) of eight (8) active sample patients (M2, M8, M12, P2, P5, J11 and J14). One (1) active sample patient (M15) did not have an MTP in the chart. Interventions were identical or similarly worded and included routine and generic discipline functions such as "assess" "encourage" "assist" written as active treatment interventions. Several interventions were listed to be implemented on an "if needed" basis instead of including a specific and scheduled frequency of contact to ensure required active treatment. These deficiencies resulted in Treatment Plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and the purpose for each. This failure, also, potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Pt. M2 (MTP update 4/30/18, with identical update 5/7/18); Pt. M8 (MTP update 5/4/18); and Pt. M12 (MTP update 5/2/18) have similar wording for modalities:

"Physician will continue to conduct individual sessions with [pt.] to assess effectiveness of medication and titrate dosage ...."

"Nursing staff will continue to administer medications as ordered, educate [pt.] about medication compliance, encourage [pt.] to attend daily groups, and conduct safety checks ...."

2. For Pt. M2 (MTP update 4/30/18, with identical update 5/7/18); Pt. M8 (MTP update 5/4/18); and Pt. M12 (MTP update 5/2/18), Activity Therapy interventions were general functions without specific modalities, frequency, duration:

For Pt. M2 the modality stated:

"AT will continue encourage [sic] interest and participation in order for [pt.] to learn coping skills that can assist ...with stress management and decreasing symptoms of depression."

For Pt. M8 the modality stated:

"Activities therapist will individually prompt [pt.] during group to encourage interest and participation. AT will also provide positive reinforcement and feedback for positive behaviors (such as attending group)."

For Pt. M12 the modality stated:

"Activities therapist will continue to approach [pt.] with empathy and assist ...with providing education in regard to problem solving skills, self-regulation skills, and mindfulness techniques."

3. For Pt. M2 (MTP update 4/30/18, with identical update 5/7/18); Pt. M8 (MTP update 5/4/18); and Pt. M12 (MTP update 5/2/18), Social Work modalities were general functions without specific modalities, frequency, duration:

Pt. M2 social work modality stated:

"Social Services will continue to facilitate daily groups and conduct 1:1 (PRN) to assist [pt.] with identifying self-regulation skills that will help ...work towards reducing ...depression and will create CSP [sic] prior to discharge."

Pts. M8 and M12 had similar wording for the social work modality:

"Therapist will facilitate daily groups and conduct 1:1's of needed, to provide support and empathy to encourage [pt.] to feel safe in expressing ...emotions, thoughts and feelings. [Pt.] will create CSP with therapist prior to DC."

4. Patient P2: MTP dated 5/4/18; no problem was identified on the Master Treatment Plan. Modalities listed were:

Physician: "Will conduct individual sessions with [Name of patient] to assess effectiveness of medication and titrate dosage to stabilize [his/her] symptoms of psychosis and depression."

RN: "Staff will administer medication as ordered, educate and encourage [Name of patient] about medication compliance, conduct safety checks (Q shift) (every shift), and encourage patient to attend daily groups."

AT: "Will approach [Name of patient] with empathy and assist [him/her] with providing education in regard to problem solving skills, self-regulation skills, and mindfulness techniques when faced with suicidal ideation or craving to drink alcohol correlated to post trauma."

Social Services: "Will facilitate daily groups and conduct brief 1:1's if needed, to provide support and empathy to encourage [Name of patient] to feel safe in expressing [his/her] emotions, thoughts, and feelings when feeling depressed or having suicidal thoughts."

5. Patient P5: MTP dated 5/4/18; no problem was identified on the Master Treatment Plan. Modalities listed were:

Physician: "Will conduct individual sessions with [Name of patient] to assess effectiveness of medication and titrate dosage to stabilize [his/her] symptoms depression and stabilize [his/her] mood."

RN: "Staff will administer medication as ordered, educate and encourage [Name of patient] about medication compliance, conduct safety checks (Q shift) (every shift), and encourage patient to attend daily groups."

AT: "Will approach [Name of patient] with empathy and assist [him/her] with providing education in regard to problem solving skills, self-regulation skills, and mindfulness techniques when faced with suicidal thoughts or depression."

Social Services: "Will facilitate daily groups and conduct brief 1:1's if needed, to provide support and empathy to encourage [Name of patient] to feel safe in expressing [his/her] emotions, thoughts, and feelings when feeling depressed or having suicidal thoughts."

6. Patient J11: MTP dated 4/30/18; no problem was identified on the Master Treatment Plan. Modalities listed were:

Physician: "Will conduct individual sessions with [Name of patient] to assess effectiveness of medication and titrate dosage to stabilize [his/her] mood and behavioral symptoms of Alzheimer's."

RN: "Staff will administer medication as ordered and observe patient for cognitive functioning, memory changes, disorientation, difficulty with communication, or changes in thinking patterns."

AT: "Will work with [Name of patient] to provide opportunity for social interaction (with staff and peers) on [his/her] own terms to avoid confusion, agitation, and hostility."

Social Services: "Will approach [Name of patient] with empathy and assist [him/her] with providing education in regard to problem solving skills, self-regulation skills. and mindfulness techniques."

7. Patient J14: MTP dated 4/30/18; no problem was identified on the Master Treatment Plan. Modalities listed were:

Physician: "Will conduct individual sessions with [Name of patient] to assess effectiveness of medication and titrate dosage to stabilize [his/her] symptoms of depression."

RN: "Staff will administer medication as ordered, educate [Name of patient] about medication compliance, encourage patient to attend daily groups, and conduct safety checks per shift."

AT: "Will approach [Name of patient] with empathy and assist [him/her] with providing education in regard to problem solving skills, self-regulation skills, and mindfulness techniques to work towards reduction of symptoms."

Social Services: "Will facilitate daily groups and conduct brief 1:1's if needed, to provide support and empathy to encourage [Name of patient] to feel safe in expressing [his/her] emotions, thoughts, and feelings."

8. Pt. M15 did not have an MTP in the record.

B. Staff Interviews

1. An interview on 5/8/18 at 1:00 p.m., with SW #1 and SW #2 the treatment interventions were reviewed. They both agreed that the interventions were general.

2. In an interview with RN #2 on 5/7/18 at 2:30 p.m., the Master Treatment Plans interventions were reviewed. The RN#2 concurred with the findings.

3. In an interview with RN #3 on 5/7/18 at 12:00 Noon, the Master Treatment Plans interventions were reviewed. The RN #3 stated, "Ok, I see what you are getting at."

4. In an interview with the Nursing Director on 5/8/18 at 10:45 a.m., the Master Treatment Plan's nursing interventions were reviewed. She agreed with the findings.

Based on record review and interview, the facility failed to ensure that the active treatment interventions assigned to social work in the charts were documented for seven (7) of eight (8) active sample patients (M8, M12, M15, P2, P5, J11 and J14). There was no documentation showing patients' participation or non-participation in their assigned active treatment interventions; the topic(s) discussed; and/or the patients' level of response to the interventions provided. The record of patient M2 noted only one group provided that may have been a social work group, although the discipline was not noted. Failure to document treatment provided and treatment response to the patient's identified problems impair the treatment team's ability to assess the adequacy of the plan of care, and to review and revise the plan when necessary, increasing the likelihood of an incomplete treatment response and/or prolonged hospital stay.

Findings include:

A. Record Review

The charts for the following patients were reviewed (admission dates in parentheses): M2 (3/16/18), M8 (4/24/18), M12 (4/8/18), M15 (4/26/18), P2 (5/4/18), P5 (5/4/18), J11(4/30/17) and J14(5/4/18). This review revealed that there were no treatment notes documented by social work showing that they met with patients in group or individual session to provide active treatment interventions assigned on the MTPs for any of the patients except M2. In the chart of Pt. M2, there was one note on 5/1/18 for a group titled "Guilt and Shame," although the discipline responsible for providing the group was not noted. In addition, there was one note by social work for an individual meeting 4/4/18 with Pt. M2 to discuss application for community placement.

B. Interview

In an interview with the Director of Social Work on 5/9/18 at approximately 10 a.m., the issue that there was no documentation in patient records to show that social work interventions were implemented was discussed; the Director did not dispute the findings.

Based on record review and interview the facility failed to ensure that physician notes were placed in the records in a timely manner for two (2) of eight (8) active sample patients (M2, M12); in addition, the facility failed to assure that the psychiatric notes written in the chart for two (2) of two (2) active sample patients (M8, M15) treated by one of the psychiatrists were legible. These deficiencies prevent all staff from accessing the most current medical and psychiatric information on the patients, which can lead to errors in care.

Findings include:

A. Record Review:

Pt. M2 had no physician progress notes related to medical care in the chart since 4/20/18. Pt. M12, who has severe dementia, had no physician notes related to medical care in the chart since 4/25/18, and no psychiatric notes in the chart since 4/29/18.

Pt. M8 and Pt. M15 were the patients of Psychiatrist #2. Review of these notes showed them to be illegible.

B. Interview:

In an interview with the Medical Director on 5/8/18 at 11:30 a.m., he agreed that psychiatrist #2's notes were illegible and stated that sometimes a nurse would ask him (the Medical Director) if he knew what psychiatrist #2's notes said. The Medical Director stated he would tell the nurse to call the doctor to find out what the note said.
In an interview with the Risk Manager on 5/7/18 at about 2 p.m., the risk manager stated that since there was not a current medical records staff person, dictated notes were possibly missing from records. She stated there was a large stack of papers in the medical records area, and the notes could be there.

Based on record review and interview the Medical Director has failed to ensure that assessments, treatment plans and physician notes are in the chart in a timely manner, assure that physician notes are legible, and that death records are reviewed in a systemized way. These failures prevent the facility from assuring that all patients are properly treated and that timely and in depth reviews of patient care occur.

Findings include:

A. Record Review:

1.The facility failed to have history and physical exams (H&P), including neurological exams, in the charts for six (6) of eight (8) active sample patients (M8, M15, P2, P5, J11, J14). For patient M12, there was a brief H&P, but it did not contain a neurological exam. Failure to provide this information in the record prevents all staff from having this medical information available to use as a baseline to assess the patients' medical needs and possible changing medical status. Refer to B109

2.The facility failed to have Psychiatric Assessments in the chart for five (5) of eight (8) active sample patients (M15, P2, P5, J11, J14). Failure to assure Psychiatric Assessments are in the chart in a timely manner prevents the staff from having access to baseline information on the patient's psychiatric status, as well as an understanding of any changes in patient status during the course of hospitalization. Refer to B110

3.The facility failed to assure that Psychiatric Assessments contained an inventory of patient assets by the physician for eight (8) of eight (8) active sample patients. Five (5) of eight (8) records did not contain the assessments (M15, P2, P5, J11, J14); three (3) of eight (8) contained psychiatric assessments, but did not contain the identification of patient assets (M2, M8, M12). Failure to identify patient assets can result in the team failing to identify treatment modalities tailored to the patient's abilities, resulting in delayed treatment and discharge. Refer to B117

4.The facility failed to develop individualized Master Treatment Plans (MTPs) that identified patient-related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (M2, M8, M12, M15, P2, P5, J11 and J14). In many of the Master Treatment Plans, similarly worded short-term goals were listed which were not measurable outcome behaviors. This deficient practice hinders the treatment team's ability to measure behavioral changes in the patients and may contribute to failure of the team to modify the Master Treatment Plans and/or Updates in response to patient needs. Refer to B121.

5.The facility failed to develop Master Treatment Plans (MTP's) that evidenced individualized treatment interventions/modalities with specific focus based on individual needs and abilities for seven (7) of eight (8) active sample patients (M2, M8, M12, P2, P5, J11 and J14). One (1) active sample patient (M15) did not have an MTP in the chart. Interventions were identical or similarly worded and included routine and generic discipline functions such as "assess" "encourage" "assist" written as active treatment interventions. Several interventions were listed to be implemented on an "if needed" basis instead of including a specific and scheduled frequency of contact to ensure required active treatment. These deficiencies result in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and the purpose for each. This failure also potentially results in inconsistent and/or ineffective treatment. Refer to B122.

6.The facility failed to conduct morbidity mortality reviews in the deaths of three of three death records reviewed from the past 12 months.

Findings include:

Review of the records revealed that two of the patients (E1, E2) were elderly patients who died in the facility and whose deaths were deemed natural, although the manner in which this determination was made was not recorded. In the case of pt. E3, the patient died after discharge, allegedly by suicide, although there was no confirmation of this. In none of these cases was there any evidence of a formal review of the death.

In repeated interviews with the risk manager on 5/8 and 5/9/18, she agreed that she could not find any formal reviews of the deaths and could not find any facility policy related to reviews of patients who died either in the facility or within any time frame after discharge. In an interview with the Medical Director on 5/8 at 11:30 a.m., he was unaware of any process for formal review of patient deaths.

Based on record review and interview, it was determined that the Director of Nursing failed to monitor and take corrective action as needed to ensure that:

I. The identified short-term goals for nursing in MTPs were observable, measurable and address the individual patient presenting problems and needs for seven (7) of eight (8) active sample patients (M2, M8, M12, P2, P5, J11 and J14); pt. M15 had no treatment plan in the record. (Refer to B121)

II. Active treatment interventions implemented by Registered Nurses for even (7) of eight (8) active sample patients (M2, M8, M12, P2, P5, J11 and J14) were linked to specific treatment goals; patient M15 had no treatment plan in the chart. The listed nursing interventions were routine, generic discipline functions expected to be regularly provided by nursing staff for all patients and were generic such as, "assess" "encourage" and "assist" written as active treatment interventions. These failures to develop focused, individualized interventions could result in fragmented nursing care, non-compliance with planned treatment and lack of accountability putting the patient at risk for adverse treatment outcomes. (Refer to B122)

Interview

In an interview with the Nursing Director on 5/8/18 at 10:45 a.m., the Treatment Plans were reviewed. She acknowledged that the treatment plans goals related to nursing were not written in observable and measurable patient behaviors to be achieved. She did not dispute the finding that nursing interventions lacked specific purpose and focus for patients and that interventions were generic and routine nursing functions.

Based on review of the facility Emergency Preparedness plan, and staff interview, it was determined the facility failed to develop and implement policy and procedures for evacuation of patients and staff during an emergency. Failure to safely evacuate residents and staff during an emergency could lead to harm to both residents and staff.

Findings include:

The Director of A&R reviewed the facility's Emergency Plan with the surveyor on April 17, 2018. The emergency plan did not identify a process for the safe evacuation of patients and staff during an emergency.

The Director of A&R indicated they had processes's they could use, but did not have a process outlined in their Emergency plan.

The Chief Executive Officer and the Director of A&R confirmed during an exit conference on April 17, 2018, the emergency plan did not identify a process for the safe evacuation of patients and staff during an emergency.

Based on review of the facility Emergency Plan (EP), record review and interview with the staff, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop emergency policies and procedures at alternative care sites may cause harm to the patients during an emergency.

Findings include:

The surveyor and the Director of A&R reviewed the facility's Emergency Plan. The plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

The Chief Executive Officer and the Director of A&R confirmed during the exit conference on April 17, 2018, their EP plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Based on review of the facility Emergency Preparedness Plan, and staff interview, it was determined the facility failed to have documentation of new and existing staff trained in the Emergency Preparedness Plan. Failure to provide facility based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients during an emergency.

Finding include:

The Director of A&R reviewed the facility's Emergency Plan (EP) on April 17, 2018. The plan did not include annual facility based training and testing for staff based on the Emergency Plan.

The Chief Executive Officer and the Director of A&R confirmed during an interview on April 17, 2018, the EP plan did not include annual facility based training and testing for staff based on the Emergency Plan.

Based on review of the facility Emergency Preparedness Plan, and staff interview, it was determined the facility failed to perform a Community-Based full scale exercise. Failure to provide facility based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients during an emergency.

Finding include:

The Director of A&R reviewed the facility's Emergency Plan (EP) on April 17, 2018. The plan did not have a documented Community-Based full scale exercise for staff based on the Emergency Plan.

The Chief Executive Officer and the Director of A&R confirmed during an interview on April 17, 2018, the EP plan did not include annual facility based training and testing for staff based on the Emergency Plan.