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Based on medical record review and staff interview it was determined that the physical examinations of eight (8) of eight (8) patients were uninformative, confusing in description and lacked follow-up attempts when initial 24 hour exam was not completed. These failures result in the treatment team not knowing the physical status or possible contributing factors that may have led to the patient ' s psychiatric hospitalization. (Patients A1, A2, A3, A4, B1, B2, B3 and B4).

The findings include:

I. Medical Record Review:

1. Patient A1: The Physical Exam dated 4/20/2016 included such statements as "pupils and irises-unknown", "abdomen-unknown", "skin inspection-unknown" and "cranial nerves-unknown".

2. Patient A2: The Physical Exam dated 4/06/2016 included "abdomen-unknown".

3. Patient A3: The Physical Exam dated 4/26/2016 included "abdomen-unknown".

4. Patient A4: The Physical Exam dated 4/29/2016 stated "pupils and irises-unknown", "or pharynx-unknown", "neck-unknown", "abdomen-unknown", and "digits and nails-unknown".

5. Patient B1: The Physical Exam dated 4/19/2016 stated "pupils and irises-unknown", "oropharynx-unknown", "abdomen-unknown", "gait and station-unknown", "skin inspection-unknown", and "sensation-unknown".

6. Patient B2: The Physical Exam dated 4/14/2016 stated "pupils and irises-unknown", "heart and auscultation--unknown", "abdomen-unknown", "digits and nails-unknown", and "skin inspection-unknown".

7. Patient B3: The Physical Exam dated 11/18/2015 stated "abdomen-unknown".

8. Patient B4: The Physical Exam dated 4/21/2016 stated "pupils and irises-unknown", "ears-unknown", "mouth-lips, teeth, gums-unknown", "oroharynx-unknown", "neck==unknown", "heart-auscultation-unknown", "extremities for edema/ varicosities-unknown", "abdomen-unknown", "gait and station-unknown", "skin-inspection-unknown, "cranial nerves-unknown".

II. Staff Interview:

On 5/02/2016 at 2:00 PM the clinical director was interviewed. The focus of this meeting was the results described in Section I above. He agreed that the statements were not reflective of a thorough physical examination.

In addition, Patient B4's physical examination stated "General Appearance-Patient was very agitated and a poor historian, unable to assess anything". The exam done 4/21/2016 had not been followed up subsequentially to provide a basic assessment. This lack of a follow-up was substantiated by the Unit charge nurse (RN#1) also. The clinical director stated that the expectation (not written in any facility policy and/or procedure) was that "within 72 hours a follow-up is expected". He agreed that this had not occurred. Thus, patient B4 had been hospitalized approximately 10 days and no routine physical examination had been performed.

Based on medical record review and staff and patient interview it was determined that for eight (8) of eight (8) patients there was no active treatment occurring for them week days after 2:00 PM, and for Saturday and Sunday "You Pick Group Topic" i.e. no therapeutic focus is indicated as the topic nor what individual needs of each patient would be addressed. Three (3) hours of "You Pick Topic Group" in the morning was the only structured treatment modality available. The remainder of the day was described as "Free Time", "Lunch", "Visitation", and "Dinner". This failure to provide active treatment results in patients not being provided with intensive 24 hour, specialized psychiatric interventions that cannot be provided outside the psychiatric hospital. (Patients A1, A2, A3, A4, B1, B2, B3 and B4).

The findings include:

I. Medical Record Review:

On 5/02/2016 the surveyors were provided with the Unit schedule titled "Hospital Group List May1st-7th". This listing provided the following information-Sunday morning there were three (3) "You Pick Topic" groups lasting until "Lunch" at noon. No further structured modalities were denoted thereafter. Monday-Friday after 2:00 PM no structured treatment interventions were listed and for Saturday there were three (3) "You Pick Topic" groups lasting until Lunch at noon. The remainder of the day was without any structured activity or therapeutic endeavors.

II. Staff and Patient Interviews:

On 5/03/2016 at 10:00 AM the clinical director and the Assistant Director of Nursing (ADON) were interviewed. They were shown the Unit schedule and the findings of the surveyors as described in Section I. above. Both expressed surprise that this was happening. "I'm not sure when this (i.e. the Unit Schedule) was changed" said the ADON. The clinical director said that "You Pick Topic" groups were popular with patients and, therefore, no specific focus was set. The Unit patient population includes acutely psychotic, involuntarily held, affectively disordered and other types of patients.

On 5/02/2016 at 11:00 AM Patient B1 who was found in his/her bed at that time told the surveyor "I mainly sleep. I don't go to groups". This report of non-attendance was confirmed by a Unit Behavioral Health Therapist (BHT#1).

On 5/02/2016 at 11:40 AM Patient B3 was found in his bed. BHT#1 reported that the patient "is very paranoid, easily upset, and will attack". Therefore, at this time there is no effort to place him/her into a group setting. This patient has been hospitalized for approximately 24 weeks.

On 5/02/2016 at 1:50 PM Patient B4 was found in his/her room. When asked to describe his/her daily routine he/she stated "I don't go to groups. I've already been to all these groups". When asked what he/she does alternatively, he/she said "I sleep. I read".

On 5/03/2016 at 10:00 AM Patient A2 was asked if he/she planned to attend the 11:00 AM group. His/her response was: "No, I'm not bipolar." The title of the group was "Bipolar Awareness."

On 5/03/2016 at 11:00 AM the surveyor attended the "Bipolar Awareness" group which was the only designated group for the entire patient population of 25. One (1) of the nine (9) patients asked the therapist what kind of group this was, and the therapist replied it was a "Process Group" without elaborating. The Unit charge nurse (RN#1) was asked what the remainder of the patients would be doing if they avoided the "Bipolar Awareness" group. RN#1 replied "They are all encouraged to go to group", and "They might be seeing the doctor". Since Patients B1, B3 and B4 were not present in the group, BHT#1 at 11:50 AM told the surveyor that Patient B1 "Is in his/her room", Patient B3 "Is in his/her room" and Patient B4 "Is in his/her bed".

Based on medical record review, staff and patient interview it was determined that the clinical director failed to ensure that physical examinations for eight (8) of eight (8) patients were meaningful and that follow-up for unsuccessful exams were conducted. The clinical director, also, failed to ensure that the varied patient population was provided active treatment throughout each day. These failures result in the physical status of a patient being undetermined and extensive segments of each day being void of any therapeutic endeavors. (Patients A1, A2, A3, A4, B1, B2, B3 and B4).

The findings include:

A. Physical Exams not meaningful and/or not complete-

1. Patient A1: The Physical Exam dated 4/20/2016 included such statements as "pupils and irises-unknown", "abdomen-unknown," "skin inspection-unknown" and "cranial nerves-unknown".

2. Patient A2: The Physical Exam dated 4/06/2016 included "abdomen-unknown".

3. Patient A3: The Physical Exam dated 4/26/2016 included "abdomen-unknown".

4. Patient A4: The Physical Exam dated 4/29/2016 stated "pupils and irises-unknown", "or pharynx-unknown", "neck-unknown", "abdomen-unknown", and "digits and nails-unknown".

5. Patient B1: The Physical Exam dated 4/19/2016 stated "pupils and irises-unknown", "oropharynx-unknown", "abdomen-unknown", "gait and station-unknown", "skin inspection-unknown", and "sensation-unknown".

6. Patient B2: The Physical Exam dated 4/14/2016 stated "pupils and irises-unknown", "heart and auscultation--unknown", "abdomen-unknown", "digits and nails-unknown", and "skin inspection-unknown".

7. Patient B3: The Physical Exam dated 11/18/2015 stated "abdomen-unknown".

8. Patient B4: The Physical Exam dated 4/21/2016 stated "pupils and irises-unknown", "ears-unknown", "mouth-lips, teeth, gums-unknown", "oroharynx-unknown", "neck==unknown", "heart-auscultation-unknown", "extremities for edema/ varicosities-unknown", "abdomen-unknown", "gait and station-unknown", "skin-inspection-unknown", "cranial nerves-unknown".

B. Lack of structured therapies on a daily basis:

On 5/02/2016 the surveyors were provided with the Unit schedule titled "Hospital Group List May1st-7th". This listing provided the following information-Sunday morning there were three (3) "You Pick Topic" groups lasting until "Lunch" at noon. No further structured modalities were denoted thereafter. Monday-Friday after 2:00 PM no structured treatment interventions were listed and for Saturday there were three (3) "You Pick Topic" groups lasting until Lunch at noon. The remainder of the day was without any structured activity or therapeutic endeavors.

II. Staff and Patient Interviews:

On 5/03/2016 at 10:00 AM the clinical director and the Assistant Director of Nursing (ADON) were interviewed. They were shown the Unit schedule and the findings of the surveyors as described in Section I. above. Both expressed surprise that this was happening. "I'm not sure when this (i.e. the Unit Schedule) was changed" said the ADON. The clinical director said that "You Pick Topic" groups were popular with patients and, therefore, no specific focus was set. The Unit patient population includes acutely psychotic, involuntarily held, affectively disordered and other types of patients.

On 5/02/2016 at 11:00 AM Patient B1 who was found in his/her bed at that time told the surveyor "I mainly sleep. I don't go to groups". This report of non-attendance was confirmed by a Unit Behavioral Health Therapist (BHT#1).

On 5/02/2016 at 11:40 AM Patient B3 was found in his bed. BHT#1 reported that the patient "is very paranoid, easily upset, and will attack". Therefore, at this time there is no effort to place him/her into a group setting. This patient has been hospitalized for approximately 24 weeks.

On 5/02/2016 at 1:50 PM Patient B4 was found in his/her room. When asked to describe his/her daily routine he/she stated "I don't go to groups. I've already been to all these groups". When asked what he/she does alternatively, he/she said "I sleep. I read".

On 5/03/2016 at 10:00 AM Patient A2 was asked if he/she planned to attend the 11:00 AM group. His/her response was: "No, I'm not bipolar." The title of the group was "Bipolar Awareness."

On 5/03/2016 at 11:00 AM the surveyor attended the "Bipolar Awareness" group which was the only designated group for the entire patient population of 25. One of the nine (9) patients asked the therapist what kind of group this was, and the therapist replied it was a "Process Group" without elaborating. The Unit charge nurse (RN#1) was asked what the remainder of the patients would be doing if they avoided the "Bipolar Awareness" group. RN#1 replied "They are all encouraged to go to group", and "They might be seeing the doctor". Since Patients B1, B3 and B4 were not present in the group, BHT#1 at 11:50 AM told the surveyor that Patient B1 "Is in his/her room", Patient B4 "Is in his/her room" and Patient B4 "Is in his/her bed".

Based on record review and interview, the Facility failed to ensure that activity therapy assessments were implemented for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 & B4).

1. Staff and Patient Interview

On 5/2/2016 at 3:30 PM AT#1 was asked by the surveyor if she did Activity Therapy assessments on patients admitted before assigning the patients to attend therapeutic groups. Her response was; "No, we've never done assessments." She went on to talk about the flexibility of the Activity list offered patients as stated in the "Centerstone Hospital Group List May 1st - 7th". AT#1 did not respond when surveyor asked about the lack of therapeutic groups on Sundays and Saturdays.

On 5/3/ 2016 at 10:20 AM, the surveyor asked RN#1 if the nursing discipline did a therapeutic activity assessment on patients admitted because the surveyor had not seen any such information on the nursing assessment form. RN#1 concurred that nursing did not assess therapeutic activity needs of the patients.

On 5/3/2016 at 10:30 AM, the surveyor asked Patient A1 if s/he was ever asked what activity s/he liked to do. "I love to sing, and I never do here."

Failure to provide active and appropriate treatment for patients results in patients being hospitalized without all interventions for recovery being provided for them, potentially delaying their improvement.