HospitalInspections.org

Based on record review and interview the facility failed to ensure a current contract existed between the facility and the contracted laboratory in 1 of 1 laboratory contracts reviewed in a total universe of 8 contracted services.

Findings include:

The facility policy titled "POLICY ON POLICIES" last reviewed on 1/29/2013 was reviewed on 6/5/2019 at 11:30 AM. This document revealed under "I. PURPOSE: To provide a plan and process for the development, implementation and maintenance of policies and procedures within the Department of Health and Human Services. II. PROCEDURE: 1. All policies and procedures will be reviewed for completeness and appropriateness: a. At least every two (2) years. b. When a practice change has occurred. c. When a change (s) occurs in the local, state, federal laws or regulations...Format d) 4. EFFECTIVE DATE: The date the policy/procedure goes into effect. 5. REVISION DATE: Indicates the last revision date. 6. DATE (S) OF EXECUTIVE MEETING: The date (s) the policy/procedure was discussed and approved at the Executive Meeting. 7. RESPONSIBLE PERSON FOR POLICY: Indicates the name and title of the person who is the owner of the policy...6. Policy and Procedure Process: (Note: Division/Unit policies and procedures will be created and revised within that Division/Unit) a. The Records Supervisor or designee will have the responsibility to: 1. Contact the owner of each policy to have them update or review their policy. 2. Ensure that the policy/procedure is typed in the correct format and assist with the typing and revision of the policy/procedure as needed. 5. Contract the policy owner and obtain a summary of what has been changed in the policy. 6. Send out the policy with the summary of changes from the policy owner to the Department staff. Retain the email notification and files with the policy. 7. Update the Department Policy and Procedure Tracking Log spreadsheet. b. The policy owner will have the responsibility to: 1. Update/revise the policy/procedure as needed. 2. Track the effective date, revision date, and date (s) that it was discussed and approved at the Executive Meeting. 3. Obtain approval signature (s). 4. Prepare a written summary of the key changes for the policy revised and route to the Records Supervisor. 5. Ensure that appropriate education has taken place, if needed."

The facility policy titled "Policy on Policies" with an effective date of 9/2014 was reviewed on 6/5/2019 at 11:30 AM. This document revealed under "I. PURPOSE: To provide a plan and process for the development, implementation and maintenance of policies and procedures within the Department of Health and Human Services Clinical Services Division for building wide policies related to the MHC (mental health center) and for the MHC inpatient service. The Inpatient Services shall follow the DHHS procedure #8101: II. PROCEDURE: Any policy that impacts the clinical division including outpatient services at the Mental Health Center shall be approved by the Clinical Supervisors at one of the regular scheduled meetings. -For Inpatient Services at the Mental Health Center, policies that are revised will be approved by the governing board first through the Medical and Psychological Committee and then the Joint Conference Committee. -A revision shall be when the actual procedure is altered. -A review shall be when there are no changes or a change is incidental in nature. Examples include but are not limited to: new phone numbers, a new job title or a new form that does not alter essential implementation of the procedure."

The facility document titled "2016 PROGRAM DESCRIPTION" dated December, 2015 was reviewed on 6/3/2019. This document revealed "PROVIDER NAME: Dynacare Laboratories. TARGET GROUP: Waukesha County Mental Health Center-Inpatient Unit. PROVIDED SERVICES: Laboratory. The following are conditions of your purchase of service contract or agreement with Waukesha County Department of Health and Human Services: PROGRAM GOALS: Dynacare will provide blood and urine laboratory testing as requested by authorized representatives of the Department, the Waukesha County Mental Health Center, located at 1501 Airport Road, Waukesha, Wisconsin 53188. The laboratory testing for the Mental Health Center shall be of urine and blood specimens."

There was no documented signature or date of facility staff on the above document.

The above findings were confirmed in an interview with Director of Nursing B on 6/5/2019 at 9:30 AM who stated "yes, there is no signature or date on the contract."

Based on record review and interview staff failed to ensure the use of physical restraints or seclusion on patients was addressed in nursing care plans in 5 of 5 restraint records reviewed (Patients 11, 12, 13, 14, 15) in a total sample of 20 records.

Findings include:

Review of facility policies titled, "Restraint" last reviewed 6/2014 revealed in part "6. A registered nurse shall update the patient's nursing care plan to reflect the need for restraint." and "Seclusion" last reviewed 6/2014 revealed in part "6. A registered nurse shall update the patient's nursing care plan to reflect the need for seclusion."

Review of Patient #11's medical record revealed Patient #11 was admitted on 01/14/2019 with a primary diagnosis of chronic schizoaffective disorder. Per Seclusion Observation Monitoring Form on 01/20/2019 at 11:35 AM Patient #11 was escorted into the seclusion room by staff for protection of self and others. At 12:25 PM Patient #11 was released from the seclusion room by staff. Per Restraint Monitoring Form on 01/20/2019 at 1:10 PM Patient #11 was placed in 5 point leather restraints by staff when Patient #11 was in the day room-jumped over the swinging half door in an attempt to leave. Review of the IP (inpatient) Treatment plan revealed no documented evidence addressing the use of seclusion and physical restraints as an active care plan problem.

Review of Patient #12's medical record revealed Patient #12 was admitted on 12/21/2018 with a primary diagnosis of schizoaffective, bipolar type. Per Seclusion Observation Monitoring Form on 01/14/2019 at 5:20 PM Patient #12 was escorted into the seclusion room by staff and 3 deputies for protection of others from threatening and aggressive behaviors. Review of the IP (inpatient) Treatment plan revealed no documented evidence addressing the use of seclusion as an active care plan problem.

Review of Patient #13's medical record revealed Patient #13 was admitted on 02/07/2018 with a primary diagnosis of depression. Per Restraint Observation Monitoring Form on 02/15/2018 at 12:20 PM Patient #13 was escorted into the restraint room by staff (4) for protection of self and others. Review of the IP (inpatient) Treatment plan revealed no documented evidence addressing the use of restraints as an active care plan problem. Per Restraint Observation Monitoring Form on 02/17/2018 at 8:40 PM Patient #13 was escorted into the restraint room by staff and police for protection of self and inappropriate behaviors. Review of the IP (inpatient) Treatment plan revealed no documented evidence addressing the use of restraints as an active care plan problem. Per Restraint Observation Monitoring Form on 02/18/2018 at 3:10 PM Patient #13 was escorted into the restraint room by staff (3) for protection of self and inappropriate behaviors. Review of the IP (inpatient) Treatment plan revealed no documented evidence addressing the use of restraints as an active care plan problem. Per Restraint Observation Monitoring Form on 02/20/2018 at 1:30 PM Patient #13 was escorted into the restraint room by staff for protection of self and inappropriate behaviors. Review of the IP (inpatient) Treatment plan revealed no documented evidence addressing the use of restraints as an active care plan problem. Per Restraint Observation Monitoring Form on 02/22/2018 at 8:45 PM Patient #13 was escorted into the restraint room by staff for protection of self/others and inappropriate behaviors. Review of the IP (inpatient) Treatment plan revealed no documented evidence addressing the use of restraints as an active care plan problem. Per Restraint Observation Monitoring Form on 02/25/2018 at 5:50 PM Patient #13 was escorted into the restraint room by staff for protection of self. Review of the IP (inpatient) Treatment plan revealed no documented evidence addressing the use of restraints as an active care plan problem. Per Restraint Observation Monitoring Form on 03/07/2018 at 11:10 AM Patient #13 was escorted into the restraint room by staff for protection of self and inappropriate behaviors. Review of the IP (inpatient) Treatment plan revealed no documented evidence addressing the use of restraints as an active care plan problem.

Review of Patient #14's medical record revealed Patient #14 was admitted on 03/02/2018 with a primary diagnosis of depression. Per Restraint Observation Monitoring Form on 03/02/18 at 7:55 PM Patient #14 was taken into the restraint room via wheelchair by police officers for protection of self and inappropriate behaviors. Review of the IP (inpatient) Treatment plan revealed no documented evidence addressing the use of seclusion as an active care plan problem.

Review of Patient #15's medical record revealed Patient #15 was admitted on 04/13/2018 with a primary diagnosis of schizophrenia. Per Restraint Observation Monitoring Form on 04/21/18 at 1:05 PM Patient #15 was escorted into the restraint room by a sheriff for protection of self and others. Review of the IP (inpatient) Treatment plan revealed no documented evidence addressing the use of seclusion as an active care plan problem.

Per interview with Director Of Nursing (DON) B on 06/05/2019 at 11:45 AM, DON B stated, "I would expect the nurse to update the care plan when restraints or seclusion is used."

Based on record review and interview, the facility failed to review the "RESTRAINT" and "SECLUSION" policies per their policy "POLICY ON POLICIES #8101."

Findings include:

Review of the facility policy titled "POLICY ON POLICIES #8101" last reviewed on 1/29/2013 revealed under "I. PURPOSE: To provide a plan and process for the development, implementation and maintenance of policies and procedures within the Department of Health and Human Services. II. PROCEDURE: 1. All policies and procedures will be reviewed for completeness and appropriateness: a. At least every two (2) years."

Review of the facility policy titled "SECLUSION" revealed it was last reviewed on 6/14.

Review of the facility policy titled "RESTRAINT" revealed it was last reviewed on 6/14.

Per interview on 06/04/2019 at 11:30 AM with Administrator A stated "We are working on reviewing and updating all the facilities policies."

Based on observation, record review and interview, the facility failed to ensure the Dietary Service Director has approved updated guidelines for the daily operation of the Dietary and Food Services to comply with Federal and State licensure regulations and food service standards, failed to demonstrate staff competency by failing to develop an appropriate orientation and training program and failed to develop guidelines for kitchen sanitation to maintain an environment that was free from potential contamination in 1 of 1 dietetic and food service departments as evidenced by the hospital's failure to:

1) To provide an appropriate staff orientation and training program (See A620).

2) To demonstrate staff competency (See A622).

3) To develop guidelines for kitchen sanitation to maintain an environment that was free from potential contamination (See A 749).

The cumulative effects of these systematic problems, impedes the hospital from having an organized and effective dietetic and food service department.

Based on record review and interview, the facility failed to ensure the Dietary Service Director has approved updated guidelines for the daily operation of the Dietary and Food Services to comply with Federal and State licensure regulations and food service standards by failing to provide an appropriate staff orientation and training program in 2 of 2 of their training materials (Dietary Orientation Checklist and Dietary Services Mandatory In-Services exam), failing to ensure dietary staff follow acceptable standards of practice by failing to update their policies and procedures as evidenced by 100% of their dietary policies reviewed (10 of 10) were not reviewed annually per their Dietary Services Policy and Procedure Policy, and failed to incorporate data for process improvement into their Quality Assurance Performance Improvement (QAPI) program to ensure quality food and dietetic services in 1 of 1 QAPI program.

Findings include:

Review of form titled "Psychiatric Technician Dietary Orientation Checklist" was not dated. No policy for implementation, evidence of compliance with Federal and State licensure requirements for food service standards and regulations, no governing board, medical staff or dietitian approval.

Review of form titled "Dietary Services Mandatory In-Services" examination was not dated. No policy for implementation, evidence of compliance with "ServSafe" training (nationally recognized food safety training) or Federal and State licensure requirements for food service standards and regulations demonstrated, no governing board, medical staff or dietitian approval.

On 6/05/19 at 1:11 PM during interview with Registered Dietetic Technician (RD Tech) J, RD Tech J stated s/he developed the "Dietary Services Mandatory In-Services" education exam using ServSafe training information to demonstrate competency of the Kitchen PsychiatricTechnician's guidelines for food and dietetic services. RD Tech J stated s/he had taken the ServSafe exam "years ago" but s/he did not have a current ServSafe certification. RD Tech J also stated s/he developed the orientation/training checklist to educate the Kitchen Psychiatric Technicians. RD Tech J confirmed the "Dietary Orientation Checklist" and the "Dietary Services Mandatory In-Services" exam were not approved by the facilities governing board, medical staff, or dietitian.

Review of policy titled "Dietary Services Policy and Procedure Manual" Section: Clinical Services Division - Dietary, revision dates "12/12/08, 7/12", signed 7/23/12 by the "Clinical Services Division Manager" revealed Purpose "The establish guidelines for daily operation of the Dietary Services Department. II. POLICY/PROCEDURE 1. The Medical Director, Consulting Dietitian and Food Service Specialist shall review and make necessary changes in the Policy and Procedure Manual on an annual basis." ..3. When the manual is reviewed and revised, the Medical Director and Consultant Dietitian shall sign and date."

Review of policy titled "Provision of Meal Service in the Event of a Disaster" not signed or dated, no review dates listed.

Review of policy titled "Food Storage-Perishable Foods" Section: Clinical Services Division-Inpatient-Dietary, effective/revision dates 12/12/08, signed 12/16/08 by "Clinical Services Division Manager".

Review of Policy titled "In-Service Training" Section: Clinical Services Division - Dietary, effective/revision date "12/12/08", signed 12/16/08 by "Clinical Services Division Manager".

Review of Policy titled "Food Service Equipment Temperature Control Chart" Section: Clinical Services Division - Dietary, effective date "12/12/08," revision dates "12/12/08, 7/12," signed 7/23/12 by "Clinical Services Division Manager".

Review of Policy titled "Food Storage - Frozen Foods" Section: Clinical Services Division - Dietary, effective date "12/12/08," revision dates "12/12/08, 7/12," signed 7/23/12 by "Clinical Services Division Manager".

Review of Policy titled "Food Storage: Non-Perishable Foods" Section: Clinical Services Division - Dietary, effective date "12/12/08," revision dates "12/12/08, 7/12," signed 7/23/12 by "Clinical Services Division Manager".

Review of Policy titled "Hand Washing" Section: Clinical Services Division - Dietary, effective date "12/12/08," revision dates "12/12/08, 7/12," signed 7/23/12 by "Clinical Services Division Manager".

Review of Policy titled "Personal Hygiene" Section: Clinical Services Division - Dietary, effective date "12/12/08," revision dates "12/12/08, 7/12," signed 7/23/12 by "Clinical Services Division Manager".

Review of Policy titled "Hair Restraints" Section: Clinical Services Division - Dietary, effective date "12/12/08," revision dates "12/12/08, 7/12," signed 7/23/12 by "Clinical Services Division Manager".

Review of Policy titled "Diet Manual" Section: Clinical Services Division - Dietary, effective date "12/12/08," revision dates "12/12/08, 7/12," signed 12/20/12 by "Clinical Services Division Manager".

On 6/05/19 at 1:58 PM during interview with Registered Dietetic Technician (RD Tech) J, RD Tech J stated they collect food temperature checks for performance improvement but could not show any trending indicators to ensure quality services.

On 6/05/19 at 2:11 PM during interview with Administrator A, A presented a spread sheet stating these are our policies that need updating. Administrator A confirmed the dietary policies have not been recently revised stating "we're working on it".

On 6/05/19 at 2:18 PM during interview with Quality RN S, RN S stated that dietary data was available for tracking and trending, but could not show evidence of how this information had been used in their performance improvement to ensure the quality of the Food and Dietetic Services.

Based on record review and interview, the facility failed to demonstrate dietary staff competency by failing to develop an appropriate orientation and training program in 2 of 2 of their training materials (Dietary Orientation Checklist and Dietary Services Mandatory In-Services examination) and failed to demonstrate appropriate dietary orientation according to the facilities process in 3 of 9 dietary staff (Registered Dietetic Technician J, Kitchen Psychiatric Technicians Q & R).

Findings include:

Review of form titled "Psychiatric Technician Dietary Orientation Checklist" was not dated. There was no policy for implementation, evidence of compliance with Federal and State licensure requirements for food service standards and regulations, no governing board, medical staff or dietitian approval.

Review of form titled "Dietary Services Mandatory In-Services" examination was not dated. There was no policy for implementation, evidence of compliance with "ServSafe" training (nationally recognized food safety training) or Federal and State licensure requirements for food service standards and regulations demonstrated, no governing board, medical staff or dietitian approval.

Review of policy titled "In-Service Training" effective and revision dates "12/12/08," signed 12/16/08 by "Clinical Services Division Manager" revealed Purpose "To establish guidelines for training Kitchen Psychiatric Technicians to assure safe food handling, kitchen sanitation and the provision of patient meals which comply with therapeutic diet orders. II. POLICY/PROCEDURE 1. Ongoing training shall be provided to Kitchen Psychiatric Technicians, as needed. Monthly in-service training shall be provided by the Consultant Dietitian or Food Service Specialist... 3. An in-service training schedule shall be developed annually and list training topics... 5. All Kitchen Psychiatric Technicians are required to attend the monthly in-service training sessions."

On 6/05/19 at 1:11 PM during interview with Registered Dietetic Technician (RD Tech) J, RD Tech J stated s/he developed the Dietary Services Mandatory In-Services education examination using the "ServSafe" training information and the orientation/training checklist to educate the Kitchen Psychiatric Technicians. RD Tech J stated s/he had taken the Servsafe exam "years ago" but s/he did not have a current ServSafe certification. RD Tech J stated there is no monthly required in-service training sessions for Kitchen Psychiatric Technicians. RD Tech J stated the orientation/checklist was developed after Kitchen Psychiatric Technicians Q & R started stating "they wouldn't have taken it". When asked if s/he had been deemed competent using the orientation checklist, RD Tech J stated "why would I take it, I made it." RD Tech J confirmed s/he and the Kitchen Psychiatric Technicians Q & R had not completed the orientation checklist.

A Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 06/04 & 05/2019. Waukesha County Mental Health was found to be NOT in compliance with the requirements of the following applicable regulations for participation in Medicare- Medicaid:

42 CFR Subpart 482.41 - CONDITION: Physical Environment was NOT MET.


FINDINGS INCLUDE:
The Hospital was found to not have a safe environment, properly constructed and maintained to protect the health and safety of patients based on the following.

K 351 (Sprinkler Systems- Installation)
K 353 (Sprinkler Systems- Maintenance)
K 712 (Fire Drills)

Please refer to the full description at the cited K-tags. Due to the accumulative effect of these citations safety of the patients, visitors, and staff was not maintained in accordance with the Life Safety Code (NFPA 101-2012).

A Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 06/04 & 05/2019. Waukesha County Mental Health was found to not be in compliance with the requirements of the following applicable regulations for participation in Medicare-Medicaid:

42 CFR Subpart 482.41(b) - Safety from Fire was NOT MET

FINDINGS INCLUDE:

K 351 (Sprinkler Systems- Installation)
K 353 (Sprinkler Systems -Maintenance)
K 712 (Fire Drills)

Please refer to the full description at the cited K-tags. Due to the accumulative effect of these citations safety of the patients, visitors, and staff was Not maintained in accordance with the Life Safety Code (NFPA 101-2012).

Based on observation, record review and interview the facility failed to maintain an environment that was free from potential contamination in 3 of 3 departments (Dietary, Unit A and Unit B) and failed to develop guidelines for kitchen sanitation in 1 of 1 food service departments.

Findings include:

Refrigerator Temperatures:

Review of policy titled "Food Service Equipment Temperature Control Chart" dated 7/23/12 revealed "PURPOSE To establish guidelines for monitoring temperatures of equipment used for food storage and ware washing... 1. Temperatures shall be recorded daily for all coolers, freezers and dish machine... 2. Temperatures which do not meet acceptable levels shall be reported to the Food Service Specialist immediately."

Review of document titled "Temperatures Log" dated May 2019 on Unit A Refrigerator revealed no temperatures documented on May 15, 16, 17, and 20.

Review of document titled "Temperatures Log" dated May 2019 on Unit B Refrigerator revealed "Guidelines to be met: Hot Food 135 or higher, Cold Food 40 or lower, Dishmachine 140-160." Columns under refrigerator dated May 11 & 12 with temperature of 160, May 25 & 26 temperature of 165. No temperature documented May 18, 19, 29, 30 & 31.

Review of document titled "Kitchen Refrigerator and Freezer Temperature Log" dated June 2019 revealed no temperature documented June 2.

On 5/03/19 at 10:15 AM during an interview with Registered Dietetic Technician (RD Tech) J, RD Tech J stated s/he was not notified refrigerator temperatures were out of range stating the staff filling out the chart "must not have known what they were doing." RD Tech J confirmed temperatures were missing for some of the dates "they should have been filled in."

Food Storage:

Review of policy titled "Food Storage - Perishable Foods" signed 12/16/08 by "Clinical Services Division Manager" revealed "PURPOSE To establish guidelines for storing perishable food in a safe and sanitary manner No... 8. All pre-dished items shall be covered to prevent off-odors, drying or cross-contamination while refrigerated."

No reference is made to expired foods.

Review of policy titled "Provision of Meal Service in the Event of a Disaster", not dated or signed, revealed 1. "All containers shall be...examined quarterly... See checklist form." Checklist form revealed DT Tech J's signature by "2nd Quarter" dated 3/25/19 and checklist columns titled "Food Item" and "First Expire Date." Rows titled Cranberry Juice-1 expiration date (exp) 4/12/19, Cranberry Juice-2 4/12/19, Tropical Fruit Salad exp 5/12/19, Fruit Cocktail (Mix)-1 exp 5/17/19, Fruit Cocktail (Mix)-2 exp 5/17/19, Mandarin Oranges-1 exp 5/21/19, Mandarin Oranges-2 exp 5/21/19, Mandarin Oranges-3 exp 5/21/19, Assorted Boxed Cereal-1 exp 4/09/19, Assorted Boxed Cereal-2 exp 4/09/19, Pineapple Juice 4/26/19, and Peanut Butter 4/17/19.

On 6/03/19 at 10:25 AM observed the following products with expired dates: Unit A refrigerator : Ensure 8 ounces, expiration date 4/2019 X 6, packages of carrots with an expiration date 6/01/19 X 8. Unit B refrigerator: l container of sour cream with no date, bread bag with 4 slices of bread with expiration date of 5/29/19.

On 6/03/19 at 11:02 AM observed box marked "Hot Sauce" manufacture date on box 3/14/18 with no expiration dates and 87 packets and 3 containers of barbeque sauce with an expiration date of 3/15/19.

On 6/03/19 observed bag in freezer containing 3 sausage/egg/cheese bagels with an expiration date of 4/28/19.

On 6/03/19 observed in kitchen cabinet Thickening Powder with an expiration date of 8/18 and 40 ounce sticky container with a worn label reading seasoning salt with no expiration date.

On 6/03/19 at 2:58 PM observed Kitchen Psychiatric Technician P put tray of pasta into refrigerator with holes in the plastic covering after temperature checks were done without recovering.

On 6/04/19 at 10:15 AM with RD Tech J observed emergency supply products the following boxes with expires written on boxes in large black marker: Smuckers jelly 4/17/19, Dole pineapple 4/16/19, mandarin oranges 5/21/19 X 2, pineapple 4/16/19, mixed fruit 5/17/19, cranberry juice 4/12/19, and Kelloggs Mueslix cereal X 2 4/19/19.

Hygiene:

Review of policy titled "Hand Washing" "Section: Clinical Services Division-Dietary" signed 7/23/12 revealed Purpose "To define guidelines for hand washing which minimize contamination of food items and help prevent food borne illness... Policy/Procedure 1. Hands shall be washed... between working with different foods."

Review of policy titled "Hair Restraints" signed 7/23/12 Policy/Procedure 1. "Hair restraints shall be worn by all Dietary Services...while on duty in kitchen and on the patient unit while serving food. Hair restraints shall cover all hair."

On 6/03/19 at 11:02 AM during observation of kitchen tray prep, observed Kitchen Psychiatric Technician P with hair net covering her/his hair bun but not the rest of her/his hair.

On 6/03/19 at 11:02 AM during observation of kitchen tray prep, observed RD Tech J put on gloves without washing her/his hands, took off gloves, transported cart to floor, put on new gloves without washing hands, prior to serving food.

On 6/04/19 at 10:11 AM during interview with RD Tech J, when questioned about hairnets and handwashing, RD Tech J stated s/he "needs to pull it down" and confirmed "I should have washed my hands."

Cleaning:

Review of "Product Specification Document" for Oasis 146 Multi-Quat Sanitizer revealed usage recommendations for dilution levels for food service sanitizing applications using "quat test strips".

Review of schedules titled "Daily cleaning schedule for the 9:30 to 6:00 Kitchen Person" dated 5/13/19 revealed tables marked Daily Duties, Weekly Cleaning Schedule, and Monthly Duties with all boxes blank. Form dated 5/20/19 Daily Duties 5/20 through 5/24 were blank, Weekly Cleaning Schedule boxes blank, Monthly Duties blank, Form dated 5/27/19 Daily Duties blank boxes in 5/27, 28, 30, 31, 6/1 & 6/2 columns, weekly cleaning schedule row dated 5/27 box "NOT HERE", Monthly Duties box blank.

On 6/03/19 at 3:10 PM during interview with Registered Dietetic Technician (RD Tech) J, RD Tech J stated they have no written policies related to cleaning or sanitization of the kitchen.

On 6/03/19 at 3:22 PM during observation of food temp process with RD Tech J, RD Tech J stated they use Ecolab Cleaner Oasis 146 Multi-Quat Sanitizer to clean their equipment in the kitchen. When questioned how they test the concentration of the cleaning solution when filling the bottles, RD Tech J stated "I'm out of those strips, I ordered them, they should be in next week". RD Tech J stated they did not have any policy to cover cleaning or sanitation of the kitchen, stated it is done daily with deep cleaning done on a monthly basis and confirmed the cleaning schedule form was not completed as s/he would expect.

Based on record reviews and interviews, the facility failed to provide current discharge planning policies and procedures in 9 of 9 discharge planning policies reviewed in a total universe of 1 discharge planning program.

Findings include:

The facility policy titled "POLICY ON POLICIES" last reviewed on 1/29/2013 was reviewed on 6/5/2019 at 11:30 AM. This document revealed under "I. PURPOSE: To provide a plan and process for the development, implementation and maintenance of policies and procedures within the Department of Health and Human Services. II. PROCEDURE: 1. All policies and procedures will be reviewed for completeness and appropriateness: a. At least every two (2) years. b. When a practice change has occurred. c. When a change (s) occurs in the local, state, federal laws or regulations...Format d) 4. EFFECTIVE DATE: The date the policy/procedure goes into effect. 5. REVISION DATE: Indicates the last revision date. 6. DATE (S) OF EXECUTIVE MEETING: The date (s) the policy/procedure was discussed and approved at the Executive Meeting. 7. RESPONSIBLE PERSON FOR POLICY: Indicates the name and title of the person who is the owner of the policy...6. Policy and Procedure Process: (Note: Division/Unit policies and procedures will be created and revised within that Division/Unit) a. The Records Supervisor or designee will have the responsibility to: 1. Contact the owner of each policy to have them update or review their policy. 2. Ensure that the policy/procedure is typed in the correct format and assist with the typing and revision of the policy/procedure as needed. 5. Contract the policy owner and obtain a summary of what has been changed in the policy. 6. Send out the policy with the summary of changes from the policy owner to the Department staff. Retain the email notification and files with the policy. 7. Update the Department Policy and Procedure Tracking Log spreadsheet. b. The policy owner will have the responsibility to: 1. Update/revise the policy/procedure as needed. 2. Track the effective date, revision date, and date (s) that it was discussed and approved at the Executive Meeting. 3. Obtain approval signature (s). 4. Prepare a written summary of the key changes for the policy revised and route to the Records Supervisor. 5. Ensure that appropriate education has taken place, if needed."

The facility policy titled "Policy on Policies" with an effective date of 9/2014 was reviewed on 6/5/2019 at 11:30 AM. This document revealed under "I. PURPOSE: To provide a plan and process for the development, implementation and maintenance of policies and procedures within the Department of Health and Human Services Clinical Services Division for building wide policies related to the MHC (mental health center) and for the MHC inpatient service. The Inpatient Services shall follow the DHHS procedure #8101: II. PROCEDURE: Any policy that impacts the clinical division including outpatient services at the Mental Health Center shall be approved by the Clinical Supervisors at one of the regular scheduled meetings. -For Inpatient Services at the Mental Health Center, policies that are revised will be approved by the governing board first through the Medical and Psychological Committee and then the Joint Conference Committee. -A revision shall be when the actual procedure is altered. -A review shall be when there are no changes or a change is incidental in nature. Examples include but are not limited to: new phone numbers, a new job title or a new form that does not alter essential implementation of the procedure."

The facility policy titled "POLICY ON POLICIES" was last reviewed on 1/29/2013 there was no documented signature or date of "APPROVED BY".

The facility policy titled "Policy on Policies" had an effective date of 9/2014 there was no documented signature or date of "APPROVED BY".

The facility policy titled "Discharge Guidelines" was last reviewed in June 2014 and approved by Clinical Services Division Manager and Mental Health Center Administrator on 5/15 (4 years ago).

The facility policy titled "Discharge Against Medical Advice (AMA)" was last reviewed in June 2014 and approved by Clinical Services Division Manager and Mental Health Center Administrator on 5/15 (4 years ago).

The facility policy titled "Advance Directive" was last reviewed and approved by Clinical Services Division Manager in June 2012 (7 years ago).

The facility policy titled "Discharge Medications Prescriptions" was last reviewed in June 2014 and approved by Clinical Services Division Manager and Mental Health Center Administrator on 5/15 (4 years ago).

The facility policy titled "Discharge Record Break down" was last reviewed in May 2010 and approved by Clinical Services Division Manager on 6/29/10 (9 years ago).

The facility policy titled "Discharge Teaching" was last reviewed in May 2013 and approved by Clinical Services Division Manager on 7/9/13 (5 years ago).

The facility policy titled "Discharge Referrals to Home Health Agencies" was last reviewed in June 2014 and approved by Clinical Services Division Manager and Mental Health Center Administrator on 5/15 (4 years ago).

The facility policy titled "Aftercare Treatment Referrals" was last reviewed in June 2012 and had no signature or date of approval by Clinical Services Division Manager.

The facility policy titled "Social Work Discharge and Aftercare Procedure" last reviewed in June 2012 and approved by Clinical Services Division Manager and Mental Health Center Administrator on 5/15 (4 years ago).

The above listed policies and their last reviewed dates were confirmed in interview with Director of Social Services P in interview on 6/4/2019 at 10:30 AM who stated "yeah, they are not up to date. We are working on that as a facility."

Based on interview and record review the facility failed to ensure a current policy and procedure existed for organ procurement organization for facility staff in 1 of 1 organ procurement organizations reviewed.

Findings include:

The facility policy titled "POLICY ON POLICIES" last reviewed on 1/29/2013 was reviewed on 6/5/2019 at 11:30 AM. This document revealed under "I. PURPOSE: To provide a plan and process for the development, implementation and maintenance of policies and procedures within the Department of Health and Human Services. II. PROCEDURE: 1. All policies and procedures will be reviewed for completeness and appropriateness: a. At least every two (2) years. b. When a practice change has occurred. c. When a change (s) occurs in the local, state, federal laws or regulations...Format d) 4. EFFECTIVE DATE: The date the policy/procedure goes into effect. 5. REVISION DATE: Indicates the last revision date. 6. DATE (S) OF EXECUTIVE MEETING: The date (s) the policy/procedure was discussed and approved at the Executive Meeting. 7. RESPONSIBLE PERSON FOR POLICY: Indicates the name and title of the person who is the owner of the policy...6. Policy and Procedure Process: (Note: Division/Unit policies and procedures will be created and revised within that Division/Unit) a. The Records Supervisor or designee will have the responsibility to: 1. Contact the owner of each policy to have them update or review their policy. 2. Ensure that the policy/procedure is typed in the correct format and assist with the typing and revision of the policy/procedure as needed. 5. Contract the policy owner and obtain a summary of what has been changed in the policy. 6. Send out the policy with he summary of changes from the policy owner to the Department staff. Retain the email notification and files with the policy. 7. Update the Department Policy and Procedure Tracking Log spreadsheet. b. The policy owner will have the responsibility to: 1. Update/revise the policy/procedure as needed. 2. Track the effective date, revision date, and date (s) that it was discussed and approved at the Executive Meeting. 3. Obtain approval signature (s). 4. Prepare a written summary of the key changes for the policy revised and route to the Records Supervisor. 5. Ensure that appropriate education has taken place, if needed."

The facility policy titled "Policy on Policies" with an effective date of 9/2014 was reviewed on 6/5/2019 at 11:30 AM. This document revealed under "I. PURPOSE: To provide a plan and process for the development, implementation and maintenance of policies and procedures within the Department of Health and Human Services Clinical Services Division for building wide policies related to the MHC (mental health center) and for the MHC inpatient service. The Inpatient Services shall follow the DHHS procedure #8101: II. PROCEDURE: Any policy that impacts the clinical division including outpatient services at the Mental Health Center shall be approved by the Clinical Supervisors at one of the regular scheduled meetings. -For Inpatient Services at the Mental Health Center, policies that are revised will be approved by the governing board first through the Medical and Psychological Committee and then the Joint Conference Committee. -A revision shall be when the actual procedure is altered. -A review shall be when there are no changes or a change is incidental in nature. Examples include but are not limited to: new phone numbers, a new job title or a new form that does not alter essential implementation of the procedure."

The facility policy titled "Organ and Tissue Donation" last reviewed on 5/13 was reviewed on 6/5/2019. This document revealed "The policy of Waukesha County Mental Health Center (WCMHC) is to encourage the donation of all medically useable organs issues and eyes from deceased patients in compliance with state and federal regulations. The Wisconsin Donor Network (WDN) is the Organ Procurement Organization designated by the Centers for Medicare & Medicaid Services (CMS) for this facility. In the event of a pronouncement of death of a patient in the hospital, WCMHC will notify WDN of the death and also inform WDN that the Waukesha County Medical Examiner has taken jurisdiction over the deceased. WDN will ascertain the viability of the deceased as a potential organ and/or tissue or eye donor. WDN's Donor Referral Line will also notify the tissue and eye banks, as appropriate."

A letter dated March 7, 2019 from "Versiti" to facility was reviewed on 6/5/2019. This letter revealed "We would like to take this opportunity to thank you and your hospital staff for your continued commitment to organ and tissue donation. This letter will serve to document your hospital's compliance with CMS Medicare Conditions of Participation and the Wisconsin Administrative Code relating to the identification, referral and recovery of donated organs and tissues." This document also included the "2018 Organ, Tissue Donation Summary" for the facility which included "Number of deaths reflected on hospital expiration list: 1".

A letter dated October 12, 2018 from "BloodCenter of Wisconsin Part of Versiti" revealed "This letter services to document the notification of a name change for BloodCenter of Wisconsin, Wisconsin Donor Network and Wisconsin Tissue Bank. Please refer to Table 1 for the name change that will apply for the Wisconsin Donor Network and Wisconsin Tissue Bank. This change will be effective November 1, 2018. Please update associated records within the Waukesha County Mental Health organization."

There was no documented facility policy and procedure that reflected the current name of the organ procurement organization.

An interview was conducted with Director of Nursing B on 6/5/2019 at 9:30 AM who stated "The policy has the old company name on it."

Based on record review and interview the facility failed to ensure a current contract existed between the facility and the organ procurement organization in 1 of 1 organ procurement program reviewed in a total universe of 8 contracted services.

Findings include:

The facility document titled "Consent to Assumption by Blood Center of Wisconsin Of Wisconsin Donor Network Contracts (Assignment and Termination of Existing WDN Contract)" was reviewed on 6/5/2019. This document revealed "Waukesha County Mental Health Center (the "Hospital") currently has a contract with the Wisconsin Donor Network ("WDN") for organ donor procurement services. WDN is currently a division of Froedtert Memorial Lutheran Hospital, Inc. (referred to herein as "Froedtert."). A copy of that existing contract ("Contract") with this Hospital is attached. Effective on Closing Date estimated to be within or about the next sixty to ninety days or thereafter, the WDN services will be provided by the BloodCenter of Wisconsin, Inc. ("BloodCenter") following transfer of the WDN to the BloodCenter. By signing this document, it is agreed between and among this Hospital, the BloodCenter, and Froedtert, that as of the Closing Date the existing Contract is and will be terminated with respect to Froedetert, that the Hospital releases Froedtert with respect to any liabilities arising under the Contract after the Closing Date, that the respective obligations of Froedtert with respect to WDS services will be assigned to and assumed by the BloodCenter and that the existing Contract will thereafter continue in full force and effect between this Hospital and the BloodCenter with respect to WDN services provided after the Closing Date. All obligations and indemnities, if any, of any party under the existing Contract with respect to services performed by Froedtert on or prior to the Closing Date will remain with that party. By signing this document, it is further agreed between Hospital and Froedtert that Froedtert's Notice of Termination of its Contract with Hospital for WDN services is rescinded. Dated as of the Hospital's signature below on this __ day of _______________, 2009."

There was no contract attached and there was no documented date of signature by Waukesha County Mental Health Center.

An interview was conducted with Administrator A on 6/5/2019 at 8:30 AM who, when asked for the current contract with organ procurement organization stated "We don't have one. We don't pay them so we don't need a contract."

Based on record review, policy review, observation, and interview, the hospital failed to:

l. Ensure that active treatment measures, such as group and/or individual treatment, were provided for two of eight sample patients (Patient A1 and Patient A7). Specifically, Patient A1 did not have groups assigned and refused to attend activities being offered on the unit. Patient A7 had one Occupational Therapy (OT) group assigned in the morning and one in the afternoon. The remainder of the time, this patient spent hours a day on the unit coloring pictures and was not scheduled or engaged in therapeutic activities. The Master Treatment Plans (MTPs) for these patients failed to include alternative interventions. In addition, many of the patients on Unit A and B who were not assigned or refused off-unit groups, were not offered alternative activities on the unit and instead were observed in their rooms or sitting/walking in the dayroom. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying the recovery process and increasing the length of hospitalization. (Refer to B125-l)

ll. Provide therapeutic or leisure groups during the evening hours. Failure to provide scheduled treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process. (Refer to B125-ll)

Based on record review, policy review, and interview the facility failed to provide social work assessments that met professional social work standards, including conclusions and recommendations that described anticipated social work roles in treatment and discharge planning. This resulted in a lack of professional social work treatment services for three of eight active sample patients (A1, A5, and A6) and/or lack of documented input to the treatment team.

Findings Include:

A. Specific Patient Findings

1. Patient A1's Social History, dated 05/29/19, listed the following interventions unrelated to social work treatment interventions during hospitalization: "Assess for safety, obtain collateral, provide resources, and set up aftercare."

2. Patient A5's Social History, dated 05/02/19, listed the following nursing intervention without listing additional social work interventions to be utilized during hospitalization: "Reinforce with [patient] the benefits of medication compliance in allowing him to not be in a hospital but instead residing in the community."

3. Patient A6's Social History, dated 05/25/19, listed the following interventions unrelated to social work treatment interventions during hospitalization: "Assess for safety, obtain collateral, provide psychosocial assessment, and coordinate aftercare plan with case management services via Care Wisconsin."

B. Policy Review

Review of Hospital Policy titled, "Social Work Post Admission Procedure," reviewed 03/04/13,
failed to delineate the requirements for the content of the Social History,

C. Interview

In an interview on 06/04/19 at 11:20 a.m., the Director of Social Worker concurred with the findings regarding the lack of specific content requirements in the Social Work Assessment Policy and voiced understanding of the findings regarding the lack of social work specific treatment services.

Based on record review, policy review, and interview the facility failed to provide treatment plans that identified patient related short-term goals (STG) and long-term goals (LTG) stated in observable, measurable, behavioral terms for eight of eight sampled patients (A1, A2, A3, A4, A5, A6, A7, and A8). This failure hinders the ability of the treatment team to measure changes in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, as well as to increase patient stays beyond the resolution of the behaviors requiring admission.

Findings Include:

A. Specific Patient Findings

1. Patient A1's Master Treatment Plan (MTP- facility term is ITP, Inpatient Treatment Plan) dated 5/25/19, listed for the Problem, "Altered Thought Processes," the non-measurable LTG, "[Patient] will identify and demonstrate reality-based thought and behaviors related to social norms and acceptable behavior along with decreasing disorganized thoughts and inappropriate behavior." The non-measurable STG this problem was, "[Patient] will partake in social interactions and share thoughts and feelings that are organized, logical, and appropriate for (3) consecutive days."

2. Patient A2's MTP dated 5/26/19, listed for the Problem, "Alteration in Thought Content as evidenced by delusions," the non-measurable LTG goal, "[Patient] will exhibit consistent ability to function appropriately in social, work, community interactions and contacts." The non-measurable STG listed for this problem was, "[Patient] will communicate thoughts and feelings in a coherent, goal-directed manner during [his/her] in patient [sic] stay."

3. Patient A3's MTP dated 5/30/19, listed for the Problem, "Noncompliance," the non-behavioral LTG, "[Patient] will acknowledge that continued treatment indicated in [his/her] commitment orders will benefit [him/her] in maintaining MH [Mental Health] stability and to remain in the community."

4. Patient A4's MTP dated 5/8/19, listed for the Problem, "Altered Thought Process" the non-measurable/ non-observable LTG, "Control or eliminate active psychotic symptoms such that supervised functioning is positive, and medication is taken consistently."

5. Patient A5's MTP dated 5/2/19, listed for the Problem, "Alteration in Thought Content as evidenced by delusions," the non-measurable LTG, "[Patient] will exhibit consistent ability to function appropriately in social, work life, and community interactions/conflicts." The non-measurable STG listed for this problem was, "[Patient] will demonstrate improved reality-based thinking via both verbal and non-verbal behavior for 3 consecutive days."

6. Patient A6's MTP dated 5/24/19, listed for the Problem, "Aggressive Behavior," the non-measurable goal, "[Patient] will demonstrate the ability to recognize and appropriately express [his/her] angry feelings as they occur." The non-measurable STGs for this problem were, "For 3 consecutive days, [Patient] will appropriately respond to limit setting when [s/he] becomes angry or frustrated, avoiding any threats to harm others," and "For 3 consecutive days [Patient] will talk to staff when [s/he] is starting to feel angry or frustrated with others verbalizing 3 healthy alternative ways to avoid physical aggression."

7. Patient A7's MTP dated 5/16/19, listed for the problem, "Altered Thought Processes," the non-measurable LTG, "[Patient] will establish the ability to effectively channel impulses toward less destructive more adaptive behaviors." The non-measurable STG for this problem was, "[Patient] will be able to verbalize a plan to cope with triggers for 3 consecutive days."

8. Patient A8's MTP dated 5/6/19, listed for the problem, "Altered Though Processes," the non-measurable LTG, "[Patient] will be able to exhibit consistent ability to function appropriately in social and community interactions without conflict." The non-measurable STG for this problem was, "[Patient] will communicate thoughts and feelings in a coherent goal directed manner for 3 consecutive days."

B. Policy Review

Review of Hospital Policy titled, "Comprehensive Treatment Planning," reviewed 7/12, approved 3/8/13, failed to delineate the requirements for writing goals to be included in the MTP.

C. Interviews

1. In an interview on 6/4/19 at 11:40 a.m., the Director of Nursing (DON) stated that she understood that the goals presented were not measurable.

Based on record review and interview, the hospital failed to develop treatment interventions based on the individual needs of the patients for six of eight patients in the sample (A1, A2, A4, A5, A7, and A8). Treatment interventions were either written as routine discipline functions or failed to address individualized patient needs. This practice has the potential to lead to failure of individualized treatment interventions and to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings Include:

A. Specific Patient Findings

1. Patient A1was admitted on 5/24/19. The Master Treatment Plan (MTP), dated 5/25/19, listed for the Problem, "Altered Thought Processes," the unrelated social worker (SW) intervention, "SW will involve [patient] in occupational therapy [OT] or on unit activities 3-4x's per week to allow [patient] to engage in meaningful activities to partake in with staff and peers."

2. Patient A2 was admitted on 5/26/19. The MTP dated 5/26/19, listed for the problem, "Alteration in thought content as evidenced by delusions," the generic nursing intervention, "Staff will administer medication(s) to [patient] as ordered and monitor the therapeutic effects and side effects throughout patient's stay."

3. Patient A4 was admitted on 5/7/19. The MTP dated 5/08/19, listed for the problem, "Altered Thought Processes," the generic social work intervention, "SW will update [patient's] case manager/supervisor weekly on [patient's] progress toward discharge and [patient's] community needs." The generic nursing intervention for this same problem was, "[Patient] will take antipsychotic medications consistently as ordered by physician for 3 consecutive days."

4. Patient A5 was admitted on 5/2/19. The MTP dated 5/2/19 listed for the problem, "Alteration in thought content as evidenced by delusions", the non-specific nursing intervention, "Nursing will meet and discuss reality-based goals and d/c planning Qsh [sic] and PRN [as needed] while awake."

5. Patient A7 was admitted on 5/16/19. The MTP dated 5/16/19 listed for the problem, "Aggressive Behavior," the generic nursing intervention, "Nursing will administer medication in PRN situations, as ordered by psychiatrist."

6. Patient A8 was admitted on 5/6/19. The MTP dated 5/6/19 listed for the problem, "Altered thought processes," the non-specific, generic nursing intervention, "Nursing staff will facilitate and encourage [patient] to attend coping skills group at least 2 times per week when appropriate to assist [patient] in identifying positive ways to cope with symptoms of [his/her] mental illness."

B. Policy Review

Review of Hospital Policy titled, "Comprehensive Treatment Planning," reviewed 7/12, approved 3/8/13, failed to delineate the requirements for writing interventions to be included in the MTP.

C. Interview

1. In an interview on 6/4/19 at 11:40 a.m., the Director of Nursing (DON) stated that she understood and agreed that the nursing interventions that were shared were generic and failed to meet the patients' needs.

Based on medical record review, policy review, observation, and interview, the facility failed to:

l. Ensure that active treatment measures, such as group and/or individual treatment, were provided for two (2) of eight (8) sample patients (Patient A1 and Patient A7). Specifically, Patient A1 did not have groups assigned and refused to attend activities being offered on the unit. Patient A7 had one Occupational Therapy (OT) group assigned in the morning and one in the afternoon. The remainder of the time, this patient spent hours a day on the unit coloring pictures and was not scheduled or engaged in therapeutic activities. The Master Treatment Plans (MTPs) for these patients failed to include alternative interventions. In addition, many of the patients on Unit A and B who were not assigned or refused off-unit groups were not offered alternative activities on the unit and instead were observed in their rooms or sitting/walking in the dayroom. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying the recovery process and increasing the length of hospitalization.

ll. Provide therapeutic or leisure groups during the evening hours. Failure to provide scheduled treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process.

Findings Include:

l. Failure to Provide Active Treatment

A. Specific Patient Findings

1. Patient A1 was evaluated for admission on 5/25/19. The Psychiatric Evaluation dated 5/25/19 indicated the patient's family were concerned about patient's "angry outbursts, aggressive behavior, smoking marijuana, as well as K2, and believing that [s/he] had a wife and a child, [s/he] is unable to hold onto a job and refusing treatment." The psychiatric evaluation listed "Primary Diagnosis: Unspecified Psychosis.

The patient's MTP, dated 5/25/19, listed the problem, "Altered thought processes". The Long-Term Goal (LTG) listed for this problem was "[Patient] will identify and demonstrate reality-based thoughts and behaviors related to social norms and acceptable behavior along with decreasing disorganized thoughts and inappropriate behavior." The Short-Term Goal (STG) for this problem was "[Patient] will participate in social interactions and share thoughts and feelings that are organized, logical, and appropriate for (3) consecutive days."

Additional review of this Patient's MTP indicated that this patient was not assigned to any therapeutic groups and was to participate in on-unit nursing staff groups.

Review of IP (Inpatient) Progress Notes revealed that on 5/26, 5/27, 5/28, 5/29, 5/29/ 5/30, 5/30, 5/31, 6/1, 6/2, and 6/4/19, the patient had refused on-unit groups and no alternative activities were listed in the progress note entries or on the MTP.

In an interview on 6/3/19 at 2:15 p.m., Patient A1 acknowledged refusing the Walking Group scheduled during this time period. Patient A1 was in his/her room and agreed to meet in an interview area. S/he cried throughout most of the interview stating his/her mother thought s/he was crazy because they had had an argument. S/he denied the need for hospitalization and stated s/he was not going to take any medications. S/he further indicated no interest or willingness to go to groups. His/her only concern was to get home to care for and be with his/her cat and dog.

During observations on Unit B on 6/3/19 at 3:15 p.m. and 6/4/19 at 9:15 a.m. and 10:30 a.m., Patient A1 was observed either in his/her room or on the unit, but not in a therapeutic activity.

In an interview on 6/3/19 at 2:40 p.m., RN 2 indicated that Patient A1 spent a great deal of time isolating in the room and did not attend groups. She stated that patients were encouraged to attend but could not be forced. She further indicated that Patient A1 was refusing all medications at this time.

In an interview on 6/4/19 at 1:15 p.m., Social Worker 1(SW1) indicated that the patient was not a candidate for therapeutic groups at this time due to lack of ability to "focus in a calm manner" and s/he was "not cooperative." She further indicated that the patient would be disruptive to other group members. SW1 indicated that she and the psychiatrist had met with the patient in team meeting and one other time on rounds since admission on 5/25/19. She indicated that no individual therapy/meetings occurred unless the psychiatrist indicated that individual therapy would be needed. She further stated, "We don't sit down and do individual," and, "We rely a lot on psych techs."

2. Patient A7 was admitted on 5/16/19. The Psychiatric Evaluation, dated 5/16/19, revealed that the patient had been admitted due to aggressive behavior at a group home. S/he was continuously running away from the home, hitting staff and other clients and attempted to strike the police. The patient's diagnosis was listed on the Psychiatric Evaluation as "Schizoaffective disorder, bipolar type."

Patient A7's MTP, dated 5/16/19, listed the patient's problems as, "Altered thought processes" and "Aggressive behavior." The MTP showed that the following group interventions had been assigned: Coping Skills Group (Nursing 1-3 times weekly), Recreation (Occupational Therapy once weekly), Leisure Skills (Occupational Therapy once weekly), and Social Work groups (3-4 times per week). The Social Work groups were Recovery, Psychotherapy and Self-Esteem groups.

In an interview on 6/3/19 at 1:40 p.m., Mental Health Technician 2 (MHT2-called Psychiatric Technicians by facility), when asked why Patient A7 was not going to one of the two scheduled groups (Life Management Skills or Coping Strategies) stated that Patient A7 did not go to groups off the unit and had only one Occupational Therapy (OT) group assigned in the morning and one in the afternoon because s/he "does better" with fewer groups. MHT2 further stated that Patient A7 liked to color and spent a lot of time coloring at a table in the dayroom. When asked if coloring helped Patient A7, MHT2 said that sometimes staff will sit down at the table with him/her and talk.

During observation on Unit A on 6/3/19 at 1:45 p.m., Patient A7 was observed sitting at a table coloring a picture on a single sheet of paper. During interview on 6/3/19 at 2:00 p.m., Patient A7 stated that s/he went to a group in the morning and one in the afternoon, that s/he didn't know why s/he got so angry and that s/he had not learned any skills while in the hospital to handle the anger.

During observation on Unit A on 6/4/19 at 10:30 a.m., Patient A7 was observed sitting alone at the same table in the dayroom. S/he was coloring a picture. Observation on Unit A on 6/4/19 at 3:00 p.m., revealed that Patient A7 was in the courtyard for the assigned Recreation Group.

Patient A7 was observed sitting at a table with several other patients. Although there were two OT staff in attendance, there was no structured organization and patients were seen pacing, laughing to self, picking at plants and sitting.

Review of IP (Inpatient) Progress Notes from 5/17/19 through 6/3/19 revealed the following notes:
(5/17/19) 8:08 p.m. "[Patient] has been out on the unit. [S/he] has been out coloring."
(5/18/19) 9:39 a.m. "[S/he] has been coloring to keep [him/herself] busy."
(5/20/19) 10:55 p.m. "[Patient] colored quietly during the afternoon and evening."
(5/21/19) 10:23 a.m. "[Patient] was invited over to join the game but said [s/he] would rather keep coloring."
(5/21/19) 2:16 p.m. "[S/he] colored out on the unit most of the shift when not at the desk."
(5/22/19) 4:10 p.m. "[Patient] was out on the unit coloring."
(5/22/19) 8:13 p.m. "Pt [Patient] was up on the unit coloring."
(5/23/19) 2:56 p.m. "[Patient] stated [s/he] did not want to attend groups or go outside but was out on the unit coloring most of the shift when not at the desk."
(5/24/19) no time ". . . declined offer to join the game, wanted to continue with [his/her] coloring pages."
(5/24/19) 1:43 p.m. "[S/he] colored out on the unit most of the shift when not at the desk."
(5/25/19) 11:33 a.m. "[S/he] worked on a coloring sheet . . ." (In group)
(5/26/19) 12:10 a.m. "Patient has been up on unit. Coloring during free time."
(5/26/19) 1:27 p.m. "[S/he] worked on coloring sheets. . ." (In group)
(5/27/19) 11:28 a.m. "[S/he] worked on coloring sheets. . ." (In group)
(5/27/19) 9:01 a.m. "Patient has been up on the unit. Colors most of the time."
(5/30/19) 11:01 p.m. "[S/he] kept [him/herself] occupied by coloring and was compliant with the unit routine."
(6/1/19) 11:51 a.m. "Pt joined the group area. Pt colored two coloring sheets." (In group)
(6/2/19) 11:39 a.m. "Pt joined the group area and colored a picture." (In group)
(6/3/19) 10:27 a.m. "Patient was up on the unit coloring at the start of group but joined writer to play a card game. [S/he] stated, "It gets boring coloring all the time."

B. Policy Review

The hospital policy titled, "Occupational Therapy Policy and Procedure Manual," reviewed 04/25/2019, stated that occupational therapy services were delivered only after an order from " ...the attending psychiatrist ...or authorized prescriber ..." The policy stated that an OT assessment would be completed within five business days after the order was written and based on the assessment, groups would be assigned. According to the Administrator during the Entrance Conference on 6/3/19 at 9:30 a.m., the average length of stay for patients was 11-12 days with most patients staying seven days or less.

C. Observation

1. Observation on Unit A on 6/3/19 at 1:40 p.m. revealed that the census was 13 patients. Eight patients were in groups and five patients remained on the unit. Patient A6 was sleeping, Patient A7 was coloring, one patient was on the phone and two patients were in their rooms.

2. Observation on Unit A on 6/4/19 at 10:30 a.m. revealed that the census was 11 patients. Five patients were in groups and six patients were on the unit. (Five patients were not assigned to groups and one was assigned but refused) Patient A6 was in bed, Patient A7 was coloring, one patient was in the shower, one patient was in his/her room, one patient was in the dayroom and one was being staffed (seeing the treatment team).

3. Observation on Unit B on 06/04/18 at 1:30 p.m., revealed that the census was 12 patients on the Unit. Two groups were scheduled for 1:30 p.m., Self-Expression and Coping Skills. Two of the twelve patients were assigned to the Self Expression Group and four of the twelve patients were assigned to the Coping Skills Group. Of note is the fact that the Coping Strategies Group did not start until 2:00 p.m. (1/2 hour late). Only one of the two patients assigned went to the Self Expression Group and only two of the four patients assigned went to the Coping Strategies Group. The other nine patients remained on the Unit. Of those patients remaining, four patients were in their rooms resting or sleeping (including A1 and A4), one patient was talking on the phone, one patient was listening to music via headphones, one was watching TV, and two were coloring (Patients A2 and A3).

4. Observations on Unit A on 6/4/19 from 1:30 p.m.-2:30 p.m. revealed that the 1:30 p.m. "Coping Strategies Group" did not start until 2:00 p.m. Three patients, including Patient A5, were scheduled for this group and were observed watching television from 1:30 p.m.-2:00 p.m. when the group leader arrived to start the group. The census on the unit was 10 patients. Six patients were assigned and attended groups. Four patients did not attend group. One patient was assigned but refused to attend and was in his/her room. Three patients were not assigned. Patient A6 was not assigned and was observed sitting on the sofa in the dayroom, Patient A7 was not assigned and was in his/her room, and one other patient, who was not assigned, was pacing in the dayroom.

5. Observations on Unit A on 6/4/19 from 2:45 p.m.-3:15 p.m. revealed that two patients were in the Psychotherapy Group and six patients were in the Exercise Group in the courtyard. Two patients remained on the unit. One patient was assigned but refused group and was in his/her room. One patient was not assigned and was also in his/her room. Patients A5, A6, A7 and A8 were in the Exercise Group. Patient A5 was walking around the courtyard. Patient A6 was walking back and forth across the courtyard and was laughing and talking to him/herself. Patient A7 was sitting at a table with others and was not exercising. Patient A8 was wandering around the courtyard, talking to him/herself and picking at the plants. There was no structure to the Exercise Group, and patients were doing what they wanted.

C. Interview

1. In an interview on 6/3/19 at 1:40 p.m., MHT2 stated that patients needed an order to attend Occupational Therapy (OT) Groups and that patients didn't get an order until they were "ready" for groups. She stated that there were always several patients on the unit who were not assigned to groups. She did not know why patients needed an order for OT groups. MHT2 explained that Patients A6 and A7 were both assigned only one OT group in the morning and one in the afternoon because they could not take the stimulation of many groups. She stated that Patient A5 was assigned to only one OT group in the morning because s/he tended to sleep late and stay in his/her room even during the unit goals group (usually the first unit group where patients share their goal for the day). When asked why Patient A5 wasn't expected to attend groups, MHT2 stated that it took him/her longer than most patients to "get going" in the morning.

2. In an interview on 6/4/19 at 10:45 a.m., MHT3 acknowledged that there were six patients (census 11) not in groups. She further stated that it was not unusual to have patients not assigned to groups or those who refused groups. When asked about treatment alternatives that were being offered, MHT3 stated that they (staff) often put out art supplies on the tables in the dayroom for patients to use if they were not in group.

3. During an interview on 06/04/19 at 1:45 p.m., RN2 (Charge Nurse) indicated she was unclear why the Coping Skills group was late, and she was unclear which staff member was supposed to be leading the group. She further indicated that phones were to be turned off during group time but that did not always happen, and the television was sometimes left playing for those patients who had not been assigned to any groups.

4. In an interview on 6/5/19 at 10:00 a.m., the OT Supervisor acknowledged that a physician order was needed for a patient to attend OT groups and that patients without an order did not attend those groups. She further stated that an order was not needed for week-end OT groups. She did not know why an order was needed for the weekday groups.

ll. Failure to Provide Evening Activities

A. Document Review

Review of the unit schedules (Unit A and Unit B's schedule were identical) showed that there were limited activities offered during the week (Monday-Friday) after 3:45 p.m. From 3:45 p.m.-7:30 p.m. the schedule was, "Supper" from 4:30 p.m.-5:30 p.m. and "Visiting" from 5:45 p.m. - 7:00 p.m. "Leisure Activities" were listed from 7:00 p.m. - 8:00 p.m. There was a "Goal Recap" group scheduled from 8:30 p.m.-9:00 p.m., which consisted of patients stating if they had met their daily goal.

B. Interview

1. In an interview on 6/3/19 at 1:40 p.m., MHT2 stated that the evenings were "leisure time" which she defined as a time when patients could watch television, use their radios or do whatever they wanted. Patients were free to stay in their rooms or in the dayroom. MHT2 also stated that few of the patients had visitors in the evening.

2. In an interview on 6/3/19 at 2:00 p.m., Patient A7, when asked what s/he did in the evenings, stated, "I color."

3. In an interview on 6/3/19 at 2:15 p.m., Patient A6, when asked about evening activities on the unit, stated, "It's boring." When asked what s/he did in the evenings, the reply was, "Watch a little television."

4. In an interview on 6/5/19 at 10:00 a.m., the OT Supervisor stated that nothing was offered by OT after 3:45 p.m. and that the unit activities after that time would be offered by nursing staff.

Based on record review, policy review, observation, and interview, the Clinical Director failed to:

1. Ensure the provision of treatment plans that identified patient related short-term goals (STG) and long-term goals (LTG) stated in observable, measurable, behavioral terms for eight (8) of eight (8) sampled patients (A1, A2, A3, A4, A5, A6, A7, and A8). This failure hinders the ability of the treatment team to measure changes in the patient as a result of treatment interventions, may contribute to failure of the team to modify plans in response to patient needs, as well as prolong patient stays beyond the resolution of the behaviors requiring admission. (See B121)

2. Ensure the development of treatment interventions based on the individual needs of the patients for six of eight patients in the sample (A1, A2, A4, A5, A7, and A8). Treatment interventions were either written as routine discipline functions or failed to address individualized patient needs. This practice has the potential to lead to failure of individualized treatment interventions and to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems. (See B122)

3. Ensure that active treatment measures, such as group and/or individual treatment, were provided for two of eight sample patients (Patient A1 and Patient A7). Specifically, Patient A1 did not have groups assigned and refused to attend activities being offered on the unit. Patient A7 had one Occupational Therapy (OT) group assigned in the morning and one in the afternoon. The remainder of the time, this patient spent hours a day on the unit coloring pictures and was not scheduled or engaged in therapeutic activities. The Master Treatment Plans (MTPs) for these patients failed to include alternative interventions. In addition, many of the patients on Unit A and B who were not assigned or refused off-unit groups, were not offered alternative activities on the unit and instead were observed in their rooms or sitting/walking in the dayroom. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying the recovery process and increasing the length of hospitalization. (Refer to B125-l)

4. Provide therapeutic or leisure groups during the evening hours. Failure to provide scheduled treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process. (Refer to B125-ll)

In an interview on 6/5/19 at 10:30 a.m. the Clinical Director was informed about the lack of observable measurable treatment goals on Master Treatment Plans, the lack of treatment interventions based of individual patient needs on the MTPs,, and the lack of active treatment for Patient's A1 and A7, the lack of patient group assignments in general, and the lack of therapeutic groups scheduled during the evening hours. He did not disagree with the findings.

Based on record review and interview, the Director of Nursing failed to ensure that nursing interventions were based on the individual needs of five (5) of eight (8) sample patients (A2, A4, A5, A7, and A8). Specifically, the nursing interventions were generic and not specific to individual patient needs. This failure has the potential to result in nursing staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems. (Refer to B122)

Findings Include:

A. Specific Patient Findings

1. Patient A2 was admitted on 5/26/19. The MTP dated 5/26/19, listed for the problem, "Alteration in thought content as evidenced by delusions," the generic nursing intervention, "Staff will administer medication(s) to [patient] as ordered and monitor the therapeutic effects and side effects throughout patient's stay."

2. Patient A4 was admitted on 5/7/19. The MTP dated 5/08/19, listed for the problem, "Altered Thought Processes," the generic nursing intervention, "[Patient] will take antipsychotic medications consistently as ordered by physician for 3 consecutive days."

3. Patient A5 was admitted on 5/2/19. The MTP dated 5/2/19 listed for the problem, "Alteration in thought content as evidenced by delusions", the non-specific intervention, "Nursing will meet and discuss reality based goals and d/c planning Qsh [sic] and PRN [as needed] while awake."

4. Patient A7 was admitted on 5/16/19. The MTP dated 5/16/19 listed for the problem, "Aggressive Behavior," the generic nursing intervention, "Nursing will administer medication in PRN situations, as ordered by psychiatrist."

5. Patient A8 was admitted on 5/6/19. The MTP dated 5/6/19 listed for the problem, "Altered thought processes," the non-specific, generic nursing intervention, "Nursing staff will facilitate and encourage [patient] to attend coping skills group at least 2 times per week when appropriate to assist [patient] in identifying positive ways to cope with symptoms of [his/her] mental illness."

B. Interview

1. In an interview on 6/4/19 at 11:40 a.m., the Director of Nursing (DON) stated that she understood and agreed that the nursing interventions that were shared were generic and failed to meet the patients' needs.