HospitalInspections.org

Based on record review and interview, the facility failed to ensure it has an effective Governing Body that provides oversight and authority over all services within the hospital. This deficiency affects all patients being treated at this facility.

Findings include:

Interim Governing Body:

On 1/12/15 at 3:40 PM, per review of the Governing Body Bylaws, adopted November 17, 1998 and amended/revised on July 8th, 2014 signed by Clinical Director W, Admin B, and Former Human Services Director/Governing Body N, it delineates the Governing Body as the "Human Services Director."

Per interview on 1/15/15 at 2:30 PM, as the position of Human Services Director is currently vacant. Dir of Community Programs L stated L is currently "Interim" Human Services Director and acting Governing Body since 1/9/2015. Interim Governing Body L is "unfamiliar" with the governing body and medical staff bylaws, polices and rules and regulations. GB L stated "just because I have the title does not mean I have the authority."

Lack of communication between the Governing Body and the hospital:

Asked to review GB meeting minutes for the past 12 months, per interview with Interim GB L on 1/15/15 at 2:30 PM, there are no documented GB meeting minutes. The facility was unable to produce documentation of communication between the hospital and governing body to reflect the GB reviews the quality of care provided and has over-site over all services provided within the hospital, including contracted services. Interim GB L confirmed GB L does not have oversight over the hospital and Interim GB L's understanding is that GB L's responsibility in the Interim is to "supervise (Admin B)."

Per Admin B on 1/15/15 at 2:00 PM, the is no documentation of the Governing Body being involved or apprised of hospital programs and services. No documents are available to confirm the Governing Body's involvement outside of the Medical Staff Committee where medical staff appointments are evaluated and approved.

Lack of response to known pharmacy issues:

Per interview with Admin B on 1/13/15 at 1:10 PM, Admin B stated the Governing Body was made aware of concerns with contracted pharmacy services not meeting the hospital needs or abiding by their contract. No interventions have been put in place to correct the inadequate pharmacy services or amend the contract. (See Tag A 490)

Lack of oversight in Quality Assessment and Performance Improvement Program:

Per interview with Interim GB L on 1/15/15 at 2:30 PM, Interim GB L was unaware the facility does not have an on-going effective QAPI program and GB L stated GB is not reviewing any Quality data. (See Tag A 263)

Lack of oversight of Infection Control Program:

Per interview with Interim GB L on 1/15/15 at 2:30 PM, Interim GB L stated Infection Control data is not being reviewed by the GB. (See Tags A 748 and A749)

Lack of Discharge Planning/Social Services:

The hospital failed to provide adequate discharge planning and social services to it's patients. The hospital does not staff or provide coverage of social services/discharge planning during evenings, on weekends or on holidays. (See Tag A 799)

Falsified Documents:

Per review on 1/14/15 at 11:00 AM, SW Manager M presented a policy titled "Social Service Assessment" dated 10/13. The "Policy #" is blank and the document is not signed or dated by the Clinical Programs Coordinator or Hospital Administrator as being officially adopted by the hospital. This un-numbered policy states "A Social Services Assessment/Psychosocial History will be completed on all clients within 72 hours of admission not including weekends and holidays."

Per review on 1/14/15 at 11:00 AM, of facility policy numbered SOC-1308, titled "Social Services Assessment" dated 6/99 and revised 08/99. This document was signed by the Clinical Programs Director in 9/22/09 and SW Manger M on 10/20/09. SW M was asked to identify which policy was currently and officially in practice. SW M identified the unnumbered policy dated 10/13 as being the current policy and further added the current practice is for the Social Services Assessment to be completed within 72 hours or admission. SW M stated the policy dated 08/99, signed by SW M, "is old and not the current policy." SW M stated, SW M would be responsible for reviewing and updating the social worker polices but does not know the expected timeline for polices to be reviewed and updated. When asked why the policy dated 10/13 was not numbered and signed by Administration, SW M stated "I gave this to our previous administrator and I don't know why it was not given a number."

On 1/14/15 at 11:45 AM, Admin B presented a copy of a computer screen shot depicting that the"Social Services Assessment" without a number and dated 10/13 was created on 11/11/2013 (after the date it was suppose to be in effect) and "last modified "Yesterday (1/13/15) at 7:51 AM." Per Admin B, the policy dated 10/13 has never been presented to Admin B's knowledge to be adopted as official policy and the facility should be going by policy # SOC-1308 for reference to Social Services Assessments. Admin B stated SW M presented a falsified document.

Per interview on, 1/14/15 at 12:00 PM, with Admin Assistant X, the current policies in practice are tracked and kept by Admin Assistant X. Per Admin Assistant X, the policy presented by SW M (the un-numbered policy dated 10/13) has never been put officially into policy as there is no signatures or policy number assigned. Admin Assistant X has no evidence of ever seeing the document before today.

The above findings were shared with Interim GB L during interview on 1/15/15 at 2:30 PM.


The cumulative effect of these systemic problems is the result of an ineffective GB providing direct oversight and involvement in the hospital.

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Based on record review and interview, the facility failed to ensure there is an effective, on going QAPI program in 1 of 1 QAPI programs. This deficiency affects all patients being treated at this facility.

Findings include:

The hospital failed to ensure QAPI data is collected, analyzed and updated as part of an on-going, effective QAPI program; failed to ensure QAPI committees were on-going with appropriate staff present; and failed to ensure all departments and services are included in the QAPI program. (See Tag A 273)

The hospital failed to complete a RCA when an adverse event was identified and the GB directed the event be reviewed as an RCA. (See Tag A 286)

The hospital failed to ensure the GB has an on-going role in the QAPI program; and contracted services are evaluated as part of the QAPI program. (See Tag A 308)

The cumulative effect of these systemic problems results in the hospital's inability to provide safe patient care for it's patients with potential adverse outcomes.

Based on record review and interview, the facility failed to collect, analyze and update quality data to ensure an on-going, effective quality improvement program in 1 of 1 QAPI programs; failed to ensure QAPI committee meetings are held on an on-going basis with appropriate staff present in 1 of 1 QAPI committees; and failed to ensure all departments and services are included in the QAPI program in 8 of 8 (nursing, social services, housekeeping, maintenance, dietary, medical records, laboratory, pharmacy)departments/services. This deficiency affects all patients being treated at this facility.

Findings include:

Lack of QAPI Program:

Per review, on 1/15/15 at 11:30 AM of document titled "Quality Improvement Plan 2013" it states "4. Goal: The goal of the Community Treatment Center's Quality Improvement Structure is to integrate a system of measurement, outcome development and rapid cycle quality improvement to the Center operations. 5. Scope of the QI (Quality Improvement) Program: All departments and services provided by the facility will be included in quality improvement activities and will be included on the Quality Improvement Team... Meetings to be scheduled quarterly."

Review of document titled "Quality Improvement Action Plan", reviewed on 1/13/15 at 11:30 AM, revealed seventeen items have been identified under the section "quality improvement aim". There are no actions, goals, or follow up data indicated on the document.

Per review of document titled "Performance Improvement Action Plan", reviewed on 1/13/15 at 11:35 AM, seven "focus areas" were identified with target dates of Feb 2014. The document is left blank in the areas of "follow up status/date completed."

Per interview, with Admin B, on 1/13/15 at 11:25 AM, Admin B stated there is minimal quality data being collected at this time. There are many identified areas for improvement but no actions, goals or evaluations have been initiated. Admin B stated "I have lots of projects but I don't have time to work on them."

Lack of QAPI committee/meetings:

Per review of "Quality Assurance/Quality Improvement Committee" meeting minutes dated 8/27/14, the minutes do not list who was in attendance or which departments are represented at committee meeting.

Per interview, with Admin B, on 1/13/15 at 11:45 AM, there has not been a Quality meeting since August 2014. Per Admin B, Quality data is not reported to the Governing Body.

Lack of department/services Reporting QAPI data:

Per review on 1/15/15 at 12:30 PM of policy titled "Nursing Quality Assurance Activities and Data Flow" # ALL-333 dated 11/2011, it states "RN Manager/Charge Nurse submits Quality Assurance materials to the Quality Assurance/Quality Improvement Coordinator to review and compile monthly reports."

Per review on 1/15/15 at 12:40 PM of policy titled "Quality Assessment/Improvement Program" # SOC-1307 dated 6/08, it states "The Social Services Manager develops a Quality Improvement/Quality Assessment Plan which is submitted annually to the Brown County Mental Health Center Quality Assessment Coordinator. This plan becomes a component of the facility-wide Quality Improvement Assessment Program."

Per interview with Admin B on 1/15/15 at 2:10 PM, this facility does not have a Quality Assurance Improvement Coordinator at this time. The data referred to in policy # ALL-333 and SOC-1307 is not being collected. Per Admin B, all departments are not reporting Quality data at this time. Admin B confirmed nursing services, social services, housekeeping, maintenance, dietary, medical records, laboratory and pharmacy do not have quality improvement projects that are being reported to the QAPI program.

Based on record review and interview, the facility failed to complete a root cause analysis for an identified adverse event in 1 of 1 adverse events. This deficiency potentially affects all patients being treated at this facility.

Findings include:

Per interview with Admin B on 1/14/15 at 11:30 AM, the facility identified one event in the past 12 months that warranted an initiation of a root cause analysis. Per Admin B the event involved a patient that self harmed while in seclusion, resulting in the seclusion room needing special cleaning due to a large amount of blood and feces from the patient. Per Admin B, the incident also resulted in two staff members being injured along with a Brown County Police officer being injured in an attempt to help with the uncontrolled patient.

Per review on 1/15/15 of e-mail document dated 10/17/14 it states "After speaking to (Human Services Dir/GB N) yesterday we both agree that it would be a benefit to perform a root cause analysis of the situation with the client in NPC (Nicolet Psych Center). (SW Manager M) please work with (DON A) to coordinate this."

Per interview with Admin B on 1/15/15 at 3:00 PM, the facility does not have a policy on RCA. Per Admin B the facility would reference the document titled "Root Cause Analysis Incident Process" dated 9/25/2009.

Per interview with Admin B on 1/15/15 at 2:00 PM, when asked to review the root cause analysis documents, Admin B stated the root cause analysis was never completed.

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Based on record review and interview the facility failed to ensure the Governing Body had a role in the Quality Program planning and implementation in 1 of 1 QAPI programs; and failed to ensure contracted services are evaluation as part of the QAPI program in 1 of 1 QAPI programs. This deficiency affects all patients receiving treatment at this facility.

Findings include:

Lack of GB involvement:

On 1/12/15 at 3:40 PM, per review of Governing Body Bylaws, adopted November 17, 1998 and amended/revised on July 8th, 2014 signed by Clinical Director W, Admin B, and Former Human Services Director/Governing Body N, it delineates the Governing Body as the "Human Services Director."

Per interview, with Interim Human Services Dir L, on 1/15/15 at 2:30 PM, Interim Dir L stated no Quality or Infection Control data or communication has not been shared or reviewed between the hospital and the Interim Governing Body.

Per interview, with Admin B, on 1/13/15 at 11:45 AM, data is not reported to the Governing Body.

Lack of inclusion of contracted services in the QAPI program:

Per review on 1/13/15 at 11:45 AM of Quality Improvement Action Plans, noted the Quality data does not include any mention of contracted services.

Per interview with Admin B on 1/13/15 at 11:30 AM, review and oversight of contracted services are not a part of the Quality Program. Per Admin B, known issues related to contracted Pharmacy services have not been initiated as a formal part of the Quality program and no interventions have been put in place to analyze or evaluate the concerns.

Based on record review and interviews, the facility failed to individualize patient careplans in 30 of 30 (#1- #30) MR's reviewed; and failed to review, update and reflect Pt progress in 30 of 30 (#1-30) MRs reviewed. This deficiency affects all patients being treated at this facility.

Findings include:

Per review on 1/12/15 at 1:20 PM of facility policy # NPC-181 titled "Treatment Plan, Master Treatment Plan, and Treatment Plan Review" dated 12/2012, revised on 5/2013, it states "An individual treatment plan is initiated on admission for all patients, based on the patient's strengths, identified problems, diagnosis and disabilities... Each individual's Treatment Plan(s) will address short and/or long term goals, depending on the patent's anticipated length of stay and specific treatment modalities. Goals should be attainable and measurable. Treatment Plan Reviews will be completed a minimum of every seven days. As changes occur in the patient's condition, or if progress is made or goals attained, the Treatment Plan should be updated to reflect changes in the patients status. Documentation ... should include the patient's progress or lack of progress toward his/her goal(s)."

Per Nursing policy reviewed on 1/12/15 at 1:00 PM#NPC-122 effective 6/1986, revised 5/2013 states: "It is the policy of the Nicolet Psychiatric Center to provide for comprehensive and individualized treatment planning for clients. Procedure: A) Integrated Care Planning shall begin upon admission to the Nicolet Psychiatric Center and will continue throughout the client stay. A-1) The RN will initiate the ICP (integrated care plan) upon admission based on data from the admission assessment. Long-term and short-term goals will be initiated. A-2a) Staff involved will usually include the Psychiatrist, RN and Social Worker, 3-b) The treatment goals and client objectives will be reviewed, Approaches/interventions for each discipline will be included, 3-c) Discharge planning will be addressed."

Per review of facility policy #NPC-144 received on 01/12/2015 at 1:00 PM, states: "#2) Documentation of nursing care shall be pertinent and concise and shall describe the client's needs, problems, capabilities, and limitations. Nursing interventions and client responses shall be noted; #3-b) Evaluate the client objectives Integrated Care Plan including response in relation to progress/lack of progress toward objectives...; #3-d) Client responses to interventions. Policy #NPC-122 states #3-b) treatment goals and client objectives will be reviewed. Approaches/interventions for each discipline will be included. #3-c) Discharge planning will be included."

Per interview 01/12/15 at 1:00 PM, DON A states, "the initial care plan on admission process is broken, they are diagnosis related and are basic medical care plans, after rounds, all disciplines should be putting in their own care plans". DON A also stated, "Social services meets with the clients, yet there is no social services input involved in the care plans".

Per interview with DON A on 1/13/15 at 9:35 AM, DON A stated patients average length of stay is three to four days and are not in the hospital long enough for long term goal. DON A stated long term goals should be community based or outpatient based goals for follow up after discharge.

Per interview with DON A on 1/12/15 at 3:00 PM, DON A stated "careplans are canned and not individualized" and "currently do not address problems or goals." Per DON A, the expectation would be for careplans to be updated with any changes or as needed.

Per interview with Admin B on 1/14/15 at 11:00 AM, Admin B stated staff have the capabilities to individual careplans but are just using "canned" careplans. Individualization is not being done.

Per interview with Admin B on 1/20/15 at 12:30 PM, average length of stay is four days. Per policy #NPC-181, (above) the treatment plans are to be reviewed a minimum of every seven days while the average length of stay is only four days. Admin B stated review of the treatment plans every seven days is inadequate.


34338


Per review of MR's for patients #1-30 on 1/12/15 between 12:00 PM and 5:00 PM, 1/13/15 between 8:00 AM and 5:00 PM, and 1/15/15 between 8:00 AM and 11:00 AM, medical records for patients #1-30 do not contain Individualized Treatment Plans (ITP) based on the patent's identified problems and diagnosis. ITP's do not contain interventions specific to each patient and do not identify specific treatment modalities for each patient. ITP's do not contain long term goals. Short term goals are identified in all 30 MR's as "client will cooperate with the admission process, be monitored closely by staff, and remain free from harm to self and others." Goals are not individuated to each patients needs and are not measurable. ITP's do not contain documentation of goals being attained or updated to reflect progress or changes in the patients status.

Based on interviews (B and K) , the facility failed to ensure all entries in Individualized Treatment Plans are a permanent part of the patients medical record in 1 of 1 Treatment Plan Programs used by the facility (Avatar). This deficiency affects all patients being treated at this facility including the 30 MR reviewed as part of this survey.

Findings include:

Per interview with Admin B and EMR Coordinator K on 1/14/15 at 11:10 AM, EMR Coordinator K stated entries in Avatar (facilities current EMR system) are not locked in the care plan module. EMR Coordinator K stated "Avatar allows staff to click on a line in the careplan, erase the content and retype." Per EMR Coordinator K, the Avatar System does not tract the time and date of each entry in the careplan and does not keep an accurate record of changes made to care plans in the medical record. Per Admin B, the record is not considered secure as staff can go in and change the record without the program noting it was changed. The facility is aware of the problem and have been working with the software company for months in an attempt to fix the problem. No safeguards have been put in place as back up until the problem can be fixed leaving the medical record unsecured in the care planing module.

Based on record review and interview, the facility failed to ensure social service assessments are completed and available to staff caring for the patients in a timely manner in 10 of 30 (#3, 5, 9, 21, 23, 24, 25, 28, 29, 30) MR's reviewed. This deficiency potentially affects all patients being treated at this facility.

Findings include:

Per review on 1/14/15 at 9:40 AM, of facility policy # SOC-1308 titled "Social Services Assessment" dated 6/99, revised 8/09, it states "A Social Services Assessment/Psychosocial History will be completed on all clients within 48 hours of admission not including weekends or holidays."

Per review of Pt # 3's MR on 1/14/15 at 8:00 AM, Pt # 3 was admitted on 7/5/14. The MR contained a social service assessment which was not entered into the MR until 7/15/14. This was verified with EMR coordinator K on 1/14/15 at 10:30 AM.

Per review of Pt # 5's MR on 1/14/15 at 8:30 AM, Pt # 5 was admitted on 1/8/15. The MR contained a social service assessment which was not entered into the MR until 1/13/15. This was verified with EMR coordinator K on 1/14/15 at 10:30 AM.

Per review of Pt # 9's MR on 1/14/15 at 10:15 AM. Pt # 9 was admitted on 1/4/15. The MR does not contain a social service assessment. This was verified with EMR coordinator K on 1/14/15 at 10:30 AM.


20878


The following MRs were reviewed on 1/13/15 between 9:00 AM and 3:00 PM.

Patient #21 was admitted on 11/13/14, the medical record contained a social service assessment which was entered on 11/24/14.

Patient #23 was admitted on 01/08/15, the medical record contained a social service assessment which was entered on 01/12/15.

Patient #24 was admitted on 11/23/14, the medical record contained a social service assessment which was entered on 12/30/14.

Patient #25 was admitted on 12/04/14, the medical record contained a social service assessment which was entered on 12/17/14.

Patient #28 was admitted on 12/10/14, the medical record contained a social service assessment which was entered on 12/26/14.

Patient #29 was admitted on 12/18/14, the medical record contained a social service assessment which was entered on 12/22/14.

Patient #30 was admitted on 12/29/14, the medical record contained a social service assessment which was entered on 01/09/15.

The preceding assessments were reviewed with Administrator B on 01/14/15 at 9:00 AM. B stated that the assessments should be entered in the medical record within 72 hours of admission.

Per interview with Admin B on 1/14/15 at 11:00 AM, Social Workers dictate notes and there is a lag time between when the assessment occurs and when the dictated assessment is available on the patients chart.

Based on record review and interview, the facility failed to ensure H&Ps done within 24 hours of admission per facility policy and part of the Pt's MR in 8 of 30 MRs reviewed (# 3, 4, 5, 11, 12, 18, 19, 20). This deficiency potentially affects all patients being treated at this facility.

Findings include:

Per review on 1/12/15 at 10:45 AM, facility policy titled "Psychiatric Clients with Medical Conditions" # MED-213 dated 4/91 and revised on 2/2012 states "Medical Director/designee will perform physical examination within 24 hours of admission."

Per review on 1/14/15 at 8:30 AM, Pt #5's MR does not contain an H&P. Per EMR Coordinator K, at the time of discovery, "if it is not there it is not done."

Per review on 1/12/15 at 3:30 PM, Pt #3's MR does not contain an H&P. EMR Coordinator K confirmed that Pt # 3's MR does not contain an H&P.

Per review on 1/14/15 at 8:00 AM, Pt #4's MR does not contain an H&P. EMR Coordinator K confirmed that Pt #3's MR does not contain an H&P.


34338

Medical record chart review on 01/12/2015 between 9:30 AM and 9:30 PM, revealed the following H&Ps not on the chart within the 24 hour requirement. Pt #11 (53.5 hours), Pt #12 (26 hours), Pt #18 (31 hours), Pt #19 (25 hours) and Pt #20's MR did not contain an H&P.

Per interview on 1/14/15 at 9:00 AM, EMR coordinator stated H&Ps should be on all charts within 24 hours.

Based on record review and interview it was determined that the hospital failed to have an effective and safe pharmacy practice in 1 of 1 pharmacy services.

Findings include:

The hospital failed to ensure that a pharmacist maintain overall responsibility for the pharmacy service, including development, supervision, and coordination of all pharmacy services. (See Tag A-492)

The hospital failed to ensure that a drug formulary with P&P for it's use is established and approved by the medical staff. (See Tag A-511)

The cumulative effect of these systemic pharmacy problems can lead to unsafe dispensing, storage, administration, control and disposal of medications within the facility and result in the facility's inability to ensure patient safety.

Based record review and interview, the facility failed to ensure that a pharmacist maintained overall responsibility for the pharmacy service, including development, supervision and coordination of all activities of the hospital wide pharmacy service. This deficiency can lead to unsafe storage, use, administration, control and disposal of medications within the facility. This deficiency has the potential to affect all patients served at the facility.

Findings include:

During 1/12/15 through 1/14/15 reviewed multiple e-mail communications referring to the hospital having numerous difficulties in the provision of pharmacy services through the hospital's contracted pharmacy and consultant pharmacist:

-An e-mail dated 09/24/14 from the contracted pharmacy manager identifies problems with medication reconciliation and the possible use of a dispensing machine. The e-mail reads; "This new system is not working, missing 136 items, many controlled. I am not sure how to attack this now. If we don't make drastic changes soon, I am afraid of the trouble we could be in with the authorities. In fact, we may need to self report soon. I will be talking to owners to see what we need on our end, and if they have any ideas. We are also working diligently on a proposal for a dispensing machine."

- An e-mail dated 09/25/14 from the Executive Director (also the hospital's GB) N to Admin B, indicates N was notified of pharmacy issues related to tracking and dispensing of medications. The e-mail reads; "Thanks for keeping me appraised. Please let me know when the team has isolated the issue and changed the process to eliminate it. At this point, it appears to me to be a counting/tracking issue rather than a theft/diversion issue. Based on information available to you ,would you agree?"

-An e-mail dated 09/25/14 from the contracted pharmacy manager mentions problems with medication reconciliation related to incomplete documentation by hospital nursing staff and the pharmacy's claim of medication diversion. "I agree, that something may have been wrong at initial count or something. That is why I want (pharmacy tech) there sooner rather than later."

- An e-mail dated 09/26/14 from Executive Director N, indicates N was agreeable to the use of a dispensing system (i.e. Pyxis); "I don't need to be actively involved with the process, but would like to discuss the decisions with at least Administrator (B) before a final decision is reached since it becomes a financial/contracts issue at that point."

-At the time of the survey (4 months after first communication regarding pharmacy issues), the facility has not changed their medication delivery system to a dispensing system such as Pyxis or make any other changes to eliminate medication dispensing and tracking problems.


32670


Per interview with DON A on 1/13/15 at 9:40 AM, DON A stated the pharmacy issues have been tracked since July 2014. Review of document, during the time of the interview, titled "Pharmacy Issues" present by DON A states the following issues (summarized):
1) Contingency mediations depleted and not being refilled on time. Pharmacy "not wanting to be bothered on a holiday"
2) Poor tracking system of supply of mediations about to run out
3) Mediations not being delivered on time or not ordered at all. Pharmacy claims not all mediations are stocked by the pharmacy and some may take several days to be made available.
4) Lack of communication by the pharmacy to the hospital staff when mediations are not available and an alternate may need to be ordered by the physician.
5) Delivery system of mediation inadequate and time consuming.
6) Communication issues between the pharmacy and the physicians and NP's relating to how orders are written, with a constant need for order verification.
7) Cost effectiveness issues related to refill authorizations and staff time spent verifying and authorizing refill forms.
8) Narcotic tracking, delivery and storage issues related to multiple narcotics being sent to site when not needed.
9) Over the counter mediations not stocked on site
10) Mediations being delivered late due to multiple requests for delivery.

Per interview with Admin B on 1/14/15 at 10:00 AM, stated the pharmacy is a small local business that mostly supplies nursing homes and is not equipped to handle an acute care hospital. The pharmacy is not on-site of the hospital and relies on mediation to be delivered. The pharmacy does not employ enough transport drivers to make timely deliveries. The pharmacy is not holding up to their contract and can not meet the needs of the hospital. Discussion has occurred regarding the purchase of a medication expensing system within the hospital but the pharmacy agreed they would use the system but would not provide it. The facility has discussed options for purchasing the system. The GB is aware of pharmacy issues but no approval for changes in service or dispensing options have been made.

Per interview with DON A on 1/21/15 at 10:50 AM, the facility does not track medication being given late on an incident report.

Based record review and interview, the hospital failed to ensure that a drug formulary with P&P for it's use is established and approved by the medical staff in 1 of 1 pharmacy services. This deficiency does not ensure the quality and safe dispensing and administration of drugs to patients in this facility.

Findings include:

Per interview with Administrator B on 01/14/15 at 09:50 AM, the hospital medical staff has not established a drug formulary. Per B, there is a list of the drugs that are kept in the nursing medication room, but this list was not established by the medical staff. Per (A).

Minute notes from the Psychiatric/Medical Staff Committee Meeting held on 11/11/2014 state; "The pharmacy bill for the hospital and the expenses we are paying are quite significant. Trying to develop a formulary."

Based on observation, staff interview and review of maintenance records on 1/12/2015, the facility failed to construct, install, and maintain the building systems due to the citations identified below. Reference the specific citations regardng specific findings.

The cumulative effect of these environment problems resulted in the hospital's inability to ensure a safe environment for the patients.

Refer to K-11, K-18, K-29, K-56, K-62, K-147 and A-710 tags for detail.

Based on observation, staff interview and review of maintenance records on 1/12/2015, the facility failed to construct, install, and maintain the building systems due to the citations identified below. Reference the specific citations regardng specific findings.

The cumulative effect of these environment problems resulted in the hospital's inability to ensure a safe environment for the patients.

Refer to K-11, K-18, K-29, K-56, K-62, K-147 and A-710 tags for detail.

Based on interviews (H and A), this facility failed to provide a qualified individual to perform as a designated infection control nurse/officer in 1 of 1 hospital infection control programs. This deficiency potentially affects all patients receiving treatment at this facility.

Findings include:

Per interview of Nurse Educator H on 01/12/2015 at 11:05 AM, when asked about qualifying credentials to be designated Infection control nurse, Nurse Educator H responded, "I worked here as an RN on a casual basis covering infection control until a full time position became available. I now work here as a full time nurse educator and also cover infection control". Staff H also stated, "I now have my ADN (associates degree nurse) credential and my estimated bachelors degree completion should be 07/2015". When asked about specific infection control training or certification, Staff H responded, "I have no specialized training in infection control, I work with the hospital DON (Director of Nursing) Staff A on projects".

Per interview with DON A and Nurse Educator H on 01/12/2015 at 11:40 AM, DON A verified that the facility did not have a designated infection control nurse/officer.

Based on record review and interview, this facility failed to track required infection control surveillance data evidenced by lack of continued, dated documentation in 1 of 1 infection control programs. This deficient practice has the potential to affect all patients being treated at this facility.

Findings include:

Per record review of Community Treatment Center Monthly Quality Assurance infection control tracking data, provided by DON A on 01/12/2015 at 12:55 PM, found active surveillance documentation beginning September through December (no year evident on the document). Per interview with DON at at the time of record review, there is no prior documentation available.

Per record review of Laboratory Department Bacteria Monitoring document, provided by DON A on 01/12/2015 at 12:55 PM, in the year 2014 bacteria monitoring is documented by Lab for the months of January/February/March. Per DON A, no further documentation is available for the months of April through December 2014.


32670

Per interview, with Interim Human Services Dir L, on 1/15/15 at 2:30 PM, Interim Dir L stated Infection Control data or communication has not been shared or reviewed between the hospital and the Interim Governing Body.

Per interview, with Admin B, on 1/13/15 at 11:25 AM, Admin B stated Infection Control data is not part of the QAPI program at this time.

Based on record reviews and interviews, the facility failed to provide ongoing discharge planning in 30 of 30 (#1-30) MR's reviewed; and failed to provide adequate social service/discharge planning staff coverage on evening and weekends in 1 of 1 social services/discharge planning programs. This deficient practice affects all patients being treated at this facility as evidenced by re-admission rates.

Findings include:

The facility failed to provide adequate discharge planning. (See Tag 806)

The facility failed to provide adequate social services/discharge planning coverage on evening and weekends, which in turn delayed discharge planning. (See Tag 806)


The cumulative effect of these systemic problems results in the facility's inability to provide adequate discharge planning with outcomes of increased re-admission rates.

Based on record reviews and interviews, the facility failed to document Discharge planning including discussing the plan with the patient, reassessing the discharge plan, and counseling the patient to prepare them for post-discharge care on an ongoing and timely basis in 30 of 30 (#1-30) MR's reviewed. This deficient practice affects all patients being treated at this facility.

Findings include:

Lack of discharge planning:

Per review on 1/13/15 at 1:45 PM, of facility policy titled "Discharge Planning and Discharge Procedure" Policy # NPC-19, dated 08/1986, revised on 5/2013, it states "Discharge planning shall begin at the time of admission. A written discharge plan will be formulated by the social worker... 4. Planning for discharge will include continuing care needs, activity/restrictions, diet modifications, medications, treatments, follow up care, community placement/housing, education, and client and family education... An initial discharge plan is identified on the Integrated Treatment Plan upon admission by the RN. This plan is explained by the treatment team... The discharge planning is revised /updated as evaluation of client progress in treatment occurs."

Per review of MR's for patients #1-30 on 1/12/15 between 12:00 PM and 5:00 PM, 1/13/15 between 8:00 AM and 5:00 PM, and 1/15/15 between 8:00 AM and 11:00 AM, there is no evidence in the MR of documented discharge planning beginning on admission and continuing throughout the patients stay until discharge for Pt's #1-30.

Per interview with DON A, on 1/13/15 at 1:50 PM, the discharge plan should be noted on the ITP starting with admission and updated as the patient progress toward discharge. DON A stated any subsequent notes related to discharge planning would currently be put into the progress notes. DON A stated the facility has identified a lack of discharge planning and is looking at making changes.


Lack of social workers on evening and weekends:

Per review on 1/14/15 at 11:00 AM, of facility policy titled "Multidisciplinary Collaboration" # NPC-128, dated 9/1992 and revised on 5/2013, it states under Social Services/Social Worker, "identifies the need for individual and group programming during client stay. Provides 1:1 counseling with the client. Provides counseling to family members and/or significant others. Coordinates appropriate discharge planning in collaboration with the psychiatrist, medial doctor, RN staff, and referral agencies. Assists the client in pursuing and obtaining the resources to maintain community living especially in regard to financial resources."

Per interview with DON A, on 1/13/15 at 1:50 PM, DON A stated the facility has identified a lack of discharge planning and is looking at making changes. Per DON A the facility does not employee SW staff on the evenings or the weekends. At this time any patient admitted between Friday afternoon and Monday morning would not get a social services assessment or a discharge plan evaluation initiated until Monday. There are no social workers on call during off hours and no staff trained as discharge planners on site during off hours or weekends. Per DON A, the average length of stay is 3-4 days and at this time patients admitted on the weekends get a social services assessment at the time of discharge, which is most often on Monday morning.

Per interview with Admin B, on 1/13/15 at 3:35 PM, the facility has been working on making changes to the scheduled hours and coverage of the social work staff. Per Admin A there has been a significant amount of resistance which is being addressed and no changes have been put into place yet. The target date for the changes in social worker coverage was July 2014, with a date for increased coverage to begin on August 1, 2014. Admin A stated "we didn't meet our goal."

Per interview with Admin B on, 1/20/15 at 12:40 PM, the facility 30 day readmission rate for 2014 was 92 patients. This facility has a average daily census of 10 patients and Admin B stated their re-admission rates are high.

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

l. Develop and document comprehensive multidisciplinary treatment plans based on the individualized needs of patients for one (1) of eight (8) active sample patients (Patient G5). Specifically the facility failed to ensure that the treatment goals and interventions documented on the Master Treatment Plan (MTP) addressed the identified needs of Patient G5. Failure to individualize treatment plans can prevent patients from progressing in treatment and fail to give staff guidance for addressing specific patient problems which can result in unmet needs and potentially longer lengths of hospitalization. (See B118)

ll. Provide active treatment including alternative interventions for three (3) of eight (8) active sample patients (G5, G6 and G7). All of the patients were unwilling to attend many of their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement. (See B125-l)

lll. Provide therapeutic groups that regularly occurred as scheduled and when offered had patients who were assigned in attendance. This failure leads to limited opportunities for patients to work on individual issues leading to hospitalization and hinders progress toward recovery and discharge. (See B125-ll)

lV. Provide individualized active treatment for eight (8) of eight (8) sample patients (G1, G2, G3, G4, G5, G6, G7, and G8) on evenings and weekends. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion potentially delaying improvement and discharge. (See B125-lll)

Based on medical record review and interview, the facility failed to provide social work assessments that met professional social work standards, including: 1) a description of patient strengths and deficits; and 2) conclusions and recommendations that described anticipated social work roles in treatment and discharge planning. This resulted in a lack of professional social work assessments and recommendations to be utilized in the design of treatment services for five (5) of eight (8) active sample patients (G3, G4, G5, G6 and G7).

Findings Include:

Medical Record Review

Social Service Assessments For Patient G3 dated 12/08/14; Patient G4 dated 12/08/14; Patient G5 dated 11/20/14; Patient G6 dated 12/08/14, and Patient G7 dated 12/08/14 did not contain a description of patient's strengths, an assessment of information that could be used in formulation of patient's treatment plan and lacked recommendations that described the anticipated social work roles in treatment and discharge planning.

Interview

1. In an interview on 12/09/14 at 2:30 PM the Hospital Administrator and RN4 (Registered Nurse) concurred that social service assessments failed to list assessments and recommendations for treatment planning and interventions appropriate to the needs of the patients.

Based on record review and interview, the facility failed to develop and document comprehensive multidisciplinary treatment plans based on the individualized needs of patients for one (1) of eight (8) active sample patients (Patient G5). Specifically the facility failed to ensure that the treatment goals and interventions documented on the MTP addressed the identified needs of Patient G5. Failure to individualize treatment plans can prevent patients from progressing in treatment and fail to give staff guidance for addressing specific patient problems which can result in unmet needs and potentially longer lengths of hospitalization.

Findings include:

A. Record Review

1. Patient G5 was admitted on 11/19/14. The Psychiatric Evaluation dated 11/20/14 documented the diagnosis, "Schizophrenia, paranoid type, in acute exacerbation." The evaluator described the patient as "mute" and "appearing to attend to internal stimuli." S/he was further described as "...acutely psychotic, unable to care for basic needs at this point in time, and is quite vulnerable."

2. Review of Progress Notes from 11/19/14-12/8/14 revealed that Patient G5 had great difficulty sleeping, ate small amounts of food, paced the unit, was non-verbal much of the time, did not shower without assistance, had difficulty carrying out activities of daily living and refused to go to groups.

3. The MTP dated 12/09/14 (review) listed only two (2) short-term goals, "Client will verbalize understanding that delusions are a part of their illness" and "Client will demonstrate the ability to communicate [his/her] thoughts through participation in structured OT/RT groups." The treatment plan had not been modified since the Initial Treatment Plan was written by the RN on the day of admission. Problems identified in the Progress Notes were not addressed on the Treatment Plan as of 12/10/14.

B. Observation

1. On 12/8/14 at 11:15AM, when Patient G5 was asked to talk with the surveyor, stated "Everything is all safe." Patient G5 walked away and did not meet with the surveyor.

2. During observation on the unit on 12/8/14 at 12:30 PM, Patient G5 was observed leaving the Coping Skills Group after less than 15 minutes and sitting at a table by him/herself. From 2:15 PM-2:30 PM on 12/8/14, Patient G5 was observed sitting on the unit in the dayroom reading the paper (Skill Building Group in process). During observation on the unit on 12/9/14 at 8:30 AM, Patient G5 was observed talking on the phone while a scheduled Goals Group was in progress. Review of the Master Treatment Plan dated 12/8/14 revealed that Patient G5's failure to attend groups had not been addressed by the treatment team.

C. Interview

During interview on 12/10/14 at 8:30 AM, RN4 acknowledged that the Treatment Plan had not been modified since admission on 11/19/14 and failed to address the identified needs of Patient G5 (Insomnia, poor appetite, poor hygiene and lack of attendance at groups).

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active patients. (G1, G2, G3, G4, G5, G6, G7 and G8) Lack of measurable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs.

Findings Include:

Medical Record Review
1. Patient G1 admitted 12/07/14 with a diagnosis of Bipolar Disorder with Psychosis had listed on MTP [Master Treatment Plan] dated 12/07/14 for the problem, "Leaving residence without clothing, hypersexual, scratching at self, crying, yelling out name of family who are not present, disoriented to person, time, place, and situation", the following Short-Term Goal [STG]: "Client will recognize benefits of medication" and a Long-Term Goal [LTG] "Client will sustain concentration, and attention to complete tasks and function independently. Client will be able to verbalize the need for medication compliance after discharge."

2. Client G2 admitted 12/05/14 with a diagnosis of "Mood Disorder, not otherwise specified" and "Anxiety disorder not otherwise specified" had listed on MTP dated 12/05/14 for the problem, "Suicidal ideation Related To Marital issues, wife is pregnant, upset over holidays as evidenced by: Overdosing on prescription Seroquel", the following STG: "Client will verbalize no ideas of self-harm for two days prior to discharge on the unit".

3. Patient G3 admitted 12/06/14 with a diagnosis of "Schizoaffective Disorder" had listed on MTP dated 12/05/14 for the problem, "Paranoia....as evidenced by: Decreased sleep and statements consisting of beliefs that a murderer was in his/her room/home, fearful of the dark", the following STG: "Client will cooperate with the admission process, be monitored closely by all staff, and remain free from harm to self or others" and "Client will take scheduled and PRN medication as ordered by the psychiatrist."

4. Patient G4 admitted 12/05/14 with a diagnosis of "Schizoaffective disorder in acute exacerbation" and "Alcohol dependence, in remission" had listed on the MTP dated 12/05/14 for the problem, "Suicidal Risk Related to: Hearing voices, states [he/she] wants to get on disability as evidenced by: Overdosed on Tylenol and ibuprofen", the following STG: "Pt. will report a decrease in frequency of responding to the voices and improve overall affect and mood."

5. Patient G5 admitted on 11/19/14 with diagnosis of "Schizophrenia, Paranoid Type" had listed on the MTP review dated 12/9/14 for the problem, "Delusional Thought Process as evidenced by: Bizarre behaviors, catatonic state", the following STG "Client will verbalize understanding that delusions are a part of their illness."

6. Patient G6 admitted on 12/5/14 with a diagnosis of Schizoaffective Disorder had listed on the MTP dated 12/8/14 for the problem, "Depression Related to: unknown as evidenced By: not eating, flat affect", the following STG: "Client will cooperate with the admission process, be monitored closely by all staff, and remain free from harm to self or others."
For the problem "Alteration in thought process related to experiencing delusions, evidenced by believing people are breaking in (his/her) apartment and (his/her) food being poisoned", the following STG: "Pt will decrease in (his/her) delusional thinking and become more aware of reality."

7. Patient G7 admitted on 12/6/14 with a diagnosis of "Major Depression and Alcohol Dependence" had listed on the MTP dated 12/8/14 for the problem, "alteration in mood related to Major Depression as evidenced by suicidal statements at crisis due to a current divorce and unemployment", the following STG: "Client will cooperate with the admission process, be monitored closely by all staff, and remain free from harm to self or others" and "client will be of self-harm and identify source of suicidal ideation."

8. Patient G8 was admitted on 12/4/14 with a diagnosis of "Major Depression, Recurrent with Psychotic Features and Anxiety Disorder NOS" had listed on the MTP dated 12/8/14 for the problem, "Alteration in thought process related to major depression with psychotic symptoms as evidenced by intentional overdose on Vicodin, cutting behaviors", the following STG: "Client will cooperate with the admission process, be monitored closely by all staff, and remain free from harm to self or others."

Interview

1. In an interview on 12/09/14 at 1:15 PM the director of social work concurred that goals noted on the treatment plans were not observable, behavioral, and measurable.

2. In an interview on 12/09/14 at 2:30 PM the Hospital Administrator and RN4 concurred that goals noted on the treatment plans were not observable, behavioral, and measurable.

3. In an interview on 12/09/14 at 11:30 AM the medical director did not dispute the findings of goals on treatment plans not being observable, behavioral and measurable.

Based on record review and interview, the facility failed to identify in the MTP specific treatment interventions/modalities to address the identified patient problems for eight (8) of eight (8) active sample patients (G1, G2, G3, G4, G5, G6, G7 and G8). The treatment interventions were stated in vague terms and were non-individualized generic discipline functions rather than directed at specific interventions. This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients.

Findings Include:

Medical Record Review

1. Patient G1 admitted 12/07/14 with a diagnosis of Bipolar Disorder with Psychosis had listed on MTP dated 12/07/14 for the problem, "Leaving residence without clothing, hypersexual, scratching at self, crying, yelling out name of family who are not present, disoriented to person, time, place, and situation", the following STG: "Client will recognize benefits of medication" and a Long Term Goal [LTG] "Client will sustain concentration, and attention to complete tasks and function independently. Client will be able to verbalize the need for medication compliance after discharge."

Treatment intervention listed were: "The Psychiatrist will meet with the client for an initial Psychiatric Evaluation within 60 hours of admission and discuss treatment recommendations" and "RN will evaluate effectiveness and side effects of medications."

2. Client G2 admitted 12/05/14 with a diagnosis of "Mood Disorder, not otherwise specified" and "Anxiety disorder not otherwise specified" had listed on MTP dated 12/05/14 for the problem, "Suicidal ideation Related To Marital issues, wife is pregnant, upset over holidays as evidenced by: Overdosing on prescription Seroquel" the following STG: "Client will verbalize no ideas of self-harm for two days prior to discharge on the unit."

Treatment interventions listed were: "The Psychiatrist will meet with the client and an initial Psychiatric Evaluation within 60 hours of admission and discuss treatment recommendations" and "RN will obtain verbal no self-harm contract from client upon admission."

3. Patient G3 admitted 12/06/14 with a diagnosis of "Schizoaffective Disorder" had listed on MTP dated 12/05/14 for the problem, "Paranoia....as evidenced by: Decreased sleep and statements consisting of beliefs that a murderer was in his/her room/home, fearful of the dark", the following STG: "Client will cooperate with the admission process, be monitored closely by all staff, and remain free from harm to self or others" and "Client will take scheduled and PRN medication as ordered by the psychiatrist."

Treatment interventions listed were: "The Psychiatrist will meet with the client and an initial Psychiatric Evaluation within 60 hours of admission and discuss treatment recommendations" and "RN will obtain verbal no self-harm contract from client upon admission."

4. Patient G4 admitted 12/05/14 with a diagnosis of "Schizoaffective disorder in acute exacerbation" and "Alcohol dependence, in remission" had listed on the MTP dated 12/05/14 for the problem, "Suicidal Risk Related to: Hearing voices, states [he/she] wants to get on disability as evidenced by: Overdosed on Tylenol and ibuprofen", the following STG: "Pt will report a decrease in frequency of responding to the voices and improve overall affect and mood."

Treatment Interventions listed were: "The Psychiatrist will meet with the client and an initial Psychiatric Evaluation within 60 hours of admission and discuss treatment recommendations" and "RN will obtain verbal no self-harm contract from client upon admission."

5. Patient G5 admitted on 11/19/14 with diagnosis of "Schizophrenia, Paranoid Type" had listed on the MTP review dated 12/9/14 for the problem, "Delusional Thought Process as Evidenced By: Bizarre behaviors, catatonic state", the following STG: "Client will verbalize understanding that delusions are a part of their illness."

Treatment interventions listed were: "RN will assess client for the need for PRN medication as well as administer scheduled medication as ordered by the psychiatrist"; "SW (Social Worker) will elicit family support for best approaches" and "Staff will encourage non-pharmacological interventions such as writing emphasizing the need for communication, relaxation techniques."

6. Patient G6 admitted on 12/5/14 with a diagnosis of Schizoaffective Disorder had listed on the MTP dated 12/8/14 for the problem, "Depression Related to: unknown as evidenced by: not eating, flat affect", the following STG: "Client will cooperate with the admission process, be monitored closely by all staff, and remain free from harm to self or others." For the problem "Alteration in thought process related to experiencing delusions, evidenced by believing people are breaking in [his/her] apartment and [his/her] food being poisoned", the following STG: "Pt will decrease in [his/her] delusional thinking and become more aware of reality."

Treatment interventions listed were: "The Psychiatrist will meet with the client for an initial Psychiatric Evaluation within 60 hours of admission and discuss treatment recommendations"; RN will maintain client on 15 minute checks unless otherwise indicated by the psychiatrist"; "RN and CNA (Certified Nursing Assistant) will encourage client to express feelings verbally and in writing" and "All Staff working with client will provide positive support which can reinforce the client's healthy expression of feelings, realistic plans and responsible behaviors."

7. Patient G7 admitted on 12/6/14 with a diagnosis of "Major Depression and Alcohol Dependence" had listed on the MTP dated 12/8/14 for the problem, "alteration in mood related to Major Depression as evidenced by suicidal statements at crisis due to a current divorce and unemployment", the following STG: "Client will cooperate with the admission process, be monitored closely by all staff, and remain free from harm to self or others" and "client will be free of self-harm and identify source of suicidal ideation."

Treatment interventions listed were: "COTA (Certified Occupational Therapy Assistant) will conduct an initial Activity Therapy Assessment"; "The Psychiatrist will meet with the client for an Initial Psychiatric Evaluation within 60 hours of admission and discuss treatment recommendations" and "SW will participate in the initial psychiatric evaluation when possible and obtain appropriate collateral if available."

8. Patient G8 was admitted on 12/4/14 with a diagnosis of "Major Depression, Recurrent with Psychotic Features and Anxiety Disorder NOS" had listed on the MTP dated 12/8/14 for the problem, "Alteration in thought process related to major depression with psychotic symptoms as evidenced by intentional overdose on Vicodin, cutting behaviors", the following STG: "Client will cooperate with the admission process, be monitored closely by all staff, and remain free from harm to self or others."

Treatment interventions include: "COTA will conduct an initial Activity Therapy Assessment"; "The Psychiatrist will meet with the client for an Initial Psychiatric Evaluation within 60 hours of admission and discuss treatment recommendations" and "SW will participate in the initial psychiatric evaluation when possible and obtain appropriate collateral if available."

Interview

1. In an interview on 12/09/14 at 11:30 AM, the medical director upon hearing the evaluation of interventions being generic, discipline functions and not specific to patient problems and goals did not dispute the surveyor's findings.

2. In an interview on 12/09/14 at 1:15 PM, the director of social work concurred that treatment interventions were generic and not specific to patient problems.

3. In an interview on 12/09/14 at 2:30 PM, the Hospital Administrator and RN4 concurred that treatment interventions were generic discipline functions and not specific to patient's individualized goals.

Based on record review and interview, the hospital failed to identify by name and discipline of the team member responsible for the modalities selected for four (4) of eight (8) active patients. (G2, G4, G5 and G6) The treatment plans listed only the treatment modalities and did not identify the specific names and disciplines of those staff members responsible for those treatment modalities. This has the potential to create a lack of ability to determine which staff member is responsible for ensuring compliance with the various aspects of treatment.

Findings Include:

1. Patient G2's MTP dated 12/05/14 for the following STG: "Client will verbalize no ideas of self-harm for two (2) days prior to discharge on the unit", listed the following interventions without identifying a specific staff member by name and/or discipline.

Interventions: "Staff will monitor medications for effectiveness of psychotropic drugs to address target behaviors" and "Encourage the use of non-pharmacological interventions such as writing, drawing, diversion tactics, and relaxation techniques."

2. Patient G4 had listed on the MTP dated 12/05/14 for the following STG: "Pt will report a decrease in frequency of responding to the voices and improve overall affect and mood", the following interventions without identifying a specific staff member by name and/or discipline.

Interventions: "Encourage use of non-pharmacological interventions such as self-talk and coping skills in distracting from the voices" and "All staff will encouraged [sic] attendance in individually [sic] and group therapy."

3. Patient G5's MTP review dated 12/9/14 for the STG, "Client will verbalize understanding that delusions are a part of their illness", listed the following interventions without identifying a specific staff by name and/or discipline.

Intervention: "Staff will encourage non-pharmacological interventions such as writing, emphasizing the need for communication, relaxation techniques."

4. Patient G6's MTP dated 12/8/14 for the STG, "Pt will decrease in (his/her) delusional thinking and become more aware of reality", listed the following interventions without identifying a specific staff by name and/or discipline.

Interventions: "All Staff will meet with pt and process pt's understanding of reality, monitoring for a decrease in delusions" and "will encourage use of non-pharmacological interventions, such as using self-talk and exploring what is real and what is a delusion."

Interviews:

1. In an interview on 12/09/14 at 11:30 AM, the medical director upon hearing staff responsibilities were not consistently identified by name and discipline on the MTP's did not dispute the surveyor's findings.

2. In an interview on 12/09/14 at 1:15 PM the director of social work concurred that staff responsibilities were not consistently identified by name and discipline on the MTP's.

3. In an interview on 12/09/14 at 2:30 PM the Hospital Administrator and RN4 concurred that staff responsibilities were not consistently identified by name and discipline on the MTP's.

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

l. Active treatment including alternative interventions for three (3) of eight (8) active sample patients (G5, G6 and G7). All of the patients were unwilling to attend many of their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement.

ll. Therapeutic groups that regularly occurred as scheduled and when offered had patients who were assigned in attendance. This failure leads to limited opportunities for all patients to work on individual issues leading to hospitalization and hinders progress toward recovery and discharge.

lll. Individualized active treatment for eight (8) of eight (8) sample patients (G1, G2, G3, G4, G5, G6, G7, and G8) on evenings and weekends. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion potentially delaying improvement and discharge.

Findings include:


l. Treatment Interventions

A. Patient Findings

1. Patient G5 was admitted on 11/19/14 with a diagnosis of Schizophrenia, Paranoid Type. During observation on the unit on 12/8/14 at 12:30 PM, Patient G5 was observed leaving the Coping Skills Group after less than 15 minutes and sitting at a table by him/herself. From 2:15 PM - 2:30 PM on 12/8/14, Patient G5 was observed sitting on the unit in the dayroom reading the paper. (Skill Building Group in process) During observation on the unit on 12/9/14 at 8:30 AM, Patient G5 was observed talking on the phone while a scheduled Goals Group was in progress. Review of the Master Treatment Plan dated 12/8/14 revealed that Patient G5 s failure to attend groups had not been addressed by the treatment team.

The Inpatient Progress Notes included the following documentation:

"When asked if [s/he] would attend group, client stated 'yes'; however, [s/he] did not attend. Client was still standing in the same spot when group had completed." (Occupational Therapy [OT] note 11/20/14 at 10:38 AM)

"[Patient] verbally refused group upon COTA (Certified Occupational Therapy Assistant) approach stating 'Leave me alone'." (OT note 11/20/14 at 2:22 PM)

"[Patient] verbally refused group upon COTA approach stating "Not right now." (OT note 11/21/14 at 3:24 PM)

"Patient remains out in day room up by nurse's station all day." (Nurses note 11/23/14 at 2:04 PM)

"[Patient] verbally refused group upon COTA approach stating s/he had to do his/her laundry." (OT note 12/5/14 at 10:37 AM)

"[Patient] attended group and participated in "Totika" therapeutic game minimally, as s/he left the group after about 10 minutes." (OT note 12/8/14 at 2:50 PM)

"Client adamantly refused group." (Social Work note 12/9/14 at 3:48 PM)

In interview on 12/9/14 at 2:15 PM, RT1 stated that Patient G5 had attended 10 of the 15 OT groups offered since his/her admission on 11/19/14. (33.3% of the OT groups were not attended)

2. Patient G6 was admitted on 12/5/14 with a diagnosis of Major Depression, Recurrent with Psychotic Features. In interview on 12/8/14 at 10:45 AM, Patient G6 stated that s/he did not like going to groups and had only gone to one since admission. During observation on the unit, Patient G6 was observed walking the hallways or in bed during the 12:40 PM - 1:20 PM timeframe. (Coping Skills Group in process from 12:30 PM - 1:30 PM) Observation on the unit on 12/8/14 from 2:15 PM - 2:45 PM revealed that Patient G6 left the scheduled Skill Building Group after only 5 minutes and went to his/her bedroom. Observation on the unit on 12/9/14 at 8:50 AM revealed that Patient G6 was not attending the Goals Group but was instead taking a shower. During observation on the unit from 10:00 AM - 10:30 AM on 12/9/14, Patient G6 was observed in his/her room in bed. (Psycho-Education Group in process from 10:00 AM - 11:00 AM) Observation on the unit on 12/10/14 at 8:45 AM revealed that Patient G6 was not attending the Goals Group but was instead taking a shower.

The Inpatient Progress Notes included the following documentation:

"Client very isolative in room." (Nurses notes 12/7/14 at 2:43 PM)

"Participated in morning group but refused afternoon group and stated [he/she] was tired." (Nurses notes 12/8/14 at 1:32 PM)

"Client came in and out of the group room two times and was very distracted the entire time [s/he] was in the group room." (Social Work notes 12/8/14 at 3:49 PM)

In interview on 12/9/14 at 8:50 AM, RN1 stated that Patient G6 was "slow" in the morning and that was why s/he was not in Goals Group.

3. Patient G7 was admitted on 12/6/14 with a diagnosis of Major Depression. During observation on 12/8/14 at 10:30 AM, Patient G7 was observed in bed under the covers. (Psycho-Education Group in process) Observation on 12/8/14 from 12:40 PM-12:55 PM revealed that Patient G7 was talking on the phone in the dayroom instead of participating in the Coping Skills Group. Observation on 12/8/14 at 2:30 PM revealed that Patient G7 was in bed under the covers instead of attending the scheduled Skill Building Group. Observation on 12/10/14 at 8:50 AM revealed that Patient G7 was in bed under the covers instead of attending the scheduled Goals Group.

The Inpatient Progress Notes stated:

"Client was lying in bed and did not provide eye contact with writer." (Social Work notes 12/8/14 at 10:31 AM)

"Client has been in [his/her] room most of the day." (Nurses notes 12/8/14 at 12:03 PM)

"Client refused group on problem solving when asked by CNA (Certified Nursing Assistant). Client has been very isolative and angry on all contacts today." (Social Work note 12/8/14 at 3:22 PM)

During interview on 11/8/14 at 12:45 M, RN2, when asked about Patient G7 using the phone during group time, stated that the phones were never turned off and patients could use them during group time.

ll. Scheduled Groups

Document Review

1. Review of the posted schedule on the unit revealed that the groups listed included an 8:30 AM "Goals Group", at 9:00 AM "Nursing Student Group" and a 2:15 PM "Skills Building" group.

Interview

1. During interview on 12/8/14 at 10:15 AM, RN1stated that the expectation was that all patients would go to the scheduled groups but "you can't make them go."

2. During interview on 12/9/14 at 10:15 AM, RN1 stated that the nursing students were not there every week and when they were, it was usually just a couple of days a week. When asked why they were scheduled for a group five days a week at 9:00 AM, RN1 answered that s/he didn't know. S/he further stated that when the nursing students weren't there, they started the Goals Group during that time slot instead of at 8:30 AM.

3. During interview on 12/9/14 at 10:30 AM, both RN1 and RN4 stated that the 2:15 PM Skills Building group did not usually occur. RN4 stated that "Yesterday was the first time I saw the 2:15 PM Social Work group happening."

4. During interview on 12/9/14 at 2:30 PM, both the Administrator and RN4 stated that they were unaware that the unit even had a posted schedule and had never seen it.

5. During interview on 12/10/14 at 8:45 AM, the surveyor noted that the 8:30 AM Goals Group had not begun and most patients were in their rooms. When asked about the group, s/he noted that the majority of the patients went back to bed after breakfast.


Observation

1. Observation on the unit on 12/9/14 at 8:50 AM revealed that only two (2) of eight (8) active sample patients were attending the scheduled Goals Group (Patient G3 and Patient G7).

2. Observation on the unit on 12/9/14 at 9:15 AM revealed that only three (3) of eight (8) active sample patients were attending a Leisure group that had been substituted for the Nursing Student group (G2, G3 and G7).

3. Observation on the unit on 12/9/14 at 10:10 AM revealed that only four (4) of eight (8) active sample patients were attending a Psycho-Education group (G2, G5, G7 and G8).

4. Observation on the unit on 12/10/14 at 8:40 AM revealed that the Goals Group scheduled for 8:30 AM was not being held. When asked when the group would start, RN1 asked CNA1 (Certified Nursing Assistant) who was supposed to lead the Goals Group. CNA1 stated that s/he could lead it and proceeded to announce that Goals Group was meeting. At 8:50 AM four (4) of eight (8) sample patients were attending the group (G2, G3, G5 and G8).


lll. Individualized Active Treatment

A. Document Review

1. The posted schedule for the unit (undated) revealed that Monday-Friday a "Healthy Lifestyles" group (4:00 PM) was the last group offered. The schedule stated that a "Therapeutic Movies" group was scheduled at 8:15 PM however, patient interviews revealed that this was merely watching a movie without staff discussion. The posted schedule revealed that on the week-end, activities consisted of an 8:30 AM "Goals Group" and an 8:15 PM "Therapeutic Movies" group. There were no other therapeutic activities/groups offered on Saturday or Sunday. Patients G1, G2, G3, G4, G5, G6, G7 and G8 all had this same schedule as did every other patient on the unit.

2. Review of admission data for the month of November, 2014 (provided by the Director of Nursing) revealed that an average of six (6) new patients (16 bed unit capacity) were admitted on the week-ends when limited therapeutic activities were available.

B. Interviews

1. During interview on 12/8/14 at 10:45 AM, Patient G6 stated that the previous week-end (Saturday and Sunday) s/he had "watched TV and slept." Patient G6 stated that s/he did not go to any groups and s/he was not aware that any were offered. When asked about the "Therapeutic Movies", Patient G6 stated that they watched movies like you do at home.

2. During interview on 12/8/14 at 11:00 AM, Patient G8 stated that the previous week-end s/he had "slept a lot, watched movies and ate a lot." S/he denied attending any group activities or awareness that any had taken place. When asked about the "Therapeutic Movies", Patient G8 stated that the staff sat with them and watched movies. When asked about staff interventions, s/he stated that the staff "watches us watch the movies."

3. During interview on 12/08/14 at 11:00 AM, RT1 indicated that she only did one therapeutic group per day. She stated there was only one activity person in the facility and that she was only 80% time on the unit. RT1 further indicated that there were no therapeutic activities in the evenings after 5:00 PM and that activity therapy activities were not provided on either Saturday or Sunday.

4. During interview on 12/08/14 at 11:15 AM, Patient G2 stated that the only group available on Sunday was a Goals Group. S/he noted most of his/her weekend was spent sleeping.

5. During interview on 12/08/14 at 11:30 AM, Patient G3 when questioned about evening activities, noted there is not much to do at night, only a movie.

6. During interview on 12/9/14 at 1:15 PM the Director of Social Work indicated there were not evening or weekend social work groups provided by the social workers. He also noted this was due to needing additional personnel to provide such services.

7. During interview on 12/09/14 at 2:30PM, the Hospital Administrator and RN4 concurred there were no evening or weekend groups provided by either social services or activity or therapy.

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

l. Ensure the development and documentation of comprehensive multidisciplinary treatment plans based on the individualized needs of patients for one (1) of eight (8) active sample patients (Patient G5). Specifically the medical director failed to ensure that the treatment goals and interventions documented on the Master Treatment Plan (MTP) addressed the identified needs of Patient G5. Failure to individualize treatment plans can prevent patients from progressing in treatment and fail to give staff guidance for addressing specific patient problems which can result in unmet needs and potentially longer lengths of hospitalization. (See B118)

ll. Ensure the provision of active treatment including alternative interventions for three (3) of eight (8) active sample patients (G5, G6 and G7). All of the patients were unwilling to attend many of their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement. (See B125 l)

lll. Ensure the provision of therapeutic groups that regularly occurred as scheduled and when offered had patients who were assigned in attendance. This failure leads to limited opportunities for patients to work on individual issues leading to hospitalization and hinders progress toward recovery and discharge. (See B125 ll)

lV. Ensure the provision of individualized active treatment for eight (8) of eight (8) sample patients (G1, G2, G3, G4, G5, G6, G7, and G8) on evenings and weekends. The failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion potentially delaying improvement and discharge. (See B125 lll)

Based on record review and interview, the Director of Nursing failed to:

l. Identify in the MTP specific nursing interventions/modalities to address the identified patient problems for six (6) of eight (8) active sample patients (G1, G2, G3, G4, G5 and G6). The interventions were stated in vague terms and were non-individualized generic discipline functions rather than directed at specific interventions. This deficiency results in failure to guide nursing staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients.

ll. Ensure active treatment participation including alternative interventions for three (3) of eight (8) active sample patients (G5, G6 and G7). All of the patients were unwilling to attend many of their assigned groups. Failure to ensure participation in active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement.

Findings include:

l. Nursing Interventions

Medical Record Review

1. Patient G1 admitted 12/07/14 with a diagnosis of Bipolar Disorder with Psychosis had listed on MTP dated 12/07/14 for the problem, "Leaving residence without clothing, hypersexual, scratching at self, crying, yelling out name of family who are not present, disoriented to person, time, place, and situation", the following STG: "Client will recognize benefits of medication" and a Long Term Goal [LTG] "Client will sustain concentration, and attention to complete tasks and function independently. Client will be able to verbalize the need for medication compliance after discharge."

The nursing intervention listed was: "RN will evaluate effectiveness and side effects of medications."

2. Client G2 admitted 12/05/14 with a diagnosis of "Mood Disorder, not otherwise specified" and "Anxiety disorder not otherwise specified" had listed on MTP dated 12/05/14 for the problem, "Suicidal ideation Related To Marital issues, wife is pregnant, upset over holidays as evidenced by: Overdosing on prescription Seroquel" the following STG: "Client will verbalize no ideas of self-harm for two days prior to discharge on the unit."

The nursing intervention listed was: "RN will obtain verbal no self-harm contract from client upon admission."

3. Patient G3 admitted 12/06/14 with a diagnosis of "Schizoaffective Disorder" had listed on MTP dated 12/05/14 for the problem, "Paranoia....as evidenced by: Decreased sleep and statements consisting of beliefs that a murderer was in his/her room/home, fearful of the dark", the following STG: "Client will cooperate with the admission process, be monitored closely by all staff, and remain free from harm to self or others" and "Client will take scheduled and PRN medication as ordered by the psychiatrist."

The nursing intervention listed was: "RN will obtain verbal no self-harm contract from client upon admission."

4. Patient G4 admitted 12/05/14 with a diagnosis of "Schizoaffective disorder in acute exacerbation" and "Alcohol dependence, in remission" had listed on the MTP dated 12/05/14 for the problem, "Suicidal Risk Related to: Hearing voices, states [he/she] wants to get on disability as evidenced by: Overdosed on Tylenol and ibuprofen", the following STG: "Pt will report a decrease in frequency of responding to the voices and improve overall affect and mood."

The nursing intervention listed was: "RN will obtain verbal no self-harm contract from client upon admission."

5. Patient G5 admitted on 11/19/14 with diagnosis of "Schizophrenia, Paranoid Type" had listed on the MTP review dated 12/9/14 for the problem, "Delusional Thought Process as evidenced by: Bizarre behaviors, catatonic state", the following STG: "Client will verbalize understanding that delusions are a part of their illness."

The nursing intervention listed was: "RN will assess client for the need for PRN medication as well as administer scheduled medication as ordered by the psychiatrist."

6. Patient G6 admitted on 12/5/14 with a diagnosis of Schizoaffective Disorder had listed on the MTP dated 12/8/14 for the problem, "Depression Related to: unknown as evidenced by: not eating, flat affect", the following STG: "Client will cooperate with the admission process, be monitored closely by all staff, and remain free from harm to self or others." For the problem "Alteration in thought process related to experiencing delusions, evidenced by believing people are breaking in [his/her] apartment and [his/her] food being poisoned", the following STG: "Pt will decrease in [his/her] delusional thinking and become more aware of reality."

The nursing interventions listed were: "RN will maintain client on 15 minute checks unless otherwise indicated by the psychiatrist" and "RN and CNA will encourage client to express feelings verbally and in writing."

Interview

1. In an interview on 12/09/14 at 10:00 AM, the Director of Nursing acknowledged that the nursing interventions were vague, non-individualized and were instead expected generic nursing practice for all patients.


ll. Treatment Interventions

A. Patient Findings

1. Patient G5 was admitted on 11/19/14 with a diagnosis of Schizophrenia, Paranoid Type. During observation on the unit on 12/8/14 at 12:30 PM, Patient G5 was observed leaving the Coping Skills Group after less than 15 minutes and sitting at a table by him/herself. From 2:15 PM - 2:30 PM on 12/8/14, Patient G5 was observed sitting on the unit in the dayroom reading the paper (Skill Building Group in process). During observation on the unit on 12/9/14 at 8:30 AM, Patient G5 was observed talking on the phone while a scheduled Goals Group was in progress. Review of the Master Treatment Plan dated 12/8/14 revealed that Patient G5's failure to attend groups had not been addressed by the treatment team.

The Inpatient Progress Notes included the following documentation:

"When asked if [s/he] would attend group, client stated 'yes'; however, [s/he] did not attend. Client was still standing in the same spot when group had completed." (Occupational Therapy [OT] note 11/20/14 at 10:38 AM)

"[Patient] verbally refused group upon COTA (Certified Occupational Therapy Assistant) approach stating 'Leave me alone'." (OT note 11/20/14 at 2:22 PM)

"[Patient] verbally refused group upon COTA approach stating "Not right now." (OT note 11/21/14 at 3:24 PM)

"Patient remains out in day room up by nurse's station all day." (Nurses note 11/23/14 at 2:04 PM)

"[Patient] verbally refused group upon COTA approach stating s/he had to do his/her laundry." (OT note 12/5/14 at 10:37 AM)

"[Patient] attended group and participated in "Totika" therapeutic game minimally, as s/he left the group after about 10 minutes." (OT note 12/8/14 at 2:50 PM)

"Client adamantly refused group." (Social Work note 12/9/14 at 3:48 PM)

In interview on 12/9/14 at 2:15 PM, RT1 stated that Patient G5 had attended 10 of the 15 OT groups offered since his/her admission on 11/19/14. (33.3% of the OT groups were not attended)

In interview on 12/9/14 at 2:30 PM, the Director of Nursing stated that she expected the nursing staff to encourage patients to go to group and offer alternatives if groups were refused.

2. Patient G6 was admitted on 12/5/14 with a diagnosis of Major Depression, Recurrent with Psychotic Features. In interview on 12/8/14 at 10:45 AM, Patient G5 stated that s/he did not like going to groups and had only gone to one since admission. During observation on the unit, Patient G6 was observed walking the hallways or in bed during the 12:40 PM - 1:20 PM timeframe. (Coping Skills Group in process from 12:30PM-1:30PM) Observation on the unit on 12/8/14 from 2:15 PM - 2:45 PM revealed that Patient G5 left the scheduled Skill Building Group after only five (5) minutes and went to his/her bedroom. Observation on the unit on 12/9/14 at 8:50 AM revealed that Patient G5 was not attending the Goals Group but was instead taking a shower. During observation on the unit from 10:00 AM - 10:30 AM on 12/9/14, Patient G6 was observed in his/her room in bed. (Psycho-Education Group in process from 10:00 AM - 11:00 AM) Observation on the unit on 12/10/14 at 8:45 AM revealed that Patient G5 was not attending the Goals Group but was instead taking a shower.

The Inpatient Progress Notes included the following documentation:

"Client very isolative in room." (Nurses notes 12/7/14 at 2:43 PM)

"Participated in morning group but refused afternoon group and stated [he/she] was tired." (Nurses notes 12/8/14 at 1:32 PM)

"Client came in and out of the group room two times and was very distracted the entire time [s/he] was in the group room." (Social Work notes 12/8/14 at 3:49 PM)

In interview on 12/9/14 at 8:50 AM, RN1 stated that Patient G6 was "slow" in the morning and that was why s/he was not in Goals Group.

In interview on 12/9/14 at 2:30 PM, the DON stated that she expected the nursing staff to encourage patients to attend group and offer alternatives if groups were refused.

3. Patient G7 was admitted on 12/6/14 with a diagnosis of Major Depression. During observation on 12/8/14 at 10:30 AM, Patient G7 was observed in bed under the covers. (Psycho-Education Group in process) Observation on 12/8/14 from 12:40 PM - 12:55 PM revealed that Patient G7 was talking on the phone in the dayroom instead of participating in the Coping Skills Group. Observation on 12/8/14 at 2:30 PM revealed that Patient G7 was in bed under the covers instead of attending the scheduled Skill Building Group. Observation on 12/10/14 at 8:50 AM revealed that Patient G7 was in bed under the covers instead of attending the scheduled Goals Group.

The Inpatient Progress Notes stated:

"Client was lying in bed and did not provide eye contact with writer." (Social Work notes 12/8/14 at 10:31 AM)

"Client has been in [his/her] room most of the day." (Nurses notes 12/8/14 at 12:03 PM)

"Client refused group on problem solving when asked by CNA (Certified Nursing Assistant). Client has been very isolative and angry on all contacts today." (Social Work note 12/8/14 at 3:22 PM)

During interview on 11/8/14 at 12:45 PM, RN2, when asked about Patient G7 using the phone during group time, stated that the phones were never turned off and patients could use them during group time.

In interview on 12/9/14, the Director of Nursing stated that she expected nursing staff to encourage patients to attend groups and to offer alternatives if groups were refused.

Based on record review and staff interview it was determined that the facility failed to provide professional therapeutic staff that would design and implement structured therapeutic activities. This failure resulted in a lack of structured therapeutic groups/activities to assist the patient in meeting their treatment goals.

Findings include:

A. Record review

A review of the unit activity schedule revealed that only one activity group was held daily Monday-Friday (10:00 AM - 11:00 AM). There were no activity groups held in the evenings or on week-ends. The activity groups were conducted by a Certified Occupational Therapy Assistant (COTA) who reported to the Director of Social Work.

B. Interview

1. In interview on 12/09/14 at 2:15 PM, RT 1 stated that she was the only member of the Activity Therapy section and worked only 80% of the time on the hospital unit. She also stated that she was responsible for doing the Activity Therapy assessments and also tried to cover the groups when the nursing students were not there. (Nursing students were scheduled to do a group daily from Monday-Friday). RT1 acknowledged that she could not always accomplish everything.

2. In interview on 12/09/14 at 2:30 PM, the Administrator acknowledged that she knew that a qualified Activity Therapist needed to supervise RT1 and that more activity therapy activities were needed especially on evenings and week-ends. The Administrator further stated that she had already started working on making those changes.