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Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered short-term goals in observable, measurable, behavioral terms for eight (8) of eight (8) active patients. (A1, A2, A3, A4, A5, A6, A7 and A8). Lack of measureable, 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 A1 admitted on 5/8/15 with a diagnosis of "Schizoaffective Disorder, Bipolar type" had listed on the MTP dated 5/8/15 for the problem "Altered thought process related to schizoaffective disorder as evidenced by eloping from less restrictive environment, pacing, delusional thoughts", the following Short-Term Goal (STG): "[Patient] will display calm behavior on the unit daily."

2. Patient A2 admitted on 5/8/15 with a diagnosis of "Bipolar Disorder" had listed on the MTP dated 5/8/15 for the problem "Ineffective coping related to Bipolar as evidence [sic] by: expressing suicidal ideation to cut wrists with a razor blade", the following STG: "[Patient] will discuss openly about [his/her] depressive moods and thoughts to cut."

3. Patient A3 admitted on 5/3/15/ with a diagnosis of "Chronic paranoid schizophrenia in acute exacerbations, Alcohol dependence in remission, Cocaine abuse, in remission, cannabis abuse" had listed on the MTP dated 5/12/15 for the problem, "Alteration in thought process related to schizophrenia as evidence [sic] by client states that he sees cows and goat on [sic] yard, THC abuse", the following STG: "[Patient] will will [sic] think more clearly as demonstrated by logical, coherent speech."

4. Patient A4 admitted on 5/9/15 with a diagnosis of "Major Depression" had listed on the MTP dated 5//10/15 for the problem "Ineffective coping related to depression as evidence by: [Patient] has been having suicidal thought, [Patient] did cut on [his/her] left arm superficially", the following STG: "[Patient] will identify areas of [his/her] life that are causing an increase in depression."

5. Patient A5 admitted on 5/6/15 with a diagnosis of Depressive Disorder NOS (Not Otherwise Specified) had listed on the MTP dated 5/8/15 for the problem, "Ineffective coping related to alcohol use and using bovine pills (growth hormone) as evidence by: suicidal statements to hospital staff and family", the following STG: "[Patient] will safely detox and look at alternative options for medications."

6. Patient A6 admitted 5/8/15 with diagnoses of Bipolar Disorder, Manic with Psychotic Features, Opioid Use Disorder and Cannabis Use Disorder had listed on the MTP dated 5/11/15 for the problem, "Ineffective coping related to depression as evidence by: client was being booked into jail and made suicidal comments that [he/she] would suffocate [himself/herself] if [he/she] had to go to jail ", the following STG: "[Patient] will deny suicide ideation and will be accepting of pending legal consequences."

7. Patient A7 admitted 5/8/15 with diagnoses of Bipolar Disorder, Depressed with Psychotic Features, Alcohol Use Disorder and Panic Disorder had listed on the MTP dated 5/11/15 for the problem, "Risk for suicide related to depression, third suicide attempt this year as evidenced by intentional overdose on prescription Seroquel and Clonazepam", the following STG: "[Patient] will verbally identify the source of depressed mood."

8. Patient A8 admitted 5/9/15 with diagnoses of Depressive Disorder NOS, Alcohol Dependence and Borderline Personality Disorder had listed on the MTP dated 5/11/15 for the problem, "Hopelessness related to depressive disorder losing custody of [his/her] children as evidence by overdose, SI [Suicidal Ideation], SA [Substance Abuse]", the following Long-Term Goal (LTG): "[Patient] will identify a decrease in depression and an increase in hopefulness for the future."

INTERVIEW:

1. In an interview on 5/12/15 at 10:30 AM the director of social services concurred that patient short-term goals were not listed in behavioral, measurable terms.

2. In an interview on 5/12/15 at 1:00 PM the Director of Nursing and the interim CEO concurred the patient short-term goals listed on treatment plans were not listed in behavioral, measurable terms.

3. In an interview on 5/13/15 at 10:00 AM the clinical director concurred that patient short- term goals were not listed in behavioral, measurable terms.

Based on record review and interviews, the facility failed to identify in the MTP specific treatment interventions/modalities to address the identified patient problems for seven (7) of eight (8) active sample patients (A1, A2, A3, A5, A6, A7 and A8). 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 A1 admitted on 5/8/15 with a diagnosis of "Schizoaffective Disorder, Bipolar type" had listed on the MTP dated 5/8/15 for the STG, "[Patient] will display calm behavior on the unit daily", the following interventions: "RN [Registered Nurse] and CAN [sic] [Certified Nursing Assistant] will encourage [Patient] to admit and accept personal responsibility for own actions/behavior" and "SW [social worker] will work with case manager to schedule assessments for placement at a group home and assist in transition to the group home setting."

2. Patient A2 admitted on 5/8/15 with a diagnosis of "Bipolar Disorder" had listed on the MTP dated 5/8/15 for the STG, "[Patient] will discuss openly about [his/her] depressive moods and thoughts to cut", the following intervention: "SW will help assist [Patient] in setting up aftercare appointments and will work closely with Marinette County for continue [sic] of care."

3. Patient A3 admitted on 5/3/15/ with a diagnosis of "Chronic paranoid schizophrenia in acute exacerbations, Alcohol dependence in remission, Cocaine abuse, in remission, cannabis abuse" had listed on the MTP dated 5/12/15 for the STG, "[Patient] will will [sic] think more clearly as demonstrated by logical, coherent speech.", the following intervention: "SW will meet with [Patient] to explore insight to safety concerns."

4. Patient A5 admitted on 5/6/15 with a diagnosis of Depressive Disorder NOS had listed on the MTP dated 5/8/15 for the STG, "[Patient] will safely detox and look at alternative options for medications" the following interventions: "RN will encourage attendance for all visits with the psychiatrist" and "RN will encourage client to take medications as prescribed on a daily basis."

5. Patient A6 admitted 5/8/15 with diagnoses of Bipolar Disorder, Manic with Psychotic Features, Opioid Use Disorder and Cannabis Use Disorder had listed on the MTP dated 5/11/15 for the STG, "[Patient] will attend at least three (3) groups per day while [sic] on the unit and accept alternative intervention for each group refused " the following intervention: "All staff will encourage [Patient] to attend groups."

6. Patient A7 admitted 5/8/15 with diagnoses of Bipolar Disorder, Depressed with Psychotic Features, Alcohol Use Disorder and Panic Disorder had listed on the MTP dated 5/11/15 for the STG, "[Patient] will verbally identify the source of depressed mood" the following intervention: "SW (Social Worker) will meet with [Patient] to explore changes in future orientation and help [Patient] identify areas of hope."

7. Patient A8 admitted 5/9/15 with diagnoses of Depressive Disorder NOS, Alcohol Dependence and Borderline Personality Disorder had listed on the MTP dated 5/11/15 for the STG, "[Patient] will identify feared situations and discuss at least one such situation in daily 1:1 with staff" "a decrease in depression and an increase in hopefulness for the future" the following intervention: "RN and CAN [sic] will assist with developing strategies to help cope with stressful reminders and life issues."

INTERVIEW:

1. In an interview on 5/12/15 at 10:30 AM the director of social services concurred that treatment interventions frequently reflected vague generic interventions rather than being specifically related to patient's listed goals.

2. In an interview on 5/12/15 at 1:00 PM the Director of Nursing and the interim CEO concurred the treatment interventions listed on patient treatment plans were frequently vague and generic discipline functions rather than directly relating to specific patient listed goals.

3. In an interview on 5/13/15 at 10:15 AM the clinical director concurred that treatment interventions reflected vague, generic interventions rather than being specifically related to patient's listed goals.

Based on record review and interview, the clinical director failed to ensure:

I. The development of MTP's that identified patient-centered short-term goals in observable, measurable, behavioral terms for eight (8) of eight (8) active patients. (A1, A2, A3, A4, A5, A6, A7 and A8) Lack of measureable, 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.

MEDICAL RECORD REVIEW:

1. Patient A1 admitted on 5/8/15 with a diagnosis of "Schizoaffective Disorder, Bipolar type" had listed on the MTP dated 5/8/15 for the problem "Altered thought process related to schizoaffective disorder as evidenced by eloping from less restrictive environment, pacing, delusional thoughts", the following Short-Term Goal (STG): "[Patient] will display calm behavior on the unit daily."

2. Patient A2 admitted on 5/8/15 with a diagnosis of "Bipolar Disorder" had listed on the MTP dated 5/8/15 for the problem "Ineffective coping related to Bipolar as evidence [sic] by: expressing suicidal ideation to cut wrists with a razor blade", the following STG: "[Patient] will discuss openly about [his/her] depressive moods and thoughts to cut."

3. Patient A3 admitted on 5/3/15/ with a diagnosis of "Chronic paranoid schizophrenia in acute exacerbations, Alcohol dependence in remission, Cocaine abuse, in remission, cannabis abuse" had listed on the MTP dated 5/12/15 for the problem, "Alteration in thought process related to schizophrenia as evidence [sic] by client states that he sees cows and goat on [sic] yard, THC abuse, the following STG: "[Patient] will [sic] think more clearly as demonstrated by logical, coherent speech."

4. Patient A4 admitted on 5/9/15 with a diagnosis of "Major Depression" had listed on the MTP dated 5/10/15 for the problem "Ineffective coping related to depression as evidence by: [Patient] has been having suicidal thought, [Patient] did cut on [his/her] left arm superficially", the following STG: "[Patient] will identify areas of [his/her] life that are causing an increase in depression."

5. Patient A5 admitted on 5/6/15 with a diagnosis of Depressive Disorder NOS (Not Otherwise Specified) had listed on the MTP dated 5/8/15 for the problem, "Ineffective coping related to alcohol use and using bovine pills (growth hormone) as evidence by: suicidal statements to hospital staff and family", the following STG: "[Patient] will safely detox and look at alternative options for medications."

6. Patient A6 admitted 5/8/15 with diagnoses of Bipolar Disorder, Manic with Psychotic Features, Opioid Use Disorder and Cannabis Use Disorder had listed on the MTP dated 5/11/15 for the problem, "Ineffective coping related to depression as evidence by: client was being booked into jail and made suicidal comments that [he/she] would suffocate [himself/herself] if [he/she] had to go to jail", the following STG: "[Patient] will deny suicide ideation and will be accepting of pending legal consequences."

7. Patient A7 admitted 5/8/15 with diagnoses of Bipolar Disorder, Depressed with Psychotic Features, Alcohol Use Disorder and Panic Disorder had listed on the MTP dated 5/11/15 for the problem, "Risk for suicide related to depression, third suicide attempt this year as evidenced by intentional overdose on prescription Seroquel and Clonazepam", the following STG: "[Patient] will verbally identify the source of depressed mood."

8. Patient A8 admitted 5/9/15 with diagnoses of Depressive Disorder NOS, Alcohol Dependence and Borderline Personality Disorder had listed on the MTP dated 5/11/15 for the problem, "Hopelessness related to depressive disorder losing custody of [his/her] children as evidence by overdose, SI [Suicidal Ideation], SA [Substance Abuse]", the following Long-Term Goal (LTG): "[Patient] will identify a decrease in depression and an increase in hopefulness for the future."

INTERVIEW:

1. In an interview on 5/12/15 at 10:30 AM the director of social services concurred that patient short-term goals were not listed in behavioral, measurable terms.

2. In an interview on 5/12/15 at 1:00 PM the Director of Nursing and the interim CEO concurred the patient short-term goals listed on treatment plans were not listed in behavioral, measurable terms.

3. In an interview on 5/13/15 at 10:00 AM the clinical director concurred that patient short- term goals were not listed in behavioral, measurable terms.

II. The identification in the MTP specific treatment interventions/modalities to address the identified patient problems for seven (7) of eight (8) active sample patients (A1, A2, A3, A5, A6, A7 and A8). 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 A1 admitted on 5/8/15 with a diagnosis of "Schizoaffective Disorder, Bipolar type" had listed on the MTP dated 5/8/15 for the STG, "[Patient] will display calm behavior on the unit daily", the following interventions: "RN [Registered Nurse] and CAN [sic] [Certified Nursing Assistant] will encourage [Patient] to admit and accept personal responsibility for own actions/behavior" and "SW [social worker] will work with case manager to schedule assessments for placement at a group home and assist in transition to the group home setting."

2. Patient A2 admitted on 5/8/15 with a diagnosis of "Bipolar Disorder" had listed on the MTP dated 5/8/15 for the STG, "[Patient] will discuss openly about [his/her] depressive moods and thoughts to cut", the following intervention: "SW will help assist [Patient] in setting up aftercare appointments and will work closely with Marinette County for continue [sic] of care."

3. Patient A3 admitted on 5/3/15/ with a diagnosis of "Chronic paranoid schizophrenia in acute exacerbations, Alcohol dependence in remission, Cocaine abuse, in remission, cannabis abuse" had listed on the MTP dated 5/12/15 for the STG, "[Patient] will will [sic] think more clearly as demonstrated by logical, coherent speech", the following intervention: "SW will meet with [Patient] to explore insight to safety concerns."

4. Patient A5 admitted on 5/6/15 with a diagnosis of Depressive Disorder NOS had listed on the MTP dated 5/8/15 for the STG, "[Patient] will safely detox and look at alternative options for medications" the following interventions: "RN will encourage attendance for all visits with the psychiatrist" and "RN will encourage client to take medications as prescribed on a daily basis."

5. Patient A6 admitted 5/8/15 with diagnoses of Bipolar Disorder, Manic with Psychotic Features, Opioid Use Disorder and Cannabis Use Disorder had listed on the MTP dated 5/11/15 for the STG, "[Patient] will attend at least 3 groups per day while [sic] on the unit and accept alternative intervention for each group refused" the following intervention: "All staff will encourage [Patient] to attend groups."

6. Patient A7 admitted 5/8/15 with diagnoses of Bipolar Disorder, Depressed with Psychotic Features, Alcohol Use Disorder and Panic Disorder had listed on the MTP dated 5/11/15 for the STG, "[Patient] will verbally identify the source of depressed mood" the following intervention: "SW (Social Worker) will meet with [Patient] to explore changes in future orientation and help [Patient] identify areas of hope."

7. Patient A8 admitted 5/9/15 with diagnoses of Depressive Disorder NOS, Alcohol Dependence and Borderline Personality Disorder had listed on the MTP dated 5/11/15 for the STG, "[Patient] will identify feared situations and discuss at least one such situation in daily 1:1 with staff" "a decrease in depression and an increase in hopefulness for the future" the following intervention: "RN and CAN [sic] will assist with developing strategies to help cope with stressful reminders and life issues."

INTERVIEW:

1. In an interview on 5/12/15 at 10:30 AM the director of social services concurred that treatment interventions frequently reflected vague generic interventions rather than being specifically related to patient's listed goals.

2. In an interview on 5/12/15 at 1:00 PM the Director of Nursing and the interim CEO concurred the treatment interventions listed on patient treatment plans were frequently vague and generic discipline functions rather than directly relating to specific patient listed goals.

3. In an interview on 5/13/15 at 10:15 AM the clinical director concurred that treatment interventions reflected vague, generic interventions rather than being specifically related to patient's listed goals.

Based on record review and interview, the Director of Nursing to identify in the MTP specific nursing interventions/modalities to address the identified patient problems for three (3) of eight (8) active sample patients (A1, A5 and A8) 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.

Findings include:

MEDICAL RECORD REVIEW:

1. Patient A1 admitted on 5/8/15 with a diagnosis of "Schizoaffective Disorder, Bipolar type" had listed on the MTP dated 5/8/15 for the STG, "[Patient] will display calm behavior on the unit daily", the following intervention: "RN [Registered Nurse] and CAN [sic] will encourage [Patient] to admit and accept personal responsibility for own actions/behavior."

2. Patient A5 admitted on 5/6/15 with a diagnosis of Depressive Disorder NOS had listed on the MTP dated 5/8/15 for the STG, "[Patient] will safely detox and look at alternative options for medications" the following interventions: "RN will encourage attendance for all visits with the psychiatrist" and "RN will encourage client to take medications as prescribed on a daily basis."

3. Patient A8 admitted 5/9/15 with diagnoses of Depressive Disorder NOS, Alcohol Dependence and Borderline Personality Disorder had listed on the MTP dated 5/11/15 for the STG, "[Patient] will identify feared situations and discuss at least one such situation in daily 1:1 with staff " "a decrease in depression and an increase in hopefulness for the future" the following intervention: "RN and CAN [sic] will assist with developing strategies to help cope with stressful reminders and life issues."

INTERVIEW:

In an interview on 5/12/15 at 1:00 PM the Director of Nursing and the interim CEO concurred the treatment interventions listed on patient treatment plans were frequently vague and generic discipline functions rather than directly relating to specific patient listed goals.