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Based on record review and interview, facility staff failed to respond to patient grievances per policy in 2 of 3 patient grievances reviewed (Patient #8, Patient #9, Patient #10).

Findings:

Facility policy "Patient Rights and the Grievance Procedure" dated 7/2012 states in part: "The Client Rights Specialist shall investigate the facts and document the investigation, the decision, and the reasons for the decision...for hospital patients within 7 days. If more time is required to investigate the inpatient grievance, the Client Rights Specialist will notify the complainant that the grievance remains under investigation and that the Client Rights Specialist will provide the written report no later than 30 days from the date the complaint was received."

The facility's brochure "Client Rights and the Grievance Procedure for Inpatient Services", given to patients upon admission, states in part: "the Specialist will generally write a report within 7 days from the date you filed the grievance. If more time is required to investigate the grievance, the Specialist will notify you that the grievance is still under investigation and will provide the written report no longer than 30 days from the date you filed the formal grievance."

Patient #8 received inpatient services at the facility from 5/6/2015 through 5/12/2015. Patient #8's Power of Attorney filed a written grievance dated 6/1/2015 regarding the inpatient stay. The grievance record contains a written response to the complainant dated 9/28/2015.

Patient #9 received inpatient services at the facility from 8/4/2015 through 8/14/2015. Patient #9 filed a written grievance dated 8/6/2015. The grievance record contains a written response to the grievance dated 8/27/2015, more than 7 days after the grievance was filed.

Patient #10 received inpatient services at the facility from 5/29/2015 through 7/2/2015. Patient #10 filed a written grievance dated 6/29/2015. The grievance record contains a written response to the grievance dated 7/24/2015, more than 7 days after the grievance was filed.

During an interview on 4/11/2015 at 2:50 PM, Client Rights Specialist J stated the facility responds to complaints "within 30 days." In regards to Patient #8's grievance, J stated the facility did not receive the written complaint until "sometime in August." J went on to state "we don't know why we didn't get the complaint right away."

During an interview on 4/12/2015 at 1:00 PM, Administrator C stated the above grievances had all been responded to within 30 days from receiving the complaints. Administrator A confirmed the policy states grievances are responded to within 7 days for inpatients, not 30 days.

Based on record review and interview, the facility failed to track and trend quality indicators to identify trends with the potential to affect patient outcomes in 1 of 1 Quality Program.

Findings:

Facility document "Performance Improvement Plan" states in part: "Functions: The functions of the Performance Improvement Committee (Committee of the Whole meeting) shall be to: -Provide for organized systematic, on-going review and evaluation of patient care. ...-Serve as a resource for identifying problems that affect the quality of patient care and to implement actions."

During an interview on 4/12/2016 at 10:00 AM, Performance Improvement Nurse I stated the aggregate data for quality indicators "isn't compiled yet, I'm working on that." Nurse I stated there isn't a method in place to trend quality indicator results over time.

Based on record review and interview, the facility failed to track and trend patient incident data to identify trends with the potential to affect patient outcomes in 1 of 1 Quality Program.

Findings:

Facility document "Performance Improvement Plan" states in part: "Functions: The functions of the Performance Improvement Committee (Committee of the Whole meeting) shall be to: -Provide for organized systematic, on-going review and evaluation of patient care. ...-Serve as a resource for identifying problems that affect the quality of patient care and to implement actions."

During an interview on 4/11/2016 at 2:30 PM, Performance Improvement Nurse I stated the quality department is not involved in the review of incident reports. I stated "incidents go to [Supervisor H] for review."

During review of the facility's incident reports on 4/13/2016 at 11:00 AM with Supervisor H, H stated the incident report data is not aggregated in any way. Per H, "we don't do that at all." The incidents are reviewed individually as they come in, there is no system in place to allow for aggregate review to identify trends in errors and potential system-wide problems.

Based on observation, staff interviews and review of maintenance documents, the hospital failed to construct and maintain the building systems to ensure a safe physical environment. The cumulative effects of these environment deficiencies resulted in the hospital's inability to ensure a safe environment for the patients.

42 CFR 482.41- Condition of Participation: Physical Environment IS NOT MET. These deficiencies have the ability to affect 13 in-patients and an unknown number of outpatients, staff and visitors who were present during the survey.

FINDINGS INCLUDE:

The facility had the following (15) life safety deficiencies.
K-12: Building Construction,
K-18: Corridor Doors,
K-20: Shafts and Floor Separations,
K-25: Smoke Barriers,
K-29: Hazardous Spaces,
K-50: Fire Drills,
K-51: Fire Alarm Installation,
K-54: Smoke Detection Testing,
K-56: Sprinkler System Installation,
K-62: Sprinkler Maintenance & Testing,
K-67: Heating, Ventilating & Air Conditioning Installation,
K-69: Commercial Cooking Kitchen & Exhaust Hoods,
K-70: Portable Space Heaters,
K-130: Miscellaneous Life Safety Codes and
K-147: Electrical Systems.

Please refer to the full description at the cited K-tags.

Based on observation, staff interviews and review of maintenance documents, the hospital failed to construct and maintain the building systems to ensure Life Safety from Fire. The cumulative effects of these safety from fire deficiencies resulted in the hospital's inability to ensure an environment free of potential life safety from fire for the patients.

42 CFR 482.41(b) - Life Safety from Fire: IS NOT MET. These deficiencies have the ability to affect 13 in-patients and an unknown number of outpatients, staff and visitors who were present during the survey.

FINDINGS INCLUDE:
The facility had the following (15) life safety deficiencies.
K-12: Building Construction,
K-18: Corridor Doors,
K-20: Shafts and Floor Separations,
K-25: Smoke Barriers,
K-29: Hazardous Spaces,
K-50: Fire Drills,
K-51: Fire Alarm Installation,
K-54: Smoke Detection Testing,
K-56: Sprinkler System Installation,
K-62: Sprinkler Maintenance & Testing,
K-67: Heating, Ventilating & Air Conditioning Installation,
K-69: Commercial Cooking Kitchen & Exhaust Hoods,
K-70: Portable Space Heaters,
K-130: Miscellaneous Life Safety Codes and
K-147: Electrical Systems.

Please refer to the full description at the cited K-tags.

Based on observation and staff interview, the dietary staff failed to cover the garbage container noted in 1 of 1 food service areas observed (kitchen).

Findings include:

Per observation on 4/11/16 at 11:00 AM in the kitchen, during patient food tray assembly, the garbage container was noted to be uncovered.

Requested policy from Food Service Specialist K on 4/11/16 at 11:30 AM regarding garbage containers being covered, Food Service specialist K stated in an interview on 4/11/16 at 11:45 AM, "the facility does not have a policy for covered garbage containers however we are aware the garbage container should be covered and the staff will be educated".

Based on record review, observation, and interview, the facility staff failed to disinfect the glucometer after patient use in 1 of 1 patients observed requiring blood sugar monitoring (Patient #13). This deficiency has the potential to affect all diabetic patients who have blood sugars checked.

Finding include:

Per review on 4/12/16 at 12:45 PM of policy titled, Care and Cleaning of Multi-Patient Equipment, no policy number, dated 12/2013 stated in part under 1. All multi-use products, glucometers must be cleaned and sanitized between patient use.

Per observation on 4/12/16 at 3:35 PM, Registered Nurse M used a multi-patient glucometer to check a blood sugar on Patient #13. Registered Nurse M did returned the multi-patient glucometer to the medication room, no disinfection noted.

Findings were shared with Registered Nurse Supervisor H on 4/12/16 at 10:55 AM. Per interview with Supervisor H on 4/12/16 at 11:00 AM, Registered Nurse Supervisor H stated the "nurses should be cleaning the glucometer between patient use."

I. Based on observation, interview, record review and policy review, the facility failed to ensure that Master Treatment Plans (MTPs) were sufficiently individualized and updated to ensure staff had developed appropriate problem statements, goals and treatment modalities to meet the needs of active sample patients:

A. For eight (8) of eight (8) active sample patients (A1, A2, A5, A6, A14, A16, A17, and A20), the facility failed to develop and document comprehensive and individualized MTPs that included input from all discipline involved and all active treatment measures provided to patients. This lack of input by all team members and failure to include all active treatment measures on MTPs results in the potential to compromise patients' opportunity to receive appropriate treatment measures. (Refer to B118-I for details)

B. For one (1) active sample patient (A2) and two (2) non-sample patients (C2, and C3) selected to review episodes of seclusion and restraint, the facility failed to revise MTPs plans after episodes of seclusion or restraint. This failure can prevent the facility from identifying interventions, which would avoid future seclusion episodes for these patients. (Refer to B118-II for details)

C. For four (4) of eight (8) active sample patients (A2, A5, A14, and A17), the facility failed to ensure that MTPs contained behaviorally descriptive psychiatric problems based each patient's uniquely manifested assessed presenting psychiatric symptoms. This results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems. (Refer to B119 for details)

D. For four (4) of eight (8) active sample patients (A1, A6, A16, and A17). the facility failed to ensure that MTPs consistently included specific long and short-term goals written in language understandable to patients and free of psychiatric jargon. This failure could prevent the development of specific interventions to assist in reaching treatment goals in a timely fashion thereby resulting in prolonged hospital stays. (Refer to B121 for details)

E. For eight (8) of eight (8) active sample patients (A1, A2, A5, A6, A14, A16, A17, and A20), the facility failed to ensure that MTPs consistently included individualized active treatment interventions that stated specific modalities with a frequency of contact and a specific focus or purpose of treatment. Instead, MTPs included routine discipline ' s functions such as "assessing," "monitoring," "encouraging," and "documenting" or instructions to staff written as active treatment interventions. In addition, a Medication Education Group listed on the unit schedule and assigned to nursing staff was not included on MTPs of four (4) of eight (8) active sample patients (A16, A17, and A20) who attended this group. These deficiencies result in treatment plans that fail to reflect a comprehensive, integrated, individualized approach to interdisciplinary treatment. (Refer to B122- I & II for details)

II. Based on record review, document review and interview, the facility failed to provide complete and timely discharge summaries in accordance with hospital policy for one (1) of five (5) sample patients (B2). This failure has the potential in delaying continuity of appropriate care post hospitalization. (Refer to B133 for details)

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

I. Develop and document comprehensive and individualized Master Treatment Plans (MTPs), called "Comprehensive Treatment Plan" by the facility, for eight (8) of eight (8) active sample patients (A1, A2, A5, A6, A14, A16, A17, and A20). Instead, social workers, with limited or no input from other clinical disciplines, completed treatment plans. Additionally, these MTPs were not developed to reflect all active treatment measures provided to patients. This lack of input by all team members and failure to include all active treatment measures on MTPs results in the potential to compromise patients' opportunity to receive appropriate treatment measures.

Findings Include:

A. Observation

1. A treatment team planning, called "Staffing" by the facility, was observed on 8/23/16 at 1:10 p.m. The attending psychiatrist, Director of social work, a registered nurse, and the supervisor of occupational therapy attended this meeting. The social worker was observed writing the treatment plans and updates while instructing the other team members to complete their interventions.

2. Patients were assigned to group treatment each day instead being of assigned by treatment team at the time MTPs were formulated. Group treatments based on clinical assessments and targeted needs to be addressed during each patient's hospitalization were not included on MTPs.

B. Interviews

1. In an interview on 8/22/16 at 10:23 a.m., RN2 indicated that treatment plans are written by the social worker and that patients are assigned group each morning based on how they are doing.

2. In an interview on 8/22/16 at 11:10 am, SW1 indicated that the treatment plans are written by the social worker.

3. In an interview on 8/23/16 at 2:35 p.m. with the Director of Social Work, the findings were confirmed.

II. Ensure that Master Treatment Plans (MTPs) were revised when patients experienced episodes of seclusion or restraint. Specifically, MTPs were not revised to reflect the use of seclusion or restraints to manage aggressive behaviors of one (1) active sample patient (A2) and two (2) non-sample patients (C2, and C3) selected to review episodes of seclusion and restraint. This failure can prevent the facility from identifying interventions, which would avoid future seclusion episodes for these patients.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A2 (8/10/16); C2 (7/7/16); and C3 (7/7/16). This review revealed that there was no evidence that MTPs were updated or modified to reflect the use of seclusion or restraint and the behaviors that led to the need for these restrictive procedures. There were no modifications of MTPs to include the following components: (1) A problem statement related to the use of seclusion or restraint to control aggressive behavior; (2) treatment goals aimed at patients learning and using alternative ways to handle aggression; and (3) Interventions reflecting what clinical staff would do in individual or group sessions to assist patients to use healthy alternatives and approaches to replace or reduce aggressive behavior(s).

B. Policy Review

Two facility policies were reviewed - "Seclusion" approved 5/28/16 and "Restraint" approved 6/5/16. These policies revealed that the facility did not comply with the following stipulations noted in both policies: "A registered nurse shall update the patient's nursing care plan to reflect the need for seclusion [restraint]." The policy statement did not include a requirement to update the comprehensive treatment plan. The policy also stipulated that, "The registered nurse shall modify patient's nursing care plan and comprehensive treatment plan to reflect information obtained from the episode and debriefing tool as needed." These policies provided no information regarding criteria to determine when the treatment plan must be updated or modified.

III. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components of the MTPs. Specifically, the MTPs were missing the following components:

A. Behaviorally descriptive psychiatric problem statements based on how presenting psychiatric symptoms were manifested by four (4) of eight (8) active sample patients. (A2, A5, A14, and A17). (Refer to B119)

B. Behavioral, measurable and observable treatment goals for four (4) of eight (8) active sample patients (A1, A6, A16 and A17). (Refer to B121)

C. Individualized and specific active treatment interventions with the focus of treatment to address each patient's presenting psychiatric problems for eight (8) of eight (8) active sample patients (A1, A2, A5, A6, A14, A16, A17, and A20). (Refer to B122)

Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patient's active treatment needs not being met.

Based on record review, document review, and interview, the facility failed to ensure that Master Treatment Plans (MTPs) included clearly defined problem statements written in behavioral and descriptive terms for four (4) of eight (8) active sample patients (A2, A5, A14, and A17). Specifically, problems identified on the MTPs included diagnostic and/or generalized psychiatric terms rather than behaviorally descriptive terms based on clinical assessment data and how presenting psychiatric symptoms were specifically manifested by each patient. These failures can adversely affect clinical decision-making in formulating active treatment goal and intervention statements. This results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems.

Findings include:

A. Record Review

1. Patient A2's MTP, dated 8/10/16, listed the following deficient psychiatric problem statement: "Mood instability - [Patient's name] has pressured speech, tangential thoughts, labile mood." This problem statement failed to include behavioral descriptions related to precisely how this patient manifested specific symptom of mood instability that led to hospitalization.

2. Patient A5's MTP, dated 8/18/16, listed the following deficient psychiatric problem statement: "Mood Instability - [Patient's name] has a labile mood, nonsensical talk, [decrease] sleep." This problem statement failed to include behavioral descriptions related to precisely how this patient manifested specific alterations in mood that led to hospitalization. There was no descriptions the level of sleep disturbance the patient was experiencing.

3. Patient A14's MTP, updated 8/9/16, listed the following deficient psychiatric problem statement: "Mania / Hypomania - [Patient's name] has dx [diagnosis of Bipolar and stopped meds [medication] and this led to labile mood, irratic bx [behaviors] [increases] paranoia, nonsensical...grandiose [with] delusions." This problem statement included a diagnosis and diagnostic terms to describe the patient's problem. The statement failed to include behavioral descriptions related to precisely how this patient manifested specific paranoia and delusional symptoms such as descriptions of the content and behaviors associated with these symptoms.

4. Patient A17's MTP, dated 8/17/16, listed the following deficient psychiatric problem statement: "Thought Processes - [Patient's name] feared [s/he] was having a mental breakdown and felt very anxious." This problem statement failed to include behavioral descriptions related to precisely how this patient manifested specific symptoms related to alteration in thought processes.

C. Interviews

1. An interview 8/23/16 at 3:20 p.m. with the Director of Nursing and Nursing Supervisor, MTPs were discussed. They did not dispute the findings that some problem statements were not individualized or written in behaviorally descriptive terms based on each patient's presenting psychiatric symptoms.

2. In an interview on 8/24/16 at 2:05 p.m. with the Medical Director, problems statements for active sample patient A2, A5, A14, and A17 were discussed. He did not dispute findings that problem statements were not written in descriptive and behavioral terms and stated, "I understand that they should be in language the patient can understand."

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) included specific long and short term goals written in language understandable to patients and free of psychiatric jargon for four (4) of eight (8) active sample patients (A1, A6, A16, and A17). This failure could prevent the development of specific interventions to assist in reaching treatment goals in a timely fashion thereby resulting in prolonged hospital stays.

Findings include:

A. Record review

1. Patient A1's MTP, dated 5/22/16, had a short term goal, "...will display a reality based thought process with a decrease in paranoid thoughts for five (5) consecutive days" and a long term goal, "...will be able to focus her thoughts on reality on reality by time of discharge."

2. Patient A6's MTP, dated 8/18/16, had a short term goal, "...will display a reality based thought process for five (5) consecutive days" and a long term goal, "...will be able to interact with others without defensiveness or anger by time of discharge."

3. Patient A16's MTP, dated 8/16/16, had a long-term goal, "...will participate in all scheduled AODA [Alcohol and Other Drugs of Abuse] programming without interference of symptoms for five (5) consecutive days."

4. Patient A17's MTP, dated 8/17/16, had short term goals, "...will display a reality based thought process with decrease in level of anxiety for five (5) consecutive days", and "...will participate in scheduled groups without interference of sx's [symptoms] for five (5) consecutive days."

B. Interviews

1. In an interview on 8/23/16 at 2:35 p.m. with the Director of Social Work, the findings were confirmed.

2. In an interview on 8/23/16 at 3:45 p.m. with the Medical Director and Chief of Psychiatry, the findings were confirmed.

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

I. Ensure that Master Treatment Plans (MTPs) consistently included individualized active treatment interventions that stated specific modalities with a frequency of contact and a specific focus or purpose of treatment for eight (8) of eight (8) active sample patients (A1, A2, A5, A6, A14, A16, A17, and A20). Instead, MTPs included routine discipline's functions such as "assessing," "monitoring," "encouraging," and "documenting" or instructions to staff written as active treatment interventions. These intervention statements were not related to each patient's individual psychiatric problems and failed to show what would be done by clinical disciplines to assist and involve patients in their recovery. Failure to include specific and planned active treatment interventions reflecting contact with each patient to provide clinical information and active psychiatric treatment potentially results in inconsistent and/or ineffective active treatment.

II. Include group treatments on MTPs treatment plans. Specifically, groups listed on the unit's group schedule and attended by five (5) of eight (8) active sample patients (A2, A5, A16, A17, and, A20) were not included on MTPs. This deficiency potentially results in staff being unable to provide consistent and focus active treatment.

I. Failure to include individualized active treatment interventions

A. Record Review

A review of medical records revealed that interventions on MTPs assigned to the psychiatrist (MD), social worker (SW), registered nurse (RN) and occupational therapist (OT) contained the following generic and routine discipline functions written as active treatment interventions instead of individualized specific active treatment interventions to assist patients to replace problem behaviors and to improve, reduce, and/or eliminate, presenting psychiatric symptoms. In addition, many intervention statements were identical or similarly worded despite different presenting symptoms and needs of each patient.

1. Patient A1's MTP, updated 7/20/16, contained the following generic statements and discipline functions for problem #1, "SI [Suicidal Ideation]..."


MD Intervention: There were no MD interventions included for the two problem statements on this patient's MTP.

SW Interventions: "Assist Pt [Patient] in developing ways to cope [with] MH [Mental Health] sx's [symptoms] [without] use of self harm 1-2x's [times] qwk [every week]." This intervention statement did not include whether contact with the patient would occur in individual or group sessions. "Assess for ability to participate in scheduled groups Mon-Fri." This was a routine clinical task and was not a social worker intervention related to planned contact with this patient to assist him or her with presenting psychiatric symptoms. In addition, this statement was identical or similarly worded for five (5) other active sample patients (A2, A5, A16, A17, and A20)

RN Interventions - "Staff will assess pt [patient] 1-2 x [times] per waking shift for any bx's [behaviors] / comments [sic] [increased] thoughts of self harm. Staff will intervene as needed & maintain pt [patient] safety, (1:1), inform Dr. [doctor]." These intervention statements were normal and routine nursing functions and would be performed as a part of regular job duties.

OT Intervention - "Provide an opportunity to express 2 positive comments and feelings of hopefulness for her future through discussion/task groups." This intervention statement did not include a frequency of contact and failed to identify specific groups that would be appropriate to address the patient's assessed needs and presenting symptoms.

2. Patient A2's MTP, dated 8/10/16, contained the following generic statements and discipline functions for problem #1, "SI [Suicidal Ideation]..."

MD Intervention: There were no MD interventions included for the two problem statements on this patient's MTP.

SW Intervention: "Assist Pt [Patient] in developing ways to cope [with] stressors [without] use of self harm bx's [behavior] 1-2x's [times] qwk [every week]." This intervention was not individualized and did not identify which coping skills would be appropriate or which stressors were thought to trigger suicidal ideation. "Assess for ability to participate in scheduled groups Mon-Fri." This was a routine clinical task and was not related to the patient's presenting psychiatric symptoms.

RN Interventions - "Staff assigned to have contact [with] pt [patient] 1-2 times per waking shift to assess suicidal thoughts. Pt [Patient] placed on 15 minutes safety checks." These intervention statements were routine nursing functions and would be performed as a part of regular nursing job duties. There were no active treatment interventions included that reflected planned contact to assist this patient to improve, reduce, and/or understand the identified psychiatric problems.

OT Intervention - "Provide an opportunity to verbalize not feeling suicidal [with] self harm as well as engage in healthy based interactions of hopefulness." This intervention statement did not include a frequency of contact and failed to identify whether this intervention would be delivered in individual or group sessions.

3. Patient A5's MTP, dated 8/18/16, contained the following generic statements and discipline functions for problem #1, "SI [Suicidal Ideation]..."

MD Interventions: "Pt [Patient] will be offered supportive therapy, meds [medications] to [decrease] mania, assist [with] [increasing] coping skills and [check] meds for safety, efficacy & side effects. There was no focus for the supportive therapy to be offered, no frequency of contact or specific medications noted. The intervention statement regarding checking medications for safety, efficacy, and side effects was a routine MD function.

SW Intervention: "Assist Pt [Patient] in developing ways to cope [with] stressors [without] use of self harm threats 1-2x's [times] qwk [every week]." This intervention was not individualized and did not identify the focus of coping skills that would be appropriate or which stressors were thought to trigger suicidal ideation. This identical statement was also included on patient A2's MTP. "Assess for ability to participate in scheduled groups Mon-Fri." This was a routine clinical task and was not related to the patient's identified psychiatric symptoms.

RN Interventions - "Staff will meet [with] pt [patient] a minimum of 1-2 times per waking shift to assess suicidal ideations." Staff will monitor pt's safety every 15 minutes as ordered, and staff will notify MD if safety concerns arise or persist." Again, these intervention statements were normal and routine nursing functions and would be performed as a part of regular nursing job duties. There were no nursing interventions developed for this patient's MTP reflecting planned contacts with the patient to assist him or her with the identified psychiatric problems.

OT Intervention - "Provide pt [patient] an opportunity to engage in coping strategies that can be used in place of self harm or threats to others." This intervention statement did not identify a frequency of contact, which coping skills based on assessed needs would be the focus of the intervention, or whether this intervention would be delivered in individual or group sessions.

4. Patient A6's MTP, dated 8/18/16, contained the following generic statements and discipline functions for problem #1, "Thought Processes..."

MD Interventions: "Continue to prescribe medications and [check] for side effects for [sic] of meds [medications] to [decrease] psychosis." This intervention was a routine MD function, did not identify medications, or have any specific focus to assist the patient with his or her identified psychiatric problems such as providing information about medications (side effects, benefits, etc.) and/or assisting this patient to manage psychiatric symptoms.

SW Intervention: "Assess level and intensity of thought disorder through therapeutic individual contacts 1-2 x's [times] qwk [every week]." "Assess for ability to participate in scheduled groups Mon-Fri." These assessment tasks were all routine clinical functions. There were no active treatment intervention to be performed by the SW regarding discharge planning or any active treatment interventions to assist the patient to improve and/or reduce identified psychiatric symptoms.

RN Interventions - "Staff will interact [with] pt [patient] on a 1:1 to assess pt's thought process for a minimum of 1-2 times per awake shift, and staff will document presence or absence of symptoms." These intervention statements were normal and routine nursing functions and would be performed as a part of regular nursing job duties. There were no active treatment interventions focusing on assisting the patient to improve and/or reduce the identified psychiatric problems.

OT Intervention - "Provide pt [patient] an opportunity to differentiate between actual life situations & those that appear real while in discussion groups." "Provide pt an opportunity to express reality based organized thoughts during discussion & task groups x [time] 2 sessions." These intervention statements failed to identify specific groups that would be appropriate to address the patient's assessed needs and presenting symptoms associated with alterations in thought processes. The first intervention did not include a frequency of contact.

5. Patient A14's MTP, dated 8/9/16, contained the following generic statements and discipline functions for problem #1, "Mania/Hypomania..."

MD Interventions: "MD to meet [with] [Patient's name] at least 3x/week to assess effects/side effects of meds [medications] for Mania." This intervention was a routine MD function, did not identify medications, or have any specific focus to assist the patient with his or her identified psychiatric problems such as providing information about medications (compliance, side effects, benefits, etc.) and/or assisting this patient to manage psychiatric symptoms.

SW Intervention: "Meet [with] [Patient's name] 1-2 x [times] q wk [every week] to assess mood/thought process and evaluate Tx [treatment] responses; relay info [information] to tx team." "Facilitate therapy program to [increase] insight and motivation for recovery." The first intervention included routine social worker functions and not an active treatment intervention related to assisting this patient's to improve his or her identified psychiatric symptoms. The second intervention was a generic statement not an active treatment intervention reflecting a delivery method, frequency of contact, and a focus of treatment based on the identified psychiatric problems.

RN Interventions - "Staff will respond to bx [behavior] by using active listening & offer pt [patient] feedback based on interactions. Staff will set limits as needed to provide for safety of pt & peers." These intervention statements were staff instructions and included approaches such as "active listening" and "setting limits" instead of active treatment interventions focusing on assisting the patient to improve and/or reduce the identified psychiatric problems. In addition, these interventions included no delivery method or frequency of contact.

OT Intervention - "Assess the ability to attend and actively participate in groups assigned, at least 2 of four groups when involved in discussion/task groups." "Evaluate patient to maintain relationship..." These intervention statements were routine OT tasks and not active treatment interventions reflecting specific groups that would be appropriate to address the patient's assessed needs and symptoms associated "mania/hypomania" symptoms.

6. Patient A16's MTP, dated 8/16/16, contained the following generic statements and discipline functions for problem #1, "Chemical Abuse..."

MD Interventions: "[Patient's name] will receive an AODA evaluation. [S/he] will be strongly encouraged to attend AODA programming." This intervention statement was a generic clinical activity and did not identify any active treatment interventions to be performed by the attending psychiatrist.

SW Intervention: "Complete AODA [Alcohol and other Drug Abuse] eval [evaluation] and determine ongoing AODA Tx [treatment] recommendations." "Facilitate AODA Programming to [increase] insight & motivation for recovery." These interventions included routine social worker assessment functions and were not active treatment interventions reflecting a frequency of contact and focus of treatment such as individual and/or group sessions to assist him or her to understand consequences of chemical dependency and/or identify options for AODA programing in the community.

RN Interventions - "Staff will initiate AODA referral for Assessment." "Staff encourage pt to focus on consequences of use." These intervention statements were nursing functions and not active treatment interventions reflecting a frequency of contact, delivery method (individual or group sessions), and a focus of treatment based on the identified psychiatric problems.

7. Patient A17's MTP, dated 8/17/16, contained the following generic statements and discipline functions for problem #1, "Thought Processes..."

MD Interventions: "MD to meet [with] [Patient's name] at least 3x/week to assess effects/side effects of meds [medications] for thought process disorder." This intervention was a routine MD function, did not identify medications, or have any specific focus to assist the patient with his or her identified psychiatric problems such as providing information about medications (side effects, benefits, etc.) and/or assisting this patient to manage psychiatric symptoms.

SW Intervention: "Assess level and intensity of thought disorder and anxiety 2-3 x's qwk [every week]." "Assess for ability to participate in scheduled groups Mon-Fri." These intervention statements were routine clinical duties/functions. There were no active treatment interventions to be performed by social workers related to discharge planning and/or active treatment measures to assist this patient's with his or her identified psychiatric symptoms.

RN Interventions - "Staff will assess for any [increase] in symptoms of paranoia and delusions." This intervention was a routine nursing functions and would be performed as a part of regular nursing job duties and did not have any specific active treatment intervention focusing on assisting the patient to improve and/or reduce the identified psychiatric problems.

8. Patient A20's MTP, dated 8/23/16, contained the following generic statements and discipline functions for problem #1, "SI [Suicidal Ideation]..."

MD Intervention: "MD to meet [with] [Patient's name] to assess diagnosis and dangerousness. MD to order 15 minutes suicide checks as appropriate." These intervention statements included routine MD functions and did not identify any active treatment interventions to be performed by the attending psychiatrist.

SW Intervention: "Assist Pt [Patient] in developing ways to cope [with] stressors [without] use of self harm bx's [behaviors] 1-2x's [times] qwk [every week]." This intervention did not include whether contact with the patient would occur in individual or group sessions. "Assess for ability to participate in scheduled groups Mon-Fri." This statement included a routine clinical task and was not an active treatment intervention related to the patient's presenting psychiatric symptoms.

RN Interventions - "Staff will assess pt [patient] 1-2 x [times] per waking shift for any statements or gestures r/t [related to] self harm. Staff will [sic] MD as needed of [increased] level of care as indicated." These intervention statements were normal and routine nursing functions and would be performed as a part of regular job duties. There were no active treatment interventions to be performed by registered nurses that were related to assisting this patient to improve or reduce the identified psychiatric symptoms.

OT Intervention - "Assess patient's ability to identify a minimum of two coping strategies [s/he] may express during discussion / task groups..." This intervention statement included a routine OT function of assessing, did not include a frequency of contact, and failed to identify the focus of coping strategies that would be appropriate to address the patient's assessed needs and presenting symptoms.

B. Interviews

1. An interview 8/23/16 at 3:20 p.m. with the Director of Nursing and Nursing Supervisor, MTPs were discussed. They acknowledged that statements on the treatment plan were not individualized and were written as routine and generic nursing functions rather than active treatment interventions to assist patients to address their specific presenting psychiatric problems.

2. During an interview with the Director of Social Work on 8/23/16 at 2:35 p.m. the findings were not refuted.

II. Failure to include active treatment groups attended by patients on MTPs

A. Observation and Record Review

1. The following observations of group treatment occurred on 8/22/16:

a. During observation from 1:35 to 2:25 p.m., active sample patients A16, A17, and A20 with six (6) other patients attended a group treatment listed on the unit's schedule titled, "Coping Skills." Patients in the group responded to questions on card regarding coping and recovery skills. A handout on "Stress Relievers" was distributed and discussed. This group was not included on MTPs of any of these active sample patients.

b. During observation from 2:50 p.m. to 3:40 p.m., active sample patients A2 and A5 with three (3) other patients attended a group treatment listed on the unit's schedule titled, "Leisure Skills." Patients participated in various activities including games and crafts. This group was not included on MTPs of any of these active sample patients.

2. The following observations of group treatment occurred on 8/23/16:

a. During observation from 9:20 to 9:45 a.m., active sample patients A16, A17, and A20 with 4 other patients attended a group treatment listed on the unit's schedule titled, "Medication Ed [Education]." Patients in the group participated in a tic tac toe game and responded to multiple-choice questions regarding medications and psychiatric symptoms. This group was not included on MTPs for any of these active sample patients.

b. During observation from 10:25 to 11:00 a.m., active sample patients A16, A17, and A20 with five (5) other patients attended a group treatment listed on the unit's schedule titled, "AODA [Alcohol and other Drug Abuse] Group." Patients in the group responded to true and false statements on a handout regarding various statements of beliefs about addiction. This group was not included on MTPs for any of these active sample patients.

3. The following observation of group treatment occurred on 8/24/16:

a. During observation from 9:15 a.m. to 9:45 a.m., active sample patients A16 with eight (8) other patients attended a group treatment listed on the unit's schedule titled, "Nutrition." Patients in the group responded to questions on a ball regarding various nutritional issues. This group was not included on active sample A16's MTP despite having an identified treatment problem regarding changes in appetite.

B. Interviews

1. An interview was conducted on 8/23/16 at 9:48 a.m. with RN #1 after the Medication Group was completed. RN #1 stated that she attends treatment-planning meetings but was not aware that the group was not included on treatment plans. She stated, "Social workers decide the groups."

2. During an interview with the Director of Social Work on 8/23/16 at 2:35 p.m. she confirmed that patients were assigned to "appropriate groups" each morning and not specifically during the treatment planning process.

3. An interview was conducted on 8/23/16 at 3:20 p.m. with the Director of Nursing and Nursing Supervisor. MTPs were discussed and they did dispute the findings that active treatment groups conducted by registered nurses were included on treatment plans. They acknowledged that treatment plans only included routine nursing functions or job duties.

Based on record review, document review and interview, the facility failed to provide complete and timely discharge summaries in accordance with hospital policy for one (1) of five (5) sample patients (B2). This failure has the potential in delaying continuity of appropriate care post hospitalization.

Findings include:

A. Record Review

Patient B2 was admitted 7/8/16 and discharged 7/13/16. The discharge summary was dictated 8/19/16 and transcribed 8/20/16. The summary was not signed as of 8/23/16.

B. Document Review

The facility's 2007 Medical and Psychological Staff Bylaws, Rules and Regulations, page 12 reads, "...A discharge note or summary will be completed on patients as soon as possible after discharge but in no instance later than 10 days after discharge."

C. Interviews

1. During an interview, 8/23/16 at 4:00 pm, with the Medical Director and Chief of Psychiatry, the finding was confirmed.

2. During an interview, 8/24/16 at 9:40 am, with the Director of Quality, the finding was confirmed and it was stated that late discharge summaries had been a trend they were looking to improve.

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

I. Ensure that treatment plans were comprehensive, specific and individualized goals for four (4) of eight (8) active sample patients (A1, A6, A16 and A17), individualized and specific interventions for eight (8) of eight (8) active sample patients (A1, A2, A5, A6, A14, A16, A17, and A20), and that plans were revised after the use of seclusion or restraint for one (1) of eight (8) active patients (A2) and two (2) non-sample patients (C2 and C3). This deficient practice could lead to prolonged hospitalization and ineffective treatment. (Refer to B118, B119, B121 and B122)

II. Ensure that patient discharge summaries are completed in a timely fashion to allow for smooth and coordinated aftercare treatment for one (1) of five (5) discharge records (B2). This deficient practice results in disruption in continuity of care and increases the potential for inappropriate treatment. (Refer to B133)

Based on observation, record review, document review, and interview, the facility failed to provide adequate oversight to ensure the quality of nursing practices. Specifically, the Director of Nursing failed to monitor to:

I. Ensure that MTPs were adequately developed and documented to include individualized active treatment interventions with a specific modality, frequency, and focus of treatment based on presenting psychiatric symptoms of eight (8) of eight (8) active sample patients (A1, A2, A5, A6, A14, A16, A17, and A20). Specifically, nursing interventions identified on MTPs were routine nursing functions associated with normal job duties. In addition, the facility failed to ensure that active treatment groups listed on the unit schedule and assigned to nursing staff were included on MTPs of four (4) of eight (8) active sample patients (A16, A17, and A20) who attended the Medication Education Group. These deficiencies resulted in treatment plans that failed to reflect comprehensive and individualized nursing interventions for active treatment. (Refer to B122 I & II)

II. Ensure that the face-to-face assessment included all elements of a comprehensive evaluation of episodes of seclusion and/or restraint for one (1) active sample patient (A2) and three (3) non-sample patients (C1, C2, and C3) selected for review of seclusion and restraints. In addition, the facility failed to ensure that each registered nurse (RN) who conducted the one-hour face-to-face assessments of patients placed in seclusion or restraints had documented evidence of competency to perform an evaluation of these restrictive procedures. The lack of adequately trained RNs potentially results in a failure to conduct a comprehensive review of the patient's condition and failure to determine whether other factors such as medication side effects and/or medical problems may have led to the patient' s behavior.

Findings include:

A. Record and Document Review

1. Patient A2 was secluded on 8/21/16 at 10:00 p.m. and released at 11:30. The "Seclusion Observation Monitoring Form" noted that the patient was secluded for the following behaviors, "...threatening to hit staff, hitting staff on shoulder and back...refusing to take po [by mouth] scheduled HS [night] meds [medications]..." The "Seclusion and Restraint Note: One-Hour Review" did not include an evaluation of the patient ' s response to the intervention of seclusion.

2. Patient C1 was placed in 5-point restraints on 7/12/16 at 1:45 p.m. and released at 3:15 p.m. The "Seclusion Observation Monitoring Form" noted that the patient was restrained for the following behaviors, "...[Patient's name] began to hit [himself/herself] [with] [his/her] fists...directed threats toward female staff..." The "Seclusion and Restraint Note: One-Hour Review" did not include an evaluation of the patient's response to the restraint intervention.

3. Patient C2 was secluded on 7/7/16 at 11:35 p.m. and released at 1:40 a.m. The "Seclusion Observation Monitoring Form" noted that the patient was secluded for the following behaviors, "...verbally aggressive...attempting to enter other pts [patients] rooms...tried to hit staff then kick staff ..." The "Seclusion and Restraint Note: One-Hour Review" did not include an evaluation of the patient's response to the seclusion intervention.

4. Patient C3 was placed in 5-point restraints on 7/11/16 at 1:40 p.m. and released at 3:35 pm. The "Seclusion Observation Monitoring Form" noted that the patient was restrained for the following behaviors, "...making threats r/t [related to] hurting the tx [treatment] team...slamming chairs..." The "Seclusion and Restraint Note: One-Hour Review" did not include an evaluation of the patient's response to the restraint intervention. In addition, a review of the face-to-face assessment form contained no evidence that a physician was consulted regarding the findings of the one-hour face-to-face assessment. The section on the one- hour assessment form titled "Attending Physician Update" was left blank.

B. Document Review

1. A review of competency folders of the registered nurses who conducted the face-to-face evaluation of non-sample patients C1, C2, and C3 revealed that the competency assessment documents had not been evaluated to determine each RN's competency. The Director of Nursing completed an evaluation of each RN's competency on 8/24/16 after being informed by the surveyor that none of the face-to-face assessment documents had been evaluated. She found that one of the 3 RNs reviewed did not pass the competency assessment. This RN did not have documented competency to perform the one-hour face-to-face assessment for non-sample patient C2.

2. A review of the training program revealed that there was no content regarding CMS requirements to: (1) evaluate the patient's reaction to the intervention after the initiation seclusion and restraint and (2) consult with the attending physician regarding the findings of the one-hour face-to-face assessment as soon as possible.

3. A review of the facility's policies titled, "Seclusion" and "Restraint" revealed that:
(1) There was no time frame established for the "as soon as possible" consultation with the attending physician noted in the policy and (2) there was no training requirements indicated to occur at orientation or on a periodic basis for RNs who performed the one-hour face-to-face assessment or general staff to participate in placing patients in seclusion or restraints.

B. Interviews

1. During interview on 8/23/16 at 4:20 p.m. with the Nursing Supervisor, episodes of seclusion and restraint were reviewed. She acknowledged that the face-to-face assessment did not include an evaluation of the patient's response to the restrictive intervention of seclusion or restraint.

2. During interview on 8/24/16 at 11:15 a.m., the Director of Nursing admitted that the RN who had completed the face-to-face assessment of non-sample patient C2 failed the competency assessment. She acknowledged that there was no documented evidence of competency for this RN to perform the required one-hour evaluation of episodes of seclusion and restraint.