HospitalInspections.org

Based on observation, facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure a safe setting for patients.

Findings include:

Observation tour on July 8, 2013, at 10:45 AM, of Pod C unit revealed two video game cords approximately four feet in length, one phone cord approximately six feet in length, and one phone cord approximately 12 feet in length were readily accessible to the patients located in the television sitting area.

Review on July 8, 2013, of "Patient Bill of Rights," dated 2013, revealed "... 12. You have a right to a physically and emotionally safe environment."

Interview on July 8, 2013, at 11:00 AM, with EMP3 confirmed there were two video game cords approximately four feet in length, one phone cord approximately six feet in length, and one phone cord approximately 12 feet in length were readily accessible to the patients located in the television sitting area. EMP3 confirmed the unit provides services to suicidal patients.

Based on review of facility documents, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to use restraints in accordance with physician orders for two of seven restraint medical records reviewed (MR6 and MR8).

Findings include:

Review of facility policy "Holds and Restraints," dated February 2013, revealed " ... 3.0 Physician Orders, Consultation, and Evaluation: ... 3.1 Hold or restraint shall be used in emergency situations only and requires an order from a physician ... "

1) Review of MR6 revealed a physician order dated June 3, 2013, for the patient to be placed in a physical hold. Further review of nursing documentation revealed that the patient placed in mechanical restraints and not a physical hold as ordered by the physician.

Interview on July 10, 2013, at 1:30 PM, with EMP2 confirmed that the patient was placed in mechanical restraints and not a physical hold as ordered by the physician.

2) Review of MR8 revealed a physician order dated June 22, 2013, for the patient to be placed in a physical hold. Further review of nursing documentation revealed that the patient was placed in mechanical restraints and not a physical hold as ordered by the physician.

Interview on July 10, 2013, at 1:30 PM, with EMP2 confirmed that the patient was placed in mechanical restraints and not a physical hold as ordered by the physician.

Based on review of facility documents, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to monitor and assess a patient during the use of physical restraints for one of seven restraint medical records reviewed (MR7).

Findings include:

Review of facility policy "Holds and Restraints," dated February 2013, revealed "... 4.6 The patient shall be assessed every 10 minutes by a Psych Tech or RN while in a hold/restraint, and every 15 minutes by an RN while in restraint ..."

Review of MR7 revealed a physician order, dated June 1, 2013, for ankle restraints. Further review revealed that the restraints were applied at 4:00 PM and released at 8:30 PM. A review of MR7 "Restraint Observation Record," revealed no documented evidence that the patient's Circulation, Hygiene, and Comfort were assessed on June 1, 2013, from 4:00 PM to 8:30 PM in accordance with facility policy.

Interview on July 10, 2013, at approximately 1:40 PM, with EMP2 confirmed that there was no documented evidence that the patient's Circulation, Hygiene, and Comfort were assessed in accordance with facility policy.

Based on a review of facility policy and medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure that all medical records were completed within 30 days of patient discharge for eight of 13 medical records reviewed (MR16, MR20, MR23, MR26, MR28, MR39, MR42 and MR44).

Findings include:

Review of "Medical Staff Bylaws, Section 5.9, Subsection 5.9.2," revealed "...All medical documentation shall be completed within 30 days following the patient's discharge. Incomplete records exceeding 30 days following discharge will be considered delinquent."

1) Review of MR16 revealed that the patient was discharged on May 29, 2013 and the record was not completed until July 3, 2013.

2) Review of MR20 revealed that the patient was discharged on May 9, 2013 and the record was not completed until June 12, 2013.

3) Review of MR23 revealed that the patient was discharged on May 2, 2013 and the record was not completed until June 10, 2013.

4) Review of MR26 revealed that the patient was discharged on May 10, 2013. During the survey it was revealed that the record had yet to be completed.

5) Review of MR28 revealed that the patient was discharged on March 29, 2013 and the record was not completed until May 3, 2013.

6) Review of MR39 revealed that the patient was discharged on May 21, 2013. During the survey it was revealed that the record had yet to be completed.

7) Review of MR42 revealed that the patient was discharged on May 15, 2013. During the survey it was revealed that the record had yet to be completed.

8) Review of MR44 revealed that the patient was discharged on May 18, 2013. During the survey it was revealed that the record had yet to be completed.

Interview on July 9, 2013, at 3:00 PM with EMP8 confirmed that the above medical records had not been completed within thirty days after discharge.

Based on review of facility policy, observation and interview with staff (EMP), it was determined that the dietary director failed to ensure established policies and procedures were maintained and implemented related to safe practices for food handling and kitchen sanitation.

Findings include:

Review on July 9, 2013, of the dietary department's policy "Infection Control," dated January 1, 2001, revealed "... 5. Food Storage ... l) Storage areas will be cleaned routinely ... 8. Pest Control: a. Appropriate measures will be taken for prevention of pests in food storage, housekeeping and cleanliness."

Review on July 9, 2013, of the dietary department's policy "Sanitation," dated January 1, 2001, revealed "It will be the responsibility of the Food Service Manager to see that sanitary conditions are maintained in food storage, food preparation and food service areas. Procedure: 1. Cleaning schedules will be planned which contain all areas of Food Service, when each is cleaned, by whom and procedures for cleaning. The cleaning duties will be performed as scheduled."

Observation tour on July 9, 2013, at approximately 9:15 AM, of the Dietary department revealed the following:

1. The dry storage room contained a six shelving unit which had a build up of a black, sticky like substance.

2. A build up of dirt and debris was noted under a shelving unit that contained pots and pans.

3. A ceiling vent, located in the three compartment sink room, was noted with a build up of dirt, dust and debris.

4. On top of the oven there was an accumulation of dirt, dust, and debris.

5. There was an accumulation of dirt, dust and debris on the wall near the entrance door of the walk in refrigerator. There was build up of dirt, dust and debris on the five shelve unit located against this entrance wall.

6. The housekeeping closet and the paper product room was observed with several gnats.

Interview on July 9, 2013, at approximately 9:30 AM, with EMP4 confirmed the above findings. Further interview with EMP4 confirmed that there was no provision in the Dietary policies and procedures regarding the cleaning of these areas.

A review on July 10, 2013, of facility policy, "Food Storage," dated January 1, 2001, revealed "Policy: Storage facilities will be provided and all storage properly maintained for the protection of food from contamination or spoilage and for the preservation of optimum quality ... Procedure ... 16. No out-dated food item will be used. If not used before expiration date shown on container, it will be discarded ... "

Observation on July 8, 2013, of the Adolescent Building's nutrition room revealed two loafs of bread that were marked "best by" June 16, 2013, and the other July 7, 2013.

Interview on July 8, 2013, at 10:45 AM, with EMP1 confirmed the above findings.

This condition level deficiency was cited during a Division of Life Safety survey completed on July 29, 2013. Further details are provided in the Division of Life Safety report.

Based on review of facility documents, observation, and interview with staff (EMP), it was determined the facility failed to maintain the hospital environment in a manner that assured the safety and well-being of patients.

Findings Include:

Review on July 10, 2013, of "Policy on Providing a Safe Environment," dated January 2013, revealed "... 5. Areas used by patients are clean ..."

Observation tour of Pod C unit on July 8, 2013, at 10:45 AM revealed the following:

1. The hallway floor of the unit appeared to be dirty and covered with dark stains.

2. The floor of rooms 1, 2, 3, 4, and 5, appeared to be dirty. There was garbage debris on the floors.

3. The hinges on the bathroom doors of rooms 1, 2, 3, 4, and 5, appeared to be rusty with an orange-brown like appearance.

4. There was a black-like substance which appeared to be mold on the bottom of the shower area for room number 4.

5. There was a black-like substance which appeared to be mold on the bottom of the shower area for room number 5.

6. The housekeeping room for Pod C had a black like substance, which appeared to be dirt, above the floor sink on the wall surrounding the sink. The floor sink also had a black like substance, which appeared to be a build up of dirt in it. There was a hole in the drywall approximately eight inches long by three inches wide on the wall across the door entrance and near the base trim. The ceiling vent in this room appeared dirty and dusty and rusty with a darkened orange-brown color appearance. Three ceiling tiles had dark brown stains on them.

Interview on July 8, 2013, at approximately 11:00 AM, with EMP3 confirmed the above findings.

Based on review of facility policy, observation and interview with staff (EMP), it was determined that the facility failed to ensure that facilities, supplies and equipment were maintained to ensure an acceptable level of safety and quality.

Findings include:

1) Review on July 10, 2013, of facility policy, "Safety Regulations," dated January 2013, revealed "A. General Safety Rules ... 7. Anyone seeing foreign matter on floors should mop it up, pick it up, or notify housekeeping ... "

Observation on July 8, 2013, of the Adolescent Building's Conference room revealed a torn chair. There was three water stained ceiling tiles.

Interview on July 8, 2013, at 10:30 AM, with EMP1 confirmed the above findings.

Observation on July 8, 2013, of the Adolescent Building's Restraint room revealed two packets of crackers on the floor.

Interview on July 8, 2013, at 10:35 AM, with EMP1 confirmed the above findings.

Observation on July 8, 2013, of the Adolescent Building's Quiet Room revealed various amount of debris on the floor to include food particles, wrappers, chalk, plastic cups, and the carpet was observed to be stained in multiple areas.

Interview on July 8, 2013, at 10:35 AM, with EMP1 confirmed the above findings.

Observation on July 8, 2013, of the A Pod's Psychiatric unit, rooms three, four, and five, revealed a bed in each room, where there was a space from the side of the beds to the adjacent wall. The space between each bed contained a various amount of debris to include: food particles, food wrappers, socks, and other unknown substances.

Interview on July 8, 2013, at 11:20 AM, with EMP1 confirmed the above findings.

2) Review on July 10, 2013, of facility policy, "Refrigerator Cleaning," dated January 2013, revealed "Policy: All refrigerators will be kept clean and have temperatures checked daily ... Purpose: To ensure storage of medication, food, and laboratory specimens in a sanitary area ... 4. Refrigerators will be cleaned with a bactericidal soap and water 5. Thermometers will be checked and placed back into the cleaned refrigerator ... 10. Refrigerator temperatures will be monitored daily by nursing, laboratory and maintenance ... 11. Any mechanical problems should be reported to the maintenance department via a work order ... "

Observation on July 8, 2013, of the Adolescent Building nurse's station revealed a laboratory specimen refrigerator that had a build up of ice accumulation and had a various amount of unknown stains.

Interview on July 8, 2013, at 10:50 AM, with EMP1 confirmed the above findings.

Observation on July 8, 2013, of the Adolescent Building medication room revealed a refrigerator, which contained milk, Ensure, and Pediasure containers. A further observation revealed a build up of ice accumulation and no thermostat to monitor the refrigerator's temperature. A request was made to EMP1 for documented evidence that the refrigerators temperature was being monitored daily as outlined in the facility's policy.

Interview on July 8, 2013, at 11:00 AM, with EMP1 confirmed the above findings and EMP1 confirmed that the refrigerator's temperature was not being monitored as outlined in the facility's policy.

3) Review on July 10, 2013, of facility policy, "Shelf Life," revealed " I. Purpose ... To establish a policy and procedure for the designation of shelf life for commercially prepared disposable items and sterilized items ... III. Definitions ... C. Expiration Date - That point in time at which items are no longer considered sterile ... "

Observation on July 8, 2013, of the Adolescent Building medication room revealed a container of Ketone Care test reagent strips for urinalysis that was marked expired April 21, 2011.

Interview on July 8, 2013, at 11:00 AM, with EMP1 confirmed the above finding.

4) On July 10, 2013, a request was made for a policy pertaining to storage of clean linens and disposal of soiled linens. Interview on July 8, 2013, at 1:00 PM, with EMP5 confirmed there was no policy to address storage and disposal of linens.

Observation on July 8, 2013, of N6 Unit, Clean Utility Room revealed a dirty linen cart containing dirty linen and two soiled white towels on the floor. Further observation revealed four corrugated boxes of overflow supplies on the floor, including lotions and deodorant for admission packets and paper products. There were six large linen bags filled with linen bags on the floor.

Interview on July 8, 2013, at 11:00 AM, with EMP6 and EMP8 confirmed the above findings.

Observation on July 8, 2013, of the Soiled Utility Room revealed three large bins contained clean linens: (a) one bin of white towels; (b) one bin of pink bedspreads; and (c) one bin of blue bedspreads.

Interview with EMP6 and EMP8 on July 8, 2013, at 11:20 AM confirmed the above findings.

Observation on July 8, 2013, of N4 Unit, Clean Utility Room revealed large bins of towels and spreads opened to air with plastic wrap draped and lying on the floor. Damage was noted to the drywall, including two areas of approximately three feet by six inches. There was a trash can in the rear of the room containing a soiled utility bag. A dirty utility cart frame with a dirty linen bag was also found in the clean utility room.

Interview on July 8, 2013, at 1:20 PM, with EMP 7 confirmed the above findings.

Observation on July 8, 2013 of N4 Unit, Housekeeping Closet revealed a very cluttered and disorganized area with excessive equipment. The floor of the closet was noted to be dirty.

Interview on July 8, 2013, at 1:30 PM, with EMP7 confirmed the above findings.

Based on observation record review, and interview, the facility failed to provide 9 of 9 active sample patients (A1, A2, A3, A4, B1, B2, B3, B4, and B5) with Master Treatment Plans (MTPs) which included individualized interventions that stated specific treatment modalities with a specific focus based on each patient's individual problems and goals. Instead, the MTPs listed routine generic discipline functions written as treatment interventions. MTPs also contained generic intervention statements which failed to include individualized clinical information based on patients' specific presenting symptoms and how interventions would be delivered for 8 of 9 active sample patients (A1, A2, A4, B1, B2, B3, B4, and B5). In addition, the facility failed to ensure that active treatment groups were included on the MTPs for 3 of 5 active sample patients (B2, B4, and B5) on Adult Services who were observed attending groups listed on program schedules. These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention and potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

I. Routine generic discipline tasks written as interventions.

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (5/21/13), A2 (6/1/13), A3 (6/11/13), A4 (6/5/13), B1 (5/17/13), B2 (6/24/13), B3 (6/24/13), B4 (6/25/13), and B5 (6/26/13). This review revealed that the MTPs had the following routine generic discipline tasks written as treatment interventions to be delivered by the psychiatrist, registered nurse (RN), social worker (SW) and allied therapist (AT). Several interventions were identical or similarly worded.

1. Three of 4 active sample patients on Adolescent Services (A1, A2, and A4) had the following r¿outine generic discipline functions written as treatment interventions selected from the problem forms entitled "Treatment Plan...Problem: (Goal) - Violence and Aggression."

MD Intervention: Patient A1 - "The psychiatrist will meet with (Patient's name) daily to assess mental status." "The psychiatrist will prescribe medications, monitor effects, and adjust doses as needed." Patient A2 - "Daily eval (evaluation) - for safety & progress. Med (medication) monitoring." Patient A4 - "Psych (Psychiatric) Tx (treatment) rounds - angry management." "Psych Rx (prescription) - help (with) mood."

RN Interventions: Patient A1 - "Nursing will monitor (Patient's name) daily for frustration, anger, and hostility." "Nursing will encourage (Patient's name) to participate in activities that improve self-control." Patients A2 and A4 - "Nursing to monitor signs of aggression and irritability." "Nursing staff will redirect inappropriate aggressive behavior."

SW Intervention: Patient A1 and A4 "SW (Social Worker) will contact family and providers re: (regarding) hx (history) of aggression."

2. Two of 4 active sample patients on Adolescent Services (A2 and A3) had the following routine generic discipline functions written as treatment interventions selected from the problem form entitled "Treatment Plan...Problem: (Goal) - Depressed Symptoms".

MD Interventions: Patient A2 - "Daily eval (evaluation) - for safety & progress." "Med (medication) monitoring." Patient A3 - "Assess pt (patient) for SXs (symptoms) depression [sic] (with) daily [sic]." Note: The second intervention was not legible.

RN Interventions: Patient A2 - "Nursing staff will assess (Patient's name) for suicidality, mood, and med (medication) effectiveness." Patient A3 - "Nsg (Nursing) staff will intervene early to diffuse a potential crisis."

3. Two of 4 active sample patients on Adolescent Services (A2 and A4) had the following routine generic discipline functions written as treatment interventions selected from the problem form entitled "Treatment Plan...Problem: (Goal) - Treatment/Medication Noncompliance".

MD Interventions: Patient A4 - "(Psychiatric) Rx (prescription) rechallenge." "(Psychiatric) compliance education in rounds."

RN Intervention: Patient A2 - "Nursing staff will monitor participation in groups." Patient A4 - "Nursing staff will encourage pt (patient) to attend scheduled groups daily."

AT Intervention: Patient A2 - "AT (Allied Therapy) will encourage pt (patient) to participate in group therapy & psychiatric services to (increase) mood stabilization."

SW Intervention: - Patient A2 - "SW (Social Worker) will schedule [sic] to discuss aftercare options with all stakeholders." Patient A4 - "SW will encourage pt's (patient's) compliance (with) tx (treatment) and meds (medications) and risk for harm [sic]."

4. Three out of 5 active sample patients on Adult Services (B1, B4, and B5) had the following identical or similarly worded routine generic discipline functions written as treatment interventions selected on the preprinted problem form entitled "Problem: Depression".

MD Intervention: "The psychiatrist will meet with (Patient's name) to assess mental status and progress." "The psychiatrist will prescribe medications, monitor effects, and adjust doses as needed."

RN Interventions: "Nursing staff to monitor signs of depression." Nursing staff will assess (Patient's name) daily for suicidality, mood, & med effectiveness." "Nursing staff to administer routine and prn (as needed) medications as needed." "Nursing staff will provide (Patient's name) with a safe, secure environment." "Nursing staff will offer daily encouragement to (Patient's name) for participation in Tx (treatment) plan." Interventions for Patient B5 were: "Nursing assessment to determine mood, physical status, & effectiveness of medication." "Nursing staff will encourage (Patient's name) to attend scheduled groups daily."

SW Intervention: "SW (Social Worker) will encourage pt (patient) to work on positive coping skills."

AT Intervention: "AT (Allied Therapy) will encourage (Patient's name) to participate in groups to build symptom [sic] to (decrease) depression."

5. Four of 5 active sample patients on Adult Services (B2, B3, B4, and B5) had the following identical or similarly worded routine generic discipline functions written as treatment interventions selected from the preprinted problem form entitled "Problem: Violence and Aggression."

MD Intervention: "The psychiatrist will meet with (Patient's name) daily to assess mental status and progress." "The psychiatrist will prescribe medications, monitor effects, and adjust doses as needed."

RN Interventions: "Nursing staff to monitor signs of aggression and irritability." "Nursing staff to administer routine and prn (as needed) medications as needed." "Nursing staff will question (Patient's name) about aggressive thoughts." For Patient B2 - "Nursing will encourage pt (patient) to participate in/attend scheduled groups, daily."

SW Intervention: "SW (Social Work) will contact family and providers re: hx (history) of aggression."

6. Two out of 5 active sample patients on Adult Services (B1 and B3) had the following routine generic discipline functions written as treatment interventions selected on the preprinted problem form entitled "Problem: Treatment Noncompliance."

MD Intervention: "The psychiatrist will meet with (Patient's name) to assess mental status and progress." "The psychiatrist will prescribe medications, monitor effects, and adjust doses as needed."

RN Interventions: "Nursing staff to administer routine and prn (as needed) medications as needed." "Nursing staff will monitor on precautions as ordered by physician."

SW Intervention: Patient B1 - "SW (Social Worker) will encourage pt (patient) to be compliance [sic] with tx (treatment)."

B. Staff Interviews

1. In the interview on 7/8/13 at 10:00 a.m. the Medical Director agreed that all interventions on the treatment plans were routine generic discipline functions.

2. In the interview on 7/8/13 at 10:30 a.m. Director of Psychology who agreed that interventions on treatment plans were routine generic discipline functions.

3. During interview on 7/8/13 at 4:00 p.m., with the Co-Director of Adult Services 1, Patient B1's MTP was reviewed. He confirmed that the treatment plan contained interventions that were routine generic nursing functions.

4. During interview on 7/10/13 at 9:00 a.m. with the Co-Director of Adult Services 2, the MTPs for Patients B2, B3, and B4 were reviewed. She confirmed that MTPs contained routine generic nursing tasks.

II. Failure to include individualized clinical information and delivery method for interventions.

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (5/21/13), A2 (6/1/13), A3 (6/11/13), A4 (6/5/13), B1 (5/17/13), B2 (6/24/13), B3 (6/24/13), B4 (6/25/13), and B5 (6/26/13). This review revealed that following interventions listed on MTPs to be delivered by the psychiatrist, registered nurse (RN), social worker (SW) and allied therapist (AT), failed to include individualized clinical information and to specify whether interventions would be held in group or individual sessions.

1. Patient A1 -
Problem: Violence/Aggression: SW Intervention: "SW (Social Worker) will work (with) pt (patient) to identify 2 (positive) coping skills to use (with) (his/her) anger."

Problem: Suicidal ideation: RN Intervention: "Nursing Staff will educate (Patient's name) on coping skills to deal with suicidal thoughts." SW Intervention: "SW will work (with) pt (patient) to identify 2 triggers to statements of SI (suicidal ideation)." "AT (Allied Therapy) will assist pt (patient) in identifying triggers to SI (suicidal ideation) & healthy coping skills. "

Problem: Psychosocial: RN Intervention: "Nursing will educate (Patient's name) about coping skills to deal with psychosocial issues."

2. Patient A2 -
Problem: Self Injury: "AT Intervention: AT (Allied Therapy) will assist pt (patient) in identifying [sic] triggers/warning signs assoc (associated) (with) self-injury." SW Intervention: "SW (Social Worker) will assist pt (patient) to identify triggers and early warning signs of self harm."

Problem: Treatment Compliance: RN Intervention: "Nursing staff will teach the importance of medication and treatment noncompliance." MD Interventions: Patient A2 - "Daily [sic] to PRN Med/Tx (Medication/Treatment) Education."

3. Patient A4 -
Problem: Treatment Compliance: RN Intervention: "Nursing staff will teach the importance of medication and treatment noncompliance." "Nursing staff will provide education about the possible consequences of noncompliance." AT Intervention: "AT (Allied Therapy) will educate pt (patient) on importance of being Tx (treatment) compliant."

4. Patient B1 -
Problem: Treatment Compliance: RN Intervention: "Nursing staff will teach the importance of medication and treatment noncompliance." AT Intervention: "AT (Allied Therapy) will educate pt (patient) on importance of Tx (treatment) compliance."

5. Patient B2 -
Problem: Violence and Aggression: RN Intervention: "Nursing staff will educate (Patient's name) on self-control & signs of frustration, anger, and hostility." AT Intervention: "The Allied Therapist will assist (Patient's name) in identifying triggers to anger/hostility."

Problem: Psychosocial Issues: RN Intervention: "Nursing staff will educate (Patient's name) on illness to promote self care & recovery."

Problem: Manic Behaviors: RN Interventions: "Nursing staff will educate (Patient's name) on mania/bipolar disorder & the importance of medication." "Nursing staff will educate (Patient's name) on early signs of frustration and irritability." AT Intervention: "The allied therapist will assist (Patient's name) in identifying triggers to mania."

6. Patient B3 -
Problem: Homicidal Ideation: RN Intervention: "Nursing will educate (Patient's name) on coping skills to deal with homicidal thoughts."

Problem: Treatment Noncompliance: RN Intervention: "Nursing staff will teach the importance of medication and treatment compliance." SW intervention: "SW (Social Worker) will educate pt (patient) on the importance of tx (treatment) compliance."

7. Patient B4 -
Problem: Depression. RN Intervention: "Nursing staff will educate (Patient's name) on illness to promote self care & recovery." AT Intervention: "The allied therapist will provide (Patient's name) with education on depression to promote self-care."

Problem: Substance Abuse. RN Intervention: "Nursing staff will educate (Patient's name) on substance abuse to promote self care & recovery."

8. Patient B5 -
Problem: Homicidal Ideation. RN Intervention: "Nursing will educate (Patient's name) on coping skills to deal with homicidal thoughts."

B. Interviews

1. In the interview on 7/8/13 at 10:30 a.m. Director of Psychology agreed with the finding regarding interventions statements failing to include (a) delivery method(s).

2. During interview on 7/8/13 at 4:00 p.m., with the Co-Director of Adult Services, Patient B1's MTP was reviewed. He confirmed that nursing intervention statements did not include whether the intervention would be delivered in group or individual sessions.

3. During interview on 7/10/13 at 9:00 a.m. with the Co-Director of Adult Services 2, the MTPs for Patients B2, B3, and B4 were reviewed. She confirmed that nursing intervention statements did not include whether they would be delivered in group or individual sessions.

III. Failure to include groups attended by patients on MTPs.

A. Observation and Interviews

1. During observation in the Group Room on 7/8/13 at 1:15 p.m., Patient B1 attended a group listed on Unit N1's schedule as "Coping with Stress." During interview at 1:40 p.m., Psychiatric Technician 1 (PT1) who was the group leader, stated patients were expected to attend all groups.

2. During observation on 7/8/13 at 2:00 p.m. in the Group Room, Patient B4 attended a group listed on Unit N4's schedule as "SW (Social Work) group - Discharge Planning." The Group leader was the Director of Psychology who during interview on 7/9/13 at 3:10 p.m., reviewed Patient B4's MTP and acknowledged that the group conducted was not on the MTP. He also noted the group he conducted was not a social work group and upon checking the schedule, noted that the schedule was not correct. During discussion with the Co-Director of Adult Services 1 on 7/8/13 at 4:00 p.m., the "Program Schedules" for adult services were reviewed. He confirmed that none of the groups on the schedules were included on MTPs and stated, "All patients are expected to attend groups on the program schedule."

3. During observation in the Group Room on 7/9/12 at 10:20 a.m., Patient B2 attended a group listed on Unit N2's program schedule as "Group Therapy." During interview with SW1 after the group, Patient B2's MTP was reviewed. SW1 acknowledged that because groups that patients were expected to attend were not on their treatment plans, it was difficult to determine the specific focus and need for each patient as it was related to topics presented during group sessions. SW1 confirmed that the group that Patient B2 attended was not on his/her MTP.

B. Record Review

1. A review of the MTP for Patient B1 dated 5/17/13, Patient B2 dated 6/24/13, and Patient B4 dated 6/25/13 revealed that the groups attended by these patients were not included on their treatment plans.

2. A review of the "Unit or Program Schedules" for N1- N5 revealed an array of active treatment groups including but not limited to "Process Groups", "Music Therapy", and "Group Therapy" by Allied Therapists; "Medication Education", "Illness Awareness" and "Illness education" by registered nurses; "Cognitive Therapy" and "SW Group- Discharge Planning" by social workers and "Conflict Resolution" and "Stress Management" by psychiatric technicians. None of the groups listed on program schedules were included on patients' MTPs.

Based on record and interview, the facility failed to provide MTPs that specified the names of staff responsible for interventions for 9 of 9 active sample patients (A1, A2, A3, A4, B1, B2, B3, B4 and B5). All of the MTPs listed only staff initials and discipline for all interventions. The weekly MTP review sheets also failed to identify responsible persons for the interventions. Failure to assign specific staff members for intervention modalities results in inability to determine what staff member is responsible for ensuring the interventions and lack of staff accountability, potentially hampering the effective coordination of treatment modalities.

A. Record Review

The MTPs for the following patients were reviewed (Director acknowledged that the treatment plans did not specify the names of staff respodates of plans in parentheses): A1 (5/21/13), A2 (6/1/13), A3 (6/11/13), A4 (6/5/13), B1 (5/17/13), B2 (6/24/13), B3 (6/24/13), B4 (6/25/13), and B5 (6/26/13). This review revealed that none of the 9 active sample patients' treatment plans included the names of staff persons responsible for the listed interventions.

B. Interview

In an interview on 07/09/2013 at 10:00 a.m., the Medical nsible for the listed interventions and that there was no system currently in place to identify staff by initials listed on MTPs.

Based on record review and interview, the facility failed to ensure that all nursing interventions listed on the Master Treatment Plans (MTPs) were actually delivered and documented by registered nurses for 5 of 5 active sample patients (B1, B2, B3, B4, and B5). Specifically, for several interventions identified on MTPs, there was no documentation showing patients' attendance or non-attendance in individual or groups sessions; the topic(s) discussed; and/or the patients' level of response to the treatment interventions. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (5/21/13), A2 (6/1/13), A3 (6/11/13), A4 (6/5/13), B1 (5/17/13), B2 (6/24/13), B3 (6/24/13), B4 (6/25/13), and B5 (6/26/13). This review revealed that for 5 of 5 active sample patients on Adult Services (B1, B2, B3, B4, and B5), there were very few or no treatment notes documented for interventions identified on the MTPs to be the responsibility of registered nurses.

1. Patient B1 was admitted 5/16/13. There were no individual treatment notes and only 1 group treatment note found for the following intervention related to Problem 3: "Treatment Noncompliance": "Nursing staff will teach the importance of medication and treatment noncompliance." The frequency for the intervention was "daily."

2. Patient B2 was admitted 6/24/13. There were no individual and group treatment notes by registered nurses found for the following intervention related to Problem 2: "Violence and Aggression": "Nursing will educate (Patient's name) on self-control & signs of frustration, anger, and hostility." The frequency for the intervention was "daily." For the Problem "Psychosocial Issues", there were no individual or group treatment notes by registered nurses found for the following intervention: "Nursing staff will educate (Patient's name) on illness to promote self care & recovery." The frequency for the intervention was "daily."

3. Patient B3 was admitted 6/24/13. There were no individual and group treatment notes by registered nurses found for the following intervention related to Problem 2: "Homicidal Ideation" on the MTP: "Nursing will educate (Patient's name) on coping skills to deal with homicidal thoughts." The frequency for the intervention was "daily." For the Problem "Treatment Noncompliance", there were no individual treatment notes and only two "Medication Education Group treatment notes by registered nurses found for the following intervention". Nursing staff will teach the importance of medication and treatment compliance. The frequency for the intervention was "daily." During observation on 7/9/13 from 9:00 a.m. to 11:00 a.m., the two Medication Education Groups listed on the program schedules at 9:30 a.m. and 10:30 a.m. on 7/9/13 were not held. During observation of medications being administered to patients on 7/9/13 at 8:45 in the nursing station, the nurse provided patients information on the names of their medication and did not provide information on benefits of medications or medication compliance. During interview with RN1 on 7/9/13 at 10:00 a.m., the medication education group was discussed. RN1 stated, "I try to do medication education when I give them their medications." RN1 confirmed that this education was not documented in the medical record.

4. Patient B4 was admitted 6/25/13. There were no individual and group treatment notes by registered nurses found for the following intervention related to Problem 1: "Depression": "Nursing will educate (Patient's name) on illness to promote self- care & recovery." The frequency for the intervention was "daily." For Problem 2, "Substance Abuse", there were no individual or group treatment notes by registered nurses found for the following intervention: "Nursing staff will educate (Patient's name) on substance abuse to promote self care & recovery." The frequency for the intervention was "daily."

5. Patient B5 was admitted 6/24/13. There were no individual and group treatment notes by registered nurses found for the following intervention related to Problem 2: "Homicidal Ideation": "Nursing will educate (Patient's name) on coping skills to deal with homicidal thoughts." The frequency for the intervention was "daily."

B. Interviews

1. During interview on 7/8/13 at 4:00 p.m. with the Co-Director of Adult Services 1, the medical record for Patient B1was reviewed. He acknowledged that there were very few or no treatment notes documented by registered nurses given the number of interventions scheduled for the patient.

2. During interview on 7/9/13 at 1:40 p.m., Patient B2 stated, "I have not received any education about my medication from the nurse."

3. During interview on 7/10/13 at 9:00 a.m. with the Co-Director of Adult Services 2, the medical record for Patients B2, B3, and B4 were reviewed. She acknowledged that there were few or no treatment notes documented by registered nurses given the number of interventions scheduled for these patients.

Based on observation, record review and interview, the Medical Director failed to adequately ensure the quality and appropriateness of services provided. Specifically, the Medical Director failed to:

I. Ensure that MTPs for 9 of 9 active sample patients (A1, A2, A3, A4, B1, B2, B3, B4, and B5) included individualized interventions that stated specific treatment modalities with a specific focus based on each patient's individual problems and goals. Instead, the MTPs listed routine and generic discipline functions written as treatment interventions.

II. Include individualized clinical information based on patients' specific presenting symptoms and the delivery method which specified whether interventions would be held in group or individual sessions for 9 of 9 active sample patients (A1, A2, A4, B1, B2, B3, B4, and B5). Active treatment groups were not included on the MTPs for 3 of 5 active sample patients (B2, B4, and B5) on Adult Services who were observed attending groups listed on program schedules.

The deficiencies above result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention and potentially resulting in inconsistent and/or ineffective treatment. (Refer to B122)

III. Ensure that the MTPs specified the names of staff responsible for interventions for 8 of 9 active sample patients (A1, A2, A3, A4, B1, B2, B3, B4 and B5). All of the MTPs listed only staff initials and discipline for all interventions. The weekly MTP review sheets also failed to identify responsible persons for the interventions. Failure to assign specific staff members for intervention modalities results in inability to determine what staff member is responsible for ensuring the interventions and lack of staff accountability, potentially hampering the effective coordination of treatment modalities. (Refer to B123)

Based on observation, record review, and interview, the Director of Nursing (DON) failed to provide adequate oversight to ensure quality nursing services. Specifically, the DON failed to:

I. Provide 9 of 9 active sample patients (A1, A2, A3, A4, B1, B2, B3, B4, and B5) with Master Treatment Plans (MTPs) which included individualized nursing interventions that stated specific treatment modalities with a specific focus based on each patient's individual problems and goals. Instead, the MTPs listed routine and generic nursing functions written as treatment interventions. This deficiency results in a failure to guide nursing staff regarding the use of specific and individualized treatment modalities potentially resulting ineffective treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (5/21/13), A2 (6/1/13), A3 (6/11/13), A4 (6/5/13), B1 (5/17/13), B2 (6/24/13), B3 (6/24/13), B4 (6/25/13), and B5 (6/26/13). This review revealed that the MTPs had the following routine generic nursing tasks written as treatment interventions to be delivered by the registered nurse (RN). Several interventions were identical or similarly worded.

1. Three of 4 active sample patients on Adolescent Services (A1, A2, and A4) had the following identical or similarly worded routine generic nursing functions written as treatment interventions selected from the preprinted problem form entitled "Treatment Plan...Problem: (Goal) - Violence and Aggression".

RN Intervention: Patient A1 - "Nursing will monitor (Patient's name) daily for frustration, anger, and hostility." "Nursing will encourage (Patient's name) to participate in activities that improve self-control." Patients A2 and A4 - "Nursing to monitor signs of aggression and irritability." "Nursing staff will redirect inappropriate aggressive behavior."

2. Two of 4 active sample patients on Adolescent Services (A2 and A3) had the following routine generic nursing functions written as treatment interventions selected from the preprinted problem form entitled "Treatment Plan...Problem: (Goal) - Depressed Symptoms".

RN Interventions: Patient A2 - "Nursing staff will assess (Patient's name) for suicidality, mood, and med (medication) effectiveness." Patient A3 - "Nsg (Nursing) staff will intervene early to diffuse a potential crisis."

3. Patient A2 had the following routine generic nursing function written as treatment interventions selected from the preprinted problem form entitled "Treatment Plan...Problem: (Goal) - Treatment/Medication Noncompliance". RN Intervention: "Nursing staff will monitor participation in groups."

4. Three out of 5 active sample patients on Adult Services (B1, B4, and B5) had the following identical or similarly worded routine generic nursing functions written as treatment interventions selected from the preprinted problem form entitled "Problem: Depression".

RN Interventions: "Nursing staff to monitor signs of depression." "Nursing staff will assess (Patient's name) daily for suicidality, mood, & med effectiveness." "Nursing staff to administer routine and prn (as needed) medications as needed." "Nursing staff will provide (Patient's name) with a safe, secure environment." "Nursing staff will offer daily encouragement to (Patient's name) for participation in Tx (treatment) plan." Interventions for Patient B5 were: "Nursing assessment to determine mood, physical status, & effectiveness of medication." "Nursing staff will encourage (Patient's name) to attend scheduled groups daily."

5. Four of 5 active sample patients on Adult Services (B2, B3, B4, and B5) had the following identical or similarly worded routine generic nursing functions written as treatment interventions selected from the preprinted problem form entitled "Problem: Violence and Aggression".

RN Interventions: "Nursing staff to monitor signs of aggression and irritability." "Nursing staff to administer routine and prn (as needed) medications as needed." "Nursing staff will question (Patient's name) about aggressive thoughts." For Patient B2: "Nursing will encourage pt (patient) to participate in/attend scheduled groups, daily."

6. Two out of 5 active sample patients on Adult Services (B1 and B3) had the following identical routine and generic nursing functions written as treatment interventions selected from the preprinted problem form entitled "Problem: Treatment Noncompliance".

RN Interventions: "Nursing staff to administer routine and prn (as needed) medications as needed." "...monitor signs of depression." "Nursing staff will monitor on precautions as ordered by physician."

B. Staff Interviews

1. During interview on 7/8/13 at 4:00 p.m., with the Co-Director of Adult Services Patient B1's MTP was reviewed. He confirmed that the treatment plan contained interventions that were routine generic nursing functions.

2. During interview on 7/9/13 at 1:30 p.m. with the Chief Nursing Officer (CNO), the MTPs for Patient B2, B3, and B4 were reviewed. She acknowledged the treatment plans listed generic and routine generic nursing tasks.

3. During interview on 7/10/13 at 9:00 a.m. with the Co-Director of Adult Services 2, the MTPs for Patients B2, B3, and B4 were reviewed. She confirmed that MTPs contained routine generic nursing tasks.

II. Include individualized clinical information based on patients' specific presenting symptoms and the delivery method which specified whether nursing interventions would be held in group or individual sessions for 8 of 9 active sample patients (A1, A2, A4, B1, B2, B3, B4, and B5). This deficiency results in a failure to guide nursing staff regarding the specific approach needed for interventions potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (5/21/13), A2 (6/1/13), A3 (6/11/13), A4 (6/5/13), B1 (5/17/13), B2 (6/24/13), B3 (6/24/13), B4 (6/25/13), and B5 (6/26/13). This review revealed that 8 of 9 active sample patients (A1, A2, A4, A4, B1, B2, B3, B4, and B5) had the following nursing interventions listed on MTPs to be delivered by the registered nurse (RN) failed to specify whether interventions would be deliver in group or individual sessions.

1. Patient A1 - Problem: Suicidal ideation: "Nursing Staff will educate (Patient's name) on coping skills to deal with suicidal thoughts." Problem: Psychosocial: "Nursing will educate (Patient's name) about coping skills to deal with psychosocial issues."

2. Patient A2 - Problem: Treatment Compliance: "Nursing staff will teach the importance of medication and treatment noncompliance."

3. Patient A4 - Treatment Compliance: "Nursing staff will teach the importance of medication and treatment noncompliance." "Nursing staff will provide education about the possible consequences of noncompliance."

4. Patient B1 - Treatment Compliance: "Nursing staff will teach the importance of medication and treatment noncompliance."

5. Patient B2 - Violence and Aggression: "Nursing staff will educate (Patient's name) on self-control & signs of frustration, anger, and hostility". Problem: Psychosocial Issues: "Nursing staff will educate (Patient's name) on illness to promote self care & recovery." Problem: Manic Behaviors: "Nursing staff will educate (Patient's name) on mania/bipolar disorder & the importance of medication." "Nursing staff will educate (Patient's name) on early signs of frustration and irritability."

6. Patient B3 - Problem: Homicidal Ideation: "Nursing will educate (Patient's name) on coping skills to deal with homicidal thoughts." Problem: Treatment Noncompliance: "Nursing staff will teach the importance of medication and treatment compliance."

7. Patient B4 - Problem: Depression: "Nursing staff will educate (Patient's name) on illness to promote self care & recovery." Problem: Substance Abuse: "Nursing staff will educate (Patient's name) on substance abuse to promote self care & recovery."

8. Patient B5 - Problem: Homicidal Ideation: "Nursing will educate (Patient's name) on coping skills to deal with homicidal thoughts."

B. Staff Interviews

1. During interview on 7/8/13 at 4:00 p.m. with the Co-Director of Adult Services 1, Patient B1's MTP was reviewed. He confirmed that nursing intervention statements did not include whether intervention would be delivered in group or individual sessions.

2. During interview on 7/9/13 at 1:30 p.m. with the Chief Nursing Officer (CNO), the MTPs for Patient B2, B3, and B4 were reviewed. She acknowledged that nursing intervention statements did not include whether intervention would be delivered in group or individual sessions.

3. During interview on 7/10/13 at 9:00 a.m. with the Co-Director of Adult Services 2, the MTPs for Patients B2, B3, and B4 were reviewed. She confirmed that nursing intervention statements did not include whether intervention would be delivered in group or individual sessions.

III. Ensure that all nursing interventions listed on the Master Treatment Plans (MTPs) were actually delivered and documented by registered nurses for 5 of 5 active sample patients (B1, B2, B3, B4, and B5). Specifically, for several interventions identified on MTPs, there was no documentation showing patients' attendance or non-attendance in individual or groups sessions; the topic(s) discussed; and/or the patients' level of response to the treatment interventions. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed. (Refer to B124)