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Based on observations, record reviews, and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) Having an unlocked cabinet under the sink in the day room that provided an opportunity for patients to hide and having a broken formica tile on the counter in the day room with a sharp edge that provided a safety risk for patients;
2) Having hinges on the doors to the hall shower room and the doors to the toilet room within the shower room that were not ligature proof and provided an opportunity for strangulation;
3) Having a plastic liner in the trash can located in the outdoor area that was accessible to patients that provides an opportunity for suffocation;
4) Having screws on the light switch in the day room bathroom that were not tamper-proof;
5) Having beds with side rails, hand cranks, and multiple ligature points in Rooms a, b, c, d, and e that provide an opportunity for strangulation;
6) Having electrical outlets that are not safeguarded in all patient bedrooms that provide an opportunity for electrocution;
7) Having door handles not installed to be ligature-proof in patient rooms that provided an opportunity for strangulation;
8) Having door hinges that are not ligature-proof providing an opportunity for strangulation in in Rooms c, b, d, e, f, g, h, and i;
9) Having bedroom door lock systems with non-tamper-proof screws;
10) The towel dispenser in the seclusion bathroom with a sharp edge that could present a risk for cutting a patient's skin;
11) Having the video surveillance monitor located in the nurse's station able to be seen be individuals standing in the hall at the right corner of the door located between the nurse's station and the hall used by patients and staff;
12) Having an 8 feet fence surrounding the outdoor area used by patients with 7 movable chairs that presented an elopement risk.
Findings:

1) Having an unlocked cabinet under the sink in the day room that provided an opportunity for patients to hide and having a broken formica tile on the counter in the day room with a sharp edge that provided a safety risk for patients:
Observation on 11/16/16 at 9:30 a.m. with S1ADM and S2IDON present revealed the door to the cabinet under the sink in the day room was unlocked and created a large space that could be used as a hiding place for patients. Further observation revealed the formica tile on the counter in the day room was chipped and had a sharp edge that presented a safety risk for cutting.

In an interview on 11/16/16 at 9:30 a.m. at the time of the observation, S1ADM confirmed the above findings.

2) Having hinges on the doors to the hall shower room and the doors to the toilet room within the shower room that were not ligature proof and provided an opportunity for strangulation:
Observation on 11/16/16 at 8:45 a.m. revealed the entrance door to the hall shower room and the interior door to the patient toilet had hinges that were not continuous. The space between the hinges were wide enough to present a ligature risk.

In an interview on 11/16/16 at 8:45 a.m. at the time of the observation, S2IDON confirmed the hinges presented a ligature risk.

3) Having a plastic liner in the trash can located in the outdoor area that was accessible to patients that provides an opportunity for suffocation:
Observation on 11/16/16 at 9:15 a.m. revealed the trash can located on the patio in the outdoor area used by patients had a plastic liner that presented a risk for suffocation.

In an interview on 11/16/16 at 9:15 a.m., S1ADM confirmed the plastic liner was in a patient care area.

4) Having screws on the light switch in the day room bathroom that were not tamper-proof:
Observation on 11/16/16 at 9:20 a.m. revealed the screws on the light switch in the day room bathroom were not tamper-proof. This observation was confirmed by S2IDON.

5) Having beds with side rails, hand cranks, and multiple ligature points in Rooms a, b, c, d, and e that provide an opportunity for strangulation:
Observation on 11/16/16 at 9:00 a.m. revealed the beds in Rooms a, b, c, d, and e had side rails, hand cranks, and multiple ligature points that presented a risk to psychiatric patients.

Review of Patient R1's medical record record revealed she had a diagnosis of Depression with Suicidal Ideations and was placed on suicide precautions. Patient R1 was admitted to Room c (bed B).

Review of Patient R2's medical record record revealed she had a diagnosis of Depression with Suicidal Ideations and was placed on suicide precautions. Patient R2 was admitted to Room c (bed A).

Review of Patient R3's medical record record revealed she had a diagnosis of Depression with Suicidal Ideations and was placed on suicide precautions. Patient R3 was admitted to Room b.

Review of the policy titled "Suicide Precautions", presented as a current policy by S1ADM, revealed that the patient's room shall be searched for sharp objects, medications, glass, and other potentially harmful objects.

In an interview on 11/16/16 at 9:00 a.m., S2IDON confirmed the beds listed above presented a ligature risk to psychiatric patients.

In an interview on 11/16/16 at 10:30 a.m., S1ADM confirmed Patients R1, R2, and R3 were admitted to rooms that had beds with side rails, hand cranks, and other ligature points that presented a ligature risk to psychiatric patients. She further indicated that each of these patients were diagnosed with Depression with Suicide Ideations and were placed on suicide precautions.

6) Having electrical outlets that are not safeguarded in all patient bedrooms that provide an opportunity for electrocution:
Observation on 11/16/16 at 9:00 a.m. revealed all patient bedrooms had electrical outlets that were not safeguarded from tampering by patients and presented a risk for electrocution. This observation was confirmed by S2IDON.

7) Having door handles not installed to be ligature-proof in patient rooms that provided an opportunity for strangulation:
Observation on 11/16/16 at 9:00 a.m. revealed the door handles in patient rooms were not installed to be ligature-proof and provided an opportunity for strangulation by tying a sheet around the handle and hanging the tied sheet over the door. Further observation revealed S1ADM tied a sheet on the door handle and draped the sheet over the door which resulted in the sheet not coming loose from the door handle when pulled.

In an interview on 11/16/16 at 9:00 a.m., S1ADM and S2IDON confirmed the above findings.

8) Having door hinges that are not ligature-proof providing an opportunity for strangulation in in Rooms c, b, d, e, f, g, h, and i:
Observation on 11/16/16 at 9:10 a.m. revealed the door hinges in Rooms c, b, d, e, f, g, h, and i had spaces between each hinge that provided a means for strangulation. This observation was confirmed by S2IDON.

9) Having bedroom door lock systems with non-tamper-proof screws:
Observation on 11/16/16 at 9:10 a.m. revealed all bedroom door handles were installed with non-tamper-proof screws. This observation was confirmed by S2IDON.

10) The towel dispenser in the seclusion bathroom with a sharp edge that could present a risk for cutting a patient's skin:
Observation on 11/16/16 at 8:50 a.m. revealed the towel dispenser in the seclusion room bathroom had a sharp edge where the paper was dispensed that presented an opportunity for patients to cut themselves. This observation was confirmed by S2IDON.

11) Having the video surveillance monitor located in the nurse's station able to be seen be individuals standing in the hall at the right corner of the door located between the nurse's station and the hall used by patients and staff:
Observation on 11/16/16 at 9:10 a.m. revealed the video surveillance monitor screen that was located in the nursing station and used to monitor various locations in the hospital, including the seclusion room, could be seen through the glass door of the nursing station from the hallway used by patients and staff when standing in the right corner of the door. This observation was confirmed by S2IDON.

12) Having an 8 feet fence surrounding the outdoor area used by patients with 7 movable chairs that presented an elopement risk:
Observation on 11/16/16 at 9:15 a.m. of the outdoor area used by patients revealed an 8 feet wooden fence surrounding the area. There was an area that was not visible (around the corner of the building) when staff was standing on the patio outside the exit door from the hospital to the outdoor area. Further observation revealed 7 movable chairs located on the patio that could be used as a means of climbing the fence to elope.

In an interview on 11/16/16 at 9:15 a.m., S1ADM indicated the hospital has had an elopement by the patient scaling the fence while in the outdoor area while the staff member was on the patio distributing cigarettes to other patients. She further indicated the hospital planned to raise the height of the fence, but this had not been done as of the time of the survey.

Based on record reviews and interview, the hospital failed to ensure each patient received a psychiatric evaluation that included an inventory of the patient's assets in descriptive, not interpretive, fashion as evidenced by having patient assets described in interpretive fashion rather than descriptive fashion for 5 (#1, #2, #3, #4, #5) of 5 patient records reviewed for psychiatric evaluations from a total sample of 5 patients.
Findings:

Review of the policy titled "Psychiatric Evaluation", presented as a current policy by S1ADM, revealed that a psychiatric evaluation is completed by the psychiatrist or psychiatric nurse practitioner within 60 hours of admission that includes patient's assets. There was no documented evidence that the policy required the patient's assets to be documented in descriptive, not interpretive, fashion.

Review of the psychiatric evaluations conducted by S4NP for Patient #1 on 11/07/16 and for Patient #2 on 11/10/16 revealed she documented each of the patients' assets as "adequate finances." There was no documented evidence that Patient #1's and Patient #2's assets were documented in descriptive fashion as required by the regulations.

Review of Patient #3's psychiatric evaluation conducted by S4NP on 11/07/16 revealed his asset, "motivated", was not documented in descriptive terms.

Review of the closed medical records of Patient #4 and Patient #5 revealed their psychiatric evaluation was conducted by S3MD on 10/05/16. Their asset was documented by S3MD as "motivated." There was no documented evidence that Patient #4's and Patient #5's asset was documented in descriptive fashion.

In an interview on 11/17/16 at 11:20 a.m., S1ADM indicated S4NP was not available for interview while the surveyor was onsite. She reviewed the psychiatric evaluations conducted by S4NP and S3MD for Patients #1, #2, #3, #4, and #5 and confirmed each asset was documented in interpretive fashion rather than descriptive fashion.

Based on record reviews and interview, the hospital failed to ensure each patient had an individualized comprehensive treatment plan that included patients' medical diagnoses as evidenced by failure to include patients' medical diagnoses in the patients' comprehensive treatment plan for 2 (#1, #2) of 3 (#1, #2, #3) patient records reviewed for comprehensive treatment plans from a total sample of 5 patients.
Findings:

Review of the policy titled "Treatment Plans", presented as a current policy by S1ADM, revealed that each patient will have an individualized inter-disciplinary treatment plan developed under the direction of the psychiatrist. The plan will incorporate treatment interventions and outline individualized specific short-term and long-term goals to evaluate therapeutic progress. Within 8 hours of admission, a problem list is initiated based on the initial assessments of the interdisciplinary team. Further review revealed a nurse completes the initial treatment plan that is based on an assessment of presenting problems, physical health, and emotional and behavioral status.

Patient #1
Review of Patient #1's medical record revealed his diagnoses included Depression with Suicidal Ideations, Hypertension, Bariatric Surgery, and Polysubstance Abuse. Review of his treatment plan revealed no documented evidence that his plan included problems of Hypertension and Bariatric Surgery with interventions and goals related to each.

Patient #2
Review of Patient #2's medical record revealed his diagnosis was Paranoid Schizophrenia. Further review revealed his medications included Catapres 0.05 milligram orally at bedtime for Hypertension. Further review revealed a physician's order on 11/11/16 at 7:05 p.m. for Robitussin 10 milliliters orally every 4 hours as needed for cough/congestion. Review of Patient #2's treatment plan revealed no documented evidence that a plan was developed for Hypertension and revised when medication was prescribed for cough/congestion.

In an interview on 11/17/16 at 11:10 a.m., S8RN indicated if a physician orders an antibiotic for an infection, the nurse would add infection to the treatment plan. She further indicated she doesn't usually revise the treatment plan when medication is ordered for cough/congestion. S8RN indicated the nurses do treatment plans for psychiatric diagnoses only, unless a patient's medical diagnosis isn't maintained.

Based on record reviews and interviews, the hospital failed to ensure the written treatment plan of each patient included the specific treatment modalities utilized as evidenced by failure to have documented evidence that each patient's written treatment plan included the active treatment measures provided to the patient by S7AD that included the specific purpose and focus for each patient for 5 (#1, #2, #3, #4, #5) of 5 patient records reviewed for inclusion of all treatment modalities from a total sample of 5 patients.
Findings:

Review of the policy titled "Treatment Plans", presented as a current policy by S1ADM, revealed that each patient will have an individualized inter-disciplinary treatment plan developed under the direction of the psychiatrist. The plan will incorporate treatment interventions and outline individualized specific short-term and long-term goals to evaluate therapeutic progress. The Master Treatment Plan is based on the findings of each contributing discipline which describes the patient's problems, strengths, clinical needs, and the patient's goals for treatment. The type and frequency of interventions used to obtain the objectives are specified, and the staff member(s) are identified.

Review of the policy titled "Activity Therapy", presented as a current policy by S1ADM, revealed that activity groups will be structured groups provided by designated staff under the written plan and supervision of the Activities Director. Assessments will be completed within 72 hours of admission and will be used to identify problems, set goals, and implement specific treatment modalities in the patient's multidisciplinary treatment plan.

Review of the physician's orders for Patients #1, #2, #3, #4, and #5 revealed an order for groups per program schedule.

Review of the "Daily Patient Schedule", presented as the current group schedule by S1ADM, revealed that an activity therapy group was held from 10:15 a.m. to 11:00 a.m. Monday through Friday, a MHT activity group was held from 10:15 a.m. to 11:00 a.m. on Saturday and Sunday, and a MHT activity group was held from 11:00 a.m. to 11:45 a.m. Monday through Sunday.

Review of the written treatment plans for current Patients #1, #2, and #3 and closed medical records of Patients #4 and #5 revealed no documented evidence that their individualized written treatment plan included the activity therapy provided with the specific purpose and focus for each patient.

In an interview on 11/17/16 at 10:55 a.m., S7AD indicated she works Monday through Friday and documents in each patient's record when she conducts activity therapy. S7AD indicated the MHTs conduct leisure group therapy when she isn't available, but they don't conduct any educational groups with patients.

In an interview on 11/17/16 at 12:40 p.m., S7AD indicated she signs the treatment plan, but she doesn't incorporate activity therapy interventions and goals into the treatment plan.

Based on record reviews and interview, the hospital failed to ensure the written treatment plan of each patient included the responsibilities of each member of the treatment team as evidenced by failure to have documented evidence of the responsibilities of S7AD and the MHTs providing activity therapy included in the written treatment plan for 5 (#1, #2, #3, #4, #5) of 5 patient records reviewed for treatment team responsibilities from a total sample of 5 patients.
Findings:

Review of the policy titled "Treatment Plans", presented as a current policy by S1ADM, revealed that each patient will have an individualized inter-disciplinary treatment plan developed under the direction of the psychiatrist. The plan will incorporate treatment interventions and outline individualized specific short-term and long-term goals to evaluate therapeutic progress. The type and frequency of interventions used to obtain the objectives are specified, and the staff member(s) are identified.

Review of the policy titled "Activity Therapy", presented as a current policy by S1ADM, revealed that activity groups will be structured groups provided by designated staff under the written plan and supervision of the Activities Director. Assessments will be completed within 72 hours of admission and will be used to identify problems, set goals, and implement specific treatment modalities in the patient's multidisciplinary treatment plan.

Review of the physician's orders for Patients #1, #2, #3, #4, and #5 revealed an order for groups per program schedule.

Review of the "Daily Patient Schedule", presented as the current group schedule by S1ADM, revealed that an activity therapy group was held from 10:15 a.m. to 11:00 a.m. Monday through Friday, a MHT activity group was held from 10:15 a.m. to 11:00 a.m. on Saturday and Sunday, and a MHT activity group was held from 11:00 a.m. to 11:45 a.m. Monday through Sunday.

Review of the written treatment plans for current Patients #1, #2, and #3 and closed medical records of Patients #4 and #5 revealed no documented evidence that the responsibilities of S7AD and the MHTs providing activity therapy were included in the written treatment plan.

In an interview on 11/17/16 at 12:40 p.m., S7AD indicated she signs the treatment plan, but she doesn't include the responsibilities for activity therapy of herself and the MHTs.

Based on record reviews and interviews, the hospital failed to ensure progress notes were recorded by the activity therapist in accordance with physician orders for each patient as evidenced by failure to have progress notes documented at the frequency ordered by the physician for 5 (#1, #2, #3, #4, #5) of 5 patient records reviewed for activity therapy progress notes from a total sample of 5 patients.
Findings:

Review of the policy titled "Activity Therapy", presented as a current policy by S1ADM, revealed that activity groups will be structured groups provided by designated staff under the written plan and supervision of the Activities Director. Assessments will be completed within 72 hours of admission and will be used to identify problems, set goals, and implement specific treatment modalities in the patient's multidisciplinary treatment plan.

Review of the physician's orders for Patients #1, #2, #3, #4, and #5 revealed an order for groups per program schedule.

Review of the "Daily Patient Schedule", presented as the current group schedule by S1ADM, revealed that an activity therapy group was held from 10:15 a.m. to 11:00 a.m. Monday through Friday, a MHT activity group was held from 10:15 a.m. to 11:00 a.m. on Saturday and Sunday, and a MHT activity group was held from 11:00 a.m. to 11:45 a.m. Monday through Sunday.

Patient #1
Review of Patient #1's medical record revealed his activity assessment was performed by S7AD on 11/09/16 at 2:15 p.m. There was no documented evidence of an assessment of his strengths as evidenced by the choices listed under the heading "strengths" having no check marks and no documentation written. Further review revealed activity therapy progress notes were documented by S7AD on 11/08/16 at 2:42 p.m. and on 11/15/16 at 2:57 p.m. There was no documented evidence of activity therapy group progress notes for 11/07/16, 11/09/16, 11/10/16, 11/11/16, 11/12/16, 11/13/16, and 11/14/16 as scheduled. There was no documented evidence of attendance of Patient #1 at MHT activity groups scheduled from the time of his admission through the date of record review on 11/16/16.

Patient #2
Review of Patient #2's medical record revealed his activity assessment was performed by S7AD on 11/10/16 at 3:57 p.m. There was no documented evidence that S7AD assessed whether Patient #2 needed a treatment plan adaptation and the strengths and weaknesses of Patient #2. Further review revealed an activity therapy progress note was documented by S7AD on 11/15/16 at 1:41 p.m. There was no documented evidence of activity therapy group progress notes for 11/10/16, 11/11/16, 11/12/16, 11/13/16, and 11/14/16. There was no documented evidence of attendance of Patient #1 at MHT activity groups scheduled from the time of his admission through the date of record review on 11/16/16.

Patient #3
Review of Patient #3's medical record revealed his activity assessment was performed by S7AD on 11/10/16 at 2:00 p.m. There was no documented evidence of an assessment of Patient #3's strengths. Further review revealed activity therapy progress notes documented by S7AD on 11/08/16 at 2:51 p.m. and on 11/15/16 at 3:01 p.m. There was no documented evidence of activity therapy group progress notes for 11/09/16, 11/10/16, 11/11/16, 11/12/16, 11/13/16. and 11/14/16. There was no documented evidence of attendance of Patient #3 at MHT activity groups scheduled from the time of his admission through the date of record review on 11/16/16.

Patient #4
Review of Patient #4's medical record revealed his activity assessment was performed by S7AD on 10/07/16 at 4:25 p.m. There was no documented evidence of an assessment whether a treatment plan adaptation was needed and of Patient #4's strengths. Further review revealed an activity therapy progress note was documented by S7AD on 10/11/16 at 10:15 a.m. There was no documented evidence of activity therapy group progress notes for 10/04/16, 10/05/16, 10/06/16, 10/07/16, 10/08/16. 10/09/16, 10/10/16, 10/12/16, 10/13/16, 10/14/16, 10/15/16, and 10/16/16. There was no documented evidence of attendance of Patient #4 at MHT activity groups scheduled during his hospital stay.

Patient #5
Review of Patient #5's medical record revealed her activity assessment was performed by S7AD on 10/07/16 at 4:31 p.m. There was no documented evidence of an assessment whether a treatment plan adaptation was needed and of Patient #5's strengths. Further review revealed an activity therapy progress note was documented by S7AD on 10/11/16 at 10:15 a.m. There was no documented evidence of activity therapy group progress notes for 10/06/16, 10/07/16, 10/08/16. 10/09/16, 10/10/16, 10/12/16, 10/13/16, 10/14/16, 10/15/16, 10/16/16, 10/17/16, 10/18/16, and 10/19/16. There was no documented evidence of attendance of Patient #5 at MHT activity groups scheduled during her hospital stay.

In an interview on 11/17/16 at 10:55 a.m., S7AD indicated she isn't licensed or certified as a recreational therapist. She further indicated she works Monday through Friday and documents in each patient's record when she conducts activity therapy. S7AD indicated the MHTs conduct leisure group therapy when she isn't available, but they don't conduct any educational groups with patients. S7AD indicated she is also the hospital's discharge planner, and on Mondays she attends the treatment team meetings, so she delegates an activity for the MHTs to do with the patients. She confirmed that she did not conduct activity therapy groups on the days without documented activity therapy progress notes. S7AD confirmed activity therapy is not being conducted as ordered by the physician.

In an interview on 11/17/16 at 12:40 p.m., S7AD indicated she sometimes she completes a patient's activity assessment before she conducts a group with the patient, so she doesn't address the patient's strengths and/or weaknesses in her assessment.

Based on record reviews and interview, the hospital failed to ensure there was an adequate number of qualified therapists and support personnel to provide comprehensive therapeutic activities in accordance with physician orders and the patient's active treatment program as evidenced by failure to have activity therapy groups conducted as ordered due to the activity therapy director (S7AD) 2 ?(S5MHT) also being responsible for discharge planning and having no documented evidence that MHTs conducting leisure activity therapy received training and were evaluated for competency for 2 (S5MHT, S9MHT) of 2 MHT personnel files reviewed for competency from a total of 20 employed MHTs.
Findings:

Review of the policy titled "Personnel Files", presented as a current policy by S1ADM, revealed the personnel file should include orientation checklists.

Review of the "2016 Staff Development Plan", presented as the current plan by S1ADM, revealed that competence assessment is an ongoing process and begins upon hire and continues throughout the employee's tenure. An evaluation of the employee's competency is conducted during the orientation process, ninety days post employment, and annually thereafter. The assessment is made during daily observations, performance evaluations, job-specific competency skills check lists, direct observations, during treatment planning, and periodic age-specific testing.

Review of the medical records of Patients #1, #2, #3, #4, and #5 revealed no documented evidence that activity therapy groups were conducted by S7AD as ordered by the physician.

Review of the personnel files of S5MHT and S9MHT revealed no documented evidence of orientation and training in conducting leisure active therapy groups to patients and an evaluation of their competency by S7AD.

In an interview on 11/17/16 at 10:55 a.m., S7AD indicated she isn't licensed or certified as a recreational therapist (required by state licensing regulations). She further indicated she works Monday through Friday and documents in each patient's record when she conducts activity therapy. S7AD indicated the MHTs conduct leisure group therapy when she isn't available, but they don't conduct any educational groups with patients. S7AD indicated she is also the hospital's discharge planner, and on Mondays she attends the treatment team meetings, so she delegates an activity for the MHTs to do with the patients. She confirmed that she did not conduct activity therapy groups each day as ordered by the physician for Patients #1, #2, #3, #4, and #5. She further indicated she taught MHTs how to conduct leisure groups, but she didn't document the training. She further indicated she did not document a competency evaluation for each MHT who conducts leisure group activities.