HospitalInspections.org

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure that capital expenditures were developed for at least a 3-year period.

Findings include:

Review on March 10, 2015, of "Amended and Restated Bylaws of the Board of Governors of Fairmount Behavioral Health System," approved February 10, 2015, revealed " ... Article V Duties and Responsibilities of the Board shall be to: 1. Be responsible for the planning, management and operational activities of the Facility ... 11. Take all reasonable steps to ensure that Facility conforms with all applicable Federal, State, and local laws and regulations and all applicable accreditation standards."

Review on March 11, 2015, of facility document "Fairmount Project List 2015," revealed a list of projects designated to be completed in 2015.

Interview on March 11, 2015, at 11:50 AM, with EMP1 confirmed the facility did not have a 3-year capital expenditures plan.

Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure that all contracted services were evaluated for quality assurance to ensure that services was provided in a safe and effective manner.

Findings include:

Review on March 10, 2015, of facility policy "Amended and Restated Bylaws of the Board of Governors of Fairmount Behavioral Health System," approved February 10, 2015, revealed "Article IV Purpose of the Facility ... The Board shall be accountable for the safety and quality of care, treatment and services of the Facility ... Article V ... 5. Ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the Facility ... "

Review on March 11, 2015, of facility document "Governing Body Meeting Minutes, " dated February 10, 2015, revealed three clinical contracts for X-ray, Pharmacy and Lab services were reviewed for quality and approved.

Review on March 11, 2015, of facility document "Fairmount Behavioral Health Systems Contracts," revealed service contracts that included trash, laundry services, pest control, preventative maintenance, bio hazardous waste management and language services.

Further review of facility documents revealed no documented evidence that the facility evaluated the quality of these contracted services.

Interview on March 11, 2015, at 9:00 AM, with EMP3 confirmed that the facility's Quality Assurance Performance Improvement Program did not include the evaluation of quality for these contracted services: trash, laundry services, pest control, preventative maintenance, bio hazardous waste management and language services.

Based on observations, review of facility documents, review of medical records (MR) and interview with staff (EMP) it was determined that the facility failed to protect and promote each patient's rights as evidence by: failing to maintain effective operation of the grievance process (A0119); failing to investigate and provide written resolution to patient grievances (A0123); failing to notify a minor's legal representative and obtain consent of the use of a physical restraint (A0131); failing to safeguard personal possessions, including personal information (A0142); failing to provide a safe and emotionally healthy enviornment (A0144); failing to complete a face-to-face evaluation within one hour after the initiation of a physical hold (A0178).

Cross Reference:
482.13(a)(2) Patient Rights
482.13.13(a)(2)(iii) Patient Rights
482.13(b)(2) Patient Rights
482.13(c) Patient Rights
482.13(c)(2) Patient Rights
482.13(e)(12) Patient Rights
482.41(a) Physical Environment
482.42(a)(1) Infection Control

Based on review of facility documents, medical records (MR) and interview with staff (EMP) it was determined the hospital's governing body failed to maintain effective operation of the grievance process for four of four (MR25, MR26, MR27, and MR28).

Findings include:

Review on March 10, 2015, of facility document "Medical Staff Bylaws," approved February 10, 2015 revealed " ... Section 10-Ethics Committee A. Composition- the Ethics Committee is a standing committee of the Medical Staff and will consist of at least two physicians from the Active and Associate categories of the Medical Staff, one of whom will be Chair, the Chief Nursing Officer, the Patient advocate, and the Assistant Hospital Administrator for Operations ... B. Responsibilities, Duties and Authority, the responsibility, duties and authority of the Ethics Committee shall be to hear, investigate and attempt resolution of a patient grievances by: 1. conducting adhoc meetings to hear patient grievances referred by the patient advocate 2. to investigate and make a written decision within 48 hours to the patient and to place a copy on the medical record. C. Meetings-The Ethics Committee shall meet as often as necessary to accomplish its function ..."

Review on March 11, 2015, of facility policy "Patient and Family Grievances/The Role of the Patient Advocate," reviewed January 2013 revealed " ... Procedure: 3.0-The Board of Governors has designated the Ethics Committee, an ad hoc sub-committee of the Medical Executive Committee, as the body responsible for the effective operation of the grievance process and for the review and resolution of grievances, as well as a Patient Advocate, who will act as a liaison between the patient and the facility to facilitate problem-solving actions when necessary ... 4.0-the Board of Governors shall have final authority and responsibility in resolving grievances ... the Patient Ethics committee shall meet to review the grievance and render a decision in writing within 48 hours ... 5.7-The patient shall be given a copy of the complaint and final decision ... 10.0-In cases involving physician-related complaints, the President of the Medical Staff should be notified and should follow-up with the individual physician involved. ..."

Review on March 11, 2015, of facility document "Board of Governors Fourth Quarter 2014 and Annual Review 2014" revealed no documented evidence that the governing body was reviewing operations of the facility's grievance process.

Review of "Ethics Committee Meeting Minutes," from September 2014 and January 2015, revealed no documented evidence that grievances were discussed or presented to the Ethics Committee for review and resolution.

Review on March 11, 2015, of facility document "Grievance Log," dated September 2014 thru January 2015, revealed patient grievances filed for MR25, MR26, MR27, and MR28. Further review revealed MR25, MR27 and MR28 patient grievances were assigned to EMP20 for investigation and resolution; and that MR26 patient grievance was assigned to EMP21 for investigation and resolution.

Review of MR25, MR26, MR27, and MR28 patient grievances revealed no documented evidence that the grievances were reviewed by the Ethics Committee and/or the President of the Medical Staff. Further review of MR25, MR26, MR27 and MR28 revealed no documented evidence that each grievance was investigated and that each patient was provided with a written resolution, in accordance with facility policy.

Interview on March 11, 2015, at 10:00 AM, with EMP3 confirmed the grievance procedure was not followed for MR25, MR26, MR27, and MR28. EMP3 confirmed grievances are not presented and/or reviewed during Ethics Committee meetings. The hospital's governing body failed to maintain effective operation and oversight over the grievance process.

Cross Reference:
482.13(a)(2)(iii) Patient Rights

Based on review of facility documents, medical records (MR), and interview with staff (EMP) it was determined the facility failed to investigate and provide written resolution of patient grievances for four of four medical records reviewed (MR25, MR26, MR27, and MR28).

Findings include:

Review on March 10, 2015, of facility document "Medical Staff Bylaws," approved February 10, 2015, revealed " ... Section 10-Ethics Committee ... B. Responsibilities, Duties and Authority- the responsibility, duties and authority of the Ethics Committee shall be to hear, investigate and attempt resolution of a patient grievances by: 1. conducting adhoc meetings to hear patient grievances referred by the patient advocate, 2. to investigate and make a written decision within 48 hours to the patient and to place a copy on the medical record ..."

Review on March 11, 2015, of facility policy "Patient and Family Grievances/The Role of the Patient Advocate" reviewed January 2013" revealed " ... Procedure: 3.0-The Board of Governors has designated the Ethics Committee, an ad hoc sub-committee of the Medical Executive Committee, as the body responsible for the effective operation of the grievance process and for the review and resolution of grievances, as well as a Patient Advocate, who will act as a liaison between the patient and the facility to facilitate problem-solving actions when necessary ... 4.0-the Board of Governors shall have final authority and responsibility in resolving grievances ... the Patient Ethics committee shall meet to review the grievance and render a decision in writing within 48 hours ... 5.7-The patient shall be given a copy of the complaint and final decision ... 10.0-In cases involving physician-related complaints, the President of the Medical Staff should be notified and should follow-up with the individual physician involved. ..."

Review of "Ethics Committee Meeting Minutes," from September 2014 and January 2015, revealed no documented evidence that grievances were discussed or presented to the Ethics Committee for review and resolution.

Review on March 11, 2015, of facility document "Grievance Log," dated September 2014 thru January 2015, revealed patient grievances filed for MR25, MR26, MR27, and MR28. Further review revealed MR25, MR27 and MR28 patient grievances were assigned to EMP20 for investigation and resolution; and that MR26 patient grievance was assigned to EMP21 for investigation and resolution.

Review of MR25, MR26, MR27, and MR28 patient grievances revealed no documented evidence that the grievances were reviewed by the Ethics Committee and/or the President of the Medical Staff. Further review of MR25, MR26, MR27 and MR28 revealed no documented evidence that each grievance was investigated and that each patient was provided with a written resolution, in accordance with facility policy.

Interview on March 11, 2015, at 10:00 AM, with EMP3 confirmed the grievance procedure was not followed for MR25, MR26, MR27, and MR28. EMP3 confirmed grievances are not presented and/or reviewed during Ethics Committee meetings.


Cross Reference:
482.13(a)(2) Patient Rights

Based on review of facility policies, medical records (MR), and interview with staff (EMP) it was determined that the facility failed to notify a minor patient's legal representative of the use of a physical restraint for one of one medical record reviewed (MR4).

Findings include:

Review on March 10, 2015, of facility policy "Informed Consent," reviewed January 2013, revealed "Policy: It is the policy of Fairmount Behavioral Health System to consider and respect patient rights and need for relevant information through informed consent. ..."

Review on March 10, 2015, of facility document "Holds and Restraints," reviewed February 2013 revealed "... 6.0 Notification of the Patient's Family, 6.1 With any hold/restraint episode for a patient that is under the age of 14 years of age, unless they are emancipated minor, shall require notification of the parent, guardian, family member, or conservator ... 6.3 The date and time of the notification of the family member/guardian will be noted on the Physical Hold/Restraint Record. ..."

Review on March 10, 2015, of MR4 revealed a 10 year old patient was admitted to the facility on December 12, 2014, and discharged February 11, 2015. Further review of MR4 revealed that the patient was identified as having a legal representative.

Review of MR4 nursing documentation revealed that the patient was placed in a physical hold. Further review of MR4 "Physical Hold/Restraint Record," dated January 6, 2015, revealed no documented evidence that the patient's designated representative was informed or consented to the use of a physical restraint.

Interview on March 10, 2015, at 11:45 AM, with EMP4 confirmed there is no documented evidence the minor's legal representative was notified or consented to the use of physical restraints.

Based on observation, review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to safeguard personal possessions, some containing personal information; and failed to ensure patient valuables were returned to the patient at the time of discharge for three of three medical records reviewed (MR21,MR22, MR24).

Findings include:

Review of the facility "Patient Handbook," revised March 2006, revealed " ... Patient Rules and Guidelines ... Valuables/Patient Belongings Fairmount cannot be responsible for any lost or missing item that is not placed in the hospital's safe. We request that no valuables, such as credit cards, checks, cash or jewelry, be brought to the hospital. Please send these items home with your family or staff will lock them in the hospital safe. Only the patient signing his or her valuables into the safe will be allowed to sign them out. ... Patient Bill of Rights ... 3. You have the right to keep and use personal possessions, unless it has been determined that specific personal property is contraband. The reasons for imposing any limitation and its scope must be clearly defined, recorded and explained to you. ... "

Review of facility policy and procedure, "Admission Procedure," dated February 10, 2015, revealed, " ... 6. For inpatients ... suitcases, purses, pockets, and hidden areas are to be check for contraband and secured and returned to patients after discharge as clinically appropriate with a physician's order ... "

Review of facility document "Patient Valuables," revealed a form for patients to list valuables to be stored during admission. Further review of the form revealed check boxes where the valuables are to be deposited, which included the "Admission Safe, Nursing Supervisor Safe or Drop Safe." Also noted was a patient signature line at the bottom of the form to acknowledge repossession of valuables.

Observation on March 9, 2015, at 1:00 PM, of the Patient Care Coordinator's Office (PCC), located near the cafeteria, revealed a locked supervisor's office with a box stored on the floor. The box contained clear plastic bags with patient identification labels on the outside of the plastic bags. The bags contained valuables from previously discharged patients.

Review of MR21 "Patient Valuables," dated February 14, 2013, revealed the following items: identification cards, a wallet with money and transportation tokens. Further review of the form revealed no documentation as to why the patients belongings were removed from the patient, where the patient's belongings were deposited nor was there documentation of the patient's signature acknowledging receipt of repossession of valuables at the time of discharge.

Observation on March 9, 2015, at 1:15 PM, of the PCC Office revealed MR21's belongings were never returned to the patient and still remained at the facility.

Review of MR22 "Patient Valuables," dated July 13, 2014 revealed the following items: one wallet, ID, a medical card, phone, ear phones, a lighter and set of keys. Further review of the form revealed no documentation as to why the patients belongings were removed from the patient, where the patient's belongings were deposited nor was there documention of the patient's signature acknowledging receipt of repossession of valuables at the time of discharge.

Observation on March 9, 2015, at 1:10 PM, of the PCC Office revealed a plastic bag, labeled with MR22's information. However, the bag contained an inhaler and did not match the items that were documented on the MR22's "Patient Valuable" form.

Review of MR24 "Patient Valuable," dated February 28, 2014, revealed no documentation of patient valuables.

Observation on March 9, 2015, at 1:15 PM, of the PCC Office revealed a plastic bag labeled with MR24's information. The bag contained a health card and various personal items.

Interview on March 9, 2015, at 1:15 PM, with EMP4 confirmed that patient belongings are to be returned to the patient at the time of discharge.

Interview on March 11, 2015, at 10:00 AM, with EMP3 confirmed the facility does not attempt to contact patients after discharge to return valuables nor does the facility have a policy regarding disposition of patient belongings.

Based on observations, review of facility documents and interview with staff (EMP), it was determined that the facility failed to provide a safe environment and emotionally healthy environment.

Findings include:

Review of the facility "Environmental / Hazard Surveillance Surveys," for January 16, 2014, May 27, 2014, July 25, 2014, and November 12, 2014, revealed no documented evidence that the patient rooms that had holes on the desks countertops were identified as a potential tie-off points for a ligature device.

Observation of N3 and N4 Psychiatric Nursing Unit revealed in each patient room there was a desk countertop that was approximately 30 inches off the ground. Each desk had a hole on the countertop which could be used as a tie off point for a ligature device.

Interview on March 9, 2015, at 1:15 PM, with EMP5 confirmed the desks countertops could be a potential tie-off point for a ligature device. EMP5 stated that it was a facility oversight that the holes in the desks countertops were not identified as a tie-off point for a ligature device, where a patient could cause harm to self.

Observation of N1 Psychiatric Nursing Unit revealed each patient room bathroom was equipped with sink, toilet and shower plumbing that would provide as a tie off point for a ligature device.

Interview on March 9, 2015, at 10:30 AM, with EMP4 confirmed the plumbing was classified as anti-ligature plumbing but could be used as a potential tie off point for a ligature device.

Cross Reference:
482.41(a) Physical Environment
482.42(a)(1) Infection Control

Based on review of facility documents, medical records (MR) and interview with staff (EMP) it was determined the facility failed to complete a face-to-face evaluation within one hour after the initiation of a physical hold for one of three medical records reviewed (MR10).

Findings include:

Review on March 9, 2015, of facility document "Holds and Restraints," reviewed February 2013, revealed "... Definitions: Physical Holds: The application of any manual method that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely [also named therapeutic hold, protective hold, or manual/physical restraint.] ... 5.0-Face to Face Evaluation-within one hour of the initiation of manual hold, the patient shall be evaluated in person by a physician or trained RN.

Review of MR10 physician's orders, "Physical Hold or Mechanical Restraint," revealed "Type and Length of Time of Restraint-12/16/14, at 8:17 PM-Physical Hold up to one hour ... Face to Face Assessment: time of assessment 11:40 PM."

Interview on March 10, 2015, at 10:00 AM, with EMP4 confirmed that a face-to-face evaluation was not completed, by a physician or trained RN, within one hour from the initiation of a physical hold on this patient.

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to measure, analyze, and track a quality indicator, hand-washing, in order to monitor for the effectiveness, safety of services and quality of care.
Findings include:
Review of the "Medical Executive Meeting Minutes," January 2015, revealed that hand-washing was a quality initiative focus for 2014. Review of the "2014 Annual Report," revealed the following outcomes: "After touching patient" Quarter (Q) 3 - 49% compliant (C) and Q4 - 83% C; "After taking off gloves" Q3 - 52% C and Q4 - 50% C; "After touching something dirty" Q3 - 52% C and Q4 -50% C; "Before starting medication pass" Q3 - 45% C and Q4 - 100% C.
Review of "Infection Control Hand Washing Data Collection," revealed no hand washing data was collected in September, October and December 2014. Further review revealed that in November only 20 staff were observed with an 80% compliance rate on A-B-C Pods. EMP25 was unable to provide any hand-washing data collection for Pod N1, N2/3, N4, D-E and C-D.
Review of August collection data revealed that only 20 staff were observed Pod N1 with 75% compliance rate and only 20 staff were observed in Pod N4 with a 70% compliance rate. EMP25 was unable to provide hand-washing data collection for Pod N2/3, N4, D-E and C-D.
Review of July collection data revealed that only 20 staff were observed on Pod C-D with a 60% compliance rate. EMP25 was unable to provide hand-washing data collection for Pod N1, N2/3, N4, and D-E.
Interview on March 10, 2015, at 10:30 AM, with EMP26 revealed that they did not collect any the hand-washing data for their pod.
Interview on March 11, 2015, at 9:30 AM, with EMP3 revealed that the facility should have observed at least 50 personnel monthly in order to determine compliance with the quality indicator, hand-washing.
Cross Reference:
482.42(b) Infection Control

Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure that all contracted services were evaluated for quality assurance to ensure that services was provided in a safe and effective manner and that services provided complied with Conditions of Participation.

Findings include:

Review on March 10, 2015, of facility policy "Amended and Restated Bylaws of the Board of Governors of Fairmount Behavioral Health System," approved February 10, 2015, revealed "Article IV Purpose of the Facility ... The Board shall be accountable for the safety and quality of care, treatment and services of the Facility ... Article V ... 5. Ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the Facility ... "

Review on March 11, 2015, of facility document "Governing Body Meeting Minutes, " dated February 10, 2015, revealed three clinical contracts for X-ray, Pharmacy and Lab services were reviewed for quality and approved.

Review on March 11, 2015, of facility document "Fairmount Behavioral Health Systems Contracts," revealed service contracts that included trash, laundry services, pest control, preventative maintenance, bio hazardous waste management and language services.

Further review of facility documents revealed no documented evidence that the facility evaluated the quality of these contracted services.

Interview on March 11, 2015, at 9:00 AM, with EMP3 confirmed that the facility's Quality Assurance Performance Improvement Program did not include the evaluation of quality for these contracted services: trash, laundry services, pest control, preventative maintenance, bio hazardous waste management and language services.

Cross reference:
482.12(e)(1) Governing Body

Based on review of facility policy, credential files (CF) and interview with staff (EMP) it was determined the facility failed to receive all required documentation for credentialing for two of 12 credential files reviewed (CF4 and CF6).

Findings include:

Review on March 12, 2015, of "Fairmount Behavioral Health System Policy/Procedure - Commonwealth of Pennsylvania Child Protective Services Law," dated August 2010, revealed " ... Policy: It is the policy of the Hospital to require Criminal History and Child Abuse History Clearances at the time of hire. The Hospital may require employees to submit Child Abuse History Clearances on a bi-annual basis thereafter. ... "

Review on March 11, 2015, of CF4 and CF6 failed to contain documentation of the Federal Bureau of Investigation (FBI) background check.

Interview on March 12, 2015, at 12:30 PM, with EMP11 confirmed that CF4 and CF6 were required to have the FBI background check. EMP11 confirmed that there was no documented evidence that the FBI background checks were completed for CF4 and CF6.

Based on observation, review of facility policy and interview with staff (EMP), it was determined that the Food Service Director failed to ensure that sanitary conditions were maintained in food storage and service areas.

Findings include:

Review of facility policy "Subject: Sanitation," dated August 21, 2013, revealed "Policy: It will be the responsibility of the Food Service Director to see that sanitary conditions are maintained in food storage, preparation and food service areas. Procedure: 1. Cleaning schedules will be planned which contain all areas of equipment and food service. The cleaning duties will be performed as scheduled. Cleaning inspection checklist will be used to monitor compliance. 2. The kitchen will be cleaned by food service personnel. ... 8. Waste will be disposed of after every meal. Trash will be placed in trash can lined with plastic bag. Trash will be emptied into a dumpster which is covered and emptied periodically by the contract sanitation service. ..."
Review of facility policy "Refrigerator Cleaning," dated September 2014, revealed "Policy: All refrigerators will be kept clean and have temperatures checked daily. ... Procedure: ... 2. The night staff will clean the patient food and drink refrigerator on a weekly basis. ... 6. ... Food is to be discarded if it is not labeled with the patient ' s name, date and time ... "
Observation on March 9, 2015, at 10:00 AM, of the Children and Adolescent food service line revealed a thick unknown film substance and multiple food particles located underneath the food service line.

Observation on March 9, 2015, at 10:10 AM, of the Children and Adolescent food dining area revealed a thick unknown film substance and multiple food particles located underneath the beverage station.

Observation on March 9, 2015, at 10:15 AM, of the Adult food dining area revealed a thick unknown film substance and multiple food particles located underneath the beverage station.

Observation on March 9, 2015, at 10:20 AM, of the Adult food service line revealed a thick unknown film substance and multiple food particles located underneath the food service line.

Interview on March 9, 2015, at 10:20 AM, with EMP27 confirmed that there was thick unknown film substances and multiple food particles located in the Children and Adolescent food services line and dining areas; and in the Adult food service lines and dining areas.

Observation on March 9, 2015, at 10:30 AM, of the Kitchen's Dry Storage Room revealed a thick unknown film substance located on the shelving units.

Interview on March 9, 2015, at 10:30 AM, with EMP27 confirmed that there was thick unknown film substance located on the shelving units.

Observation on March 9, 2015, at 10:45 AM, of the Kitchen's storage racks revealed on the bottom of three of the storage racks metal trays, pots, and pans were being stored, where the bottom of racks were open shelves, which allowed for contamination when wet mopping.

Interview on March 9, 2015, at 10:45 AM, with EMP27 confirmed that the bottom of racks were open shelves, which allowed for contamination when wet mopping.

Observation on March 9, 2015, at 10:50 AM, of the Kitchen's loading dock revealed various amounts of food related items, unknown packages, and garbage located around the dumpsters.

Interview on March 9, 2015, at 10:50 AM, with EMP27 confirmed the Kitchen's loading dock revealed various amounts of food related items, unknown packages, and garbage located around the dumpsters.

Observation on March 9, 2015, at 11:15 AM, of the N4 Psychiatric Unit's patient refrigerators revealed a thick unknown film substance located on the refrigerator shelving units.

Interview on March 9, 2015, at 11:15 AM, with EMP15 confirmed the N4 Psychiatric Unit's patient refrigerators revealed a thick unknown film substance located on the refrigerator shelving units.
Observation on March 9, 2015, at 11:00 AM, of D Pod nourishment room revealed the following: a black substance along the baseboards, under the refrigerator and around the base of the trash can, an unlabeled and uncovered salad and an unlabeled Styrofoam container of food in the refrigerator, a towel with a large orange stain on the bottom shelf of the refrigerator, and an orange sticky substance on the bottom shelf of the refrigerator, as well as in the bottom drawers. The cabinet under the sink had a broken handle and no laminate noted on the edges of the cabinet door.
Interview on March 9, 2015, at 11:30 AM, with EMP2 confirmed the above findings.
Observation on March 9, 2015, at 11:35 AM, of E Pod nourishment room revealed the following: an unlabeled Styrofoam container of food, an unlabeled and uncovered bowl of cereal on the counter, a black substance around the bottom of the ice/water dispenser, an orange sticky substance on the bottom shelf of the refrigerator, as well as in the bottom drawers, and a trash can with a broken lid and dried substances located on the outside of the trash can.

Interview on March 9, 2015, at 11:35 AM, with EMP2 confirmed the above findings.

Observation on March 9, 2015, at approximately 11:45 AM of D and E Pod's dining area revealed a black substance around the bottom of the milk dispenser, a black substance along the baseboards and along the bottom of all doors and black substance around a broken drain located below the serving line.

Interview on March 9, 2015, at 11:45 AM, with EMP2 confirmed the above findings.

Based on observation, review of facility policy 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:

Review of facility policy "Cleaning Baseboards," dated January 2013, revealed "Policy: The Support Services Department will clean the baseboards on a regular basis. ... "

Review of facility policy "Cleaning Waste Container," dated January 2013, revealed "Policy: The Support Services Department will clean waste container on a regular basis. ... "

Review of facility policy "Cleaning Water Fountains," dated January 2013, revealed "Policy: The Support Services Department will clean water fountains on a daily basis. ... 3. Wipe all surfaces including the fountain head, jet guard ... "

Review of facility policy "Cleaning Common Areas" dated January 2013, revealed "Policy: The Support Services Department personnel will clean all common areas at FBHS ... "

Review of facility policy "Cleaning Patient Room - Occupied, " dated January 2013, revealed "... All patient rooms will be cleaned on a daily basis. ... Damp dust ... with a hospital approved germicidal solution ... "

Review of facility policy "Support Services," dated January 2013, revealed "The Support Services Department will clean all patient rooms as per the following procedure when a patient has been discharged or transferred ...Damp dust over ...cabinets ...Mop floor using a hospital approved germicidal solution according to procedure ... "

Review of facility policy "Wet Mopping," dated January 2013, revealed "Policy: It is the policy of Fairmount Behavioral Health System to have all the floors cleaned on a regular basis. ... "

Review of facility policy "Subject: Pest Control," dated August 21, 2013, revealed "Policy: A program for the eradication and prevention of infestation by rodents and insects will be carried, including a contract to treat the kitchen ... Procedure ... 4. Rodents (Rats and Mice) ... a) Eliminate any holes in structure where they can enter. ..."

Review of facility document "Battery-Powered Egress Lighting & Emergency Power Supply-Systems Minimum Required Testing & Explanatory Materials," no date, revealed " ... Battery-powered Egress Lighting, Emergency Generators and Automated Transfer Switches must be tested to meet the minimum requirements ... These minimum requirements are as follows: ... EP.5 - The monthly for diesel-powered generators are conducted with a dynamic load that is at least 30% of the nameplate rating of the generator or meets the manufacturer's recommended prime movers ' exhaust gas temperature. ... If your diesel-powered generator* is unable to meet the 30% rule during any monthly test, you have two options: .... b. Test once every 12 months using supplemental (dynamic or static) loads ..."

1. N1 Patient Care Unit
Observation on March 9, 2015, at 10:00 AM, of N1 Patient Care unit revealed the entrance hallway was splattered with a dried substance. The hallway located between patient rooms 200 and 232 had a heavy layer of a dark gray substance along the floor baseboard. The flooring of the hallway was splattered with a dried light brown-gray substance throughout the unit.
In patient rooms the following was observed: Room 200- bathroom with a malodor and no hand soap,Room 201- bathroom flooring has a light gray haze and a heavy build-up of brown/white debris around base of toilet, Room 203- the bed frame had a shiny dried substance on the two side panels of the bed, Room 204- there was splatters of a dried red substance observed on the hallway wall outside of the room, Room 205- there was a broken bathroom tile and the bedroom wall had peeling paint and scratch marks, Room 206- plumbing fixture is heavily soiled with a white/reddish brown substance, Room 232- the floor had a light gray haze between the bathroom door and the bedroom entry door.

Observation of the N1 medication room revealed the floor and counter work space was heavily cluttered with books and non-clinical supplies. Floor is heavily soiled with splatters of unidentified substances. Medication cart cassettes are heavily soiled with a gray substance and covered with tape.
Observation of the Mechanical room revealed three metal shelving units with linen stored on the shelves and four large gray laundry bins. Further observation revealed a ceiling access panel that was open and an attached ladder that extended from the floor to the opening in the ceiling. The ladder was blocked with the four laundry bins.
Interview on March 9, 2015, 10:25 PM, with EMP4 confirmed the mechanical room is also the storage room for the laundry.
Interview on March 9, 2015, at 10:45 AM, with EMP9 confirmed housekeeping is on the unit daily performing housekeeping duties.

2. A and B Pod Nursing Care Units

Observation on March 9 and 10, 2015, of A Pod, revealed that in Room 1, 2 and 3 there was large amounts of grey dust and paper debris between the headboard and wall of the beds.

Observation on March 9 and 10, 2015, of B Pod revealed that in Room 2, 4 and 5, there was large amounts of grey dust and paper debris between the headboard and wall of the beds.

Interview on March 10, 2015, at 9:30 AM, with EMP15 confirmed that the dust and paper debris was present. Further interview at 10:52 AM, with EMP15 confirmed that to adequately clean the areas that the beds would need to be unfastened from the wall and caulk applied in the joint between the bed and wall and there was no documentation that proved that had been done.

3. D Pod Nursing Care Unit

Observation on March 9, 2015, at 11:15 AM, of room number 190, revealed a black substance on the floors, especially along the baseboards.

Observation March 9, 2015, at 11:20 AM, of the seclusion/quiet room revealed a two inch hole in the mattress and dust on the floor. A broken lock was noted on the door to the seclusion room as well.

Observation on March 9, 2015, at 11:25 AM, of the D Pod patient laundry room revealed loose dust on the floor between the washer and dryer.

Observation on March 9, 2015, at 11:30 AM, of the D Pod hallway revealed a water fountain with a white/green substance build up noted around the base of the water dispenser.

Interview on March 9, 2015 at 11:30 AM, with EMP2 confirmed the above findings.

Interview on March 10, 2015, at approximately 2:00 PM, with EMP28 indicated that the laundry area was cleaned daily.

4. N2 Patient Care Unit

Observations on March 9, 2015, at 11:30 AM, of N2 Patient Care Unit revealed Rooms 154 through 157 included black marks on the floors in the bedrooms and bathrooms, paint chips with exposed wallboard, soap dispensers were empty, sharp wood was exposed on doors and the shower entrance was black at corners. Observation of Rooms 186 through 188 included blackened areas on the floor and entrance to shower at the corners.

Interview on March 9, 2015, at 12:00 PM, with EMP4 confirmed the above findings.

5. N5 Patient Care Unit

Observation on March 9, 2015, at 12:30 PM, of N5 Patient Care Unit revealed Room 122, 123, 125, 127, 129, 131, 133 included blackened ares on the bedroom and bathroom floors and shower entrance, mildew on shower curtains, water puddles on BR floors, paint chippings along doorways. Room 133 was observed to have orange tinged areas in the ADA shower.

Observation on March 9, 2015, at 12:30 PM, revealed rooms 124, 126, 128, 130 included light black residue on shower curtains, around the sink faucets, and the base of the toilets.

Interview on March 9, 2015, at 1:00 PM, with EMP17 revealed that Room 133 had been cleaned and mopped.

Further observation of Room 133, after EMP17 confirmed the room was cleaned, revealed dirt and debris remained around the bedside table next to the bed where a patient was sleeping.

Observation of the N5 Housekeeping closet revealed that there was a ceiling tile not intact near the vent. The floor sink was heavily soiled with a thick black substance. Further observation revealed the shelving in the area was covered in a heavy accumulation of dust.

Observation of the N5 patient hallway revealed black scuff marks along the entire baseboard on both sides of the hallway between rooms 125 and 127 and that there was a black substance surrounding the individual tiles and where the tile meets baseboard.

Interview on March 9, 2015, at 12:50 PM, with EMP4 confirmed the above findings.

6. N3 Patient Care Unit

Observation on March 11, 2015, at 9:30 AM, of the N3 Psychiatric Nursing Unit's room 183, revealed a thick black buildup of unknown substances around the baseboards of the room.

Interview on March 11, 2015, at 9:30 AM, with EMP5 confirmed room 183 had a thick black buildup of unknown substances around the baseboards of the room.

7. N1 Patient Care Unit

Observation on March 11, 2015, at 10:00 AM, of the N1 Psychiatric Nursing Unit's Laundry Storage room revealed an approximate 18 inch by 12 inch hole in the wall.

Interview on March 11, 2015, at 10:00 AM, with EMP5 confirmed the Laundry Storage room had an approximate 18 inch by 12 inch hole in the wall.

8. N5 Nursing Care Unit
Observation on March 11, 2015, of room 133B revealed the bottom shelf of a cabinet contained dust. The floor had visible loose dirt and debris. The perimeter of the baseboards had an accumulation of dirt and there was a black/brown substance in the corners of room.
Interview on March 10, 2015, at 2:, with EMP26 confirmed the patient was discharged from 133B and the room was cleaned. EMP26 confirmed that above findings and that the room was not properly cleaned.

9. Patient Care Coordinator (PCC) Office

Observation on March 9, 2015,at 1:00 PM, of the Patient Care Coordinator Office [supervisor office used by multiple staff], located near the cafeteria, revealed an office that was cluttered; there was one mouse trap in a corner of the room near the door, patient inventory was stored in a file cabinet; there were numerous boxes stored on top of each other that contained shift to shift reports, a box of patient valuables was noted on the floor that included discharged patients bagged inventory that was left behind and that the facility was storing.

Interview on March 9, 2015, at 1:15 PM, with EMP4 confirmed the above findings in the PCC Office.

10. Basement area

Observation on March 11, 2015, at 10:30 AM, of the Hospital's basement storage room revealed approximately 20 cardboard boxes that were stored on the floor.

Interview on March 11, 2015, at 10:30 AM, with EMP5 confirmed the cardboard boxes should not be directly stored on the floor.

11. Emergency Power

Review of the facility's "Emergency Power System," binder revealed the facility's last generator annual load test occurred on April 23, 2013.

Interview on March 11, 2015, at 12:00 PM, with EMP5 confirmed the facility's diesel-powered generator is unable to meet the 30% rule during monthly tests and that the generator is to be tested every 12 months using supplemental (dynamic or static) loads. EMP5 confirmed the diesel-powered generator's annual load test was last tested April 23, 2013, which was greater than 12 months from the present date.



Cross Reference:
482.13(c)(2) Patient Rights
482.42 Infection Control

Based on observation, review of facility policy and interview with staff (EMP), it was determined the Infection Control Officer failed to implement a comprehensive hospital-wide infection prevention and control program in order to ensure a sanitary environment.
Findings include:
Review of facility policy "Support Services Policy and Procedure," dated January 2013, revealed, "The Support Services Department will clean all patient rooms as per the following procedure when a patient has been discharged or transferred ...Damp dust over ...cabinets ...Mop floor using a hospital approved germicidal solution according to procedure ... "
1. Dinning and Kitchen Areas
Observation on March 9, 2015, at 10:00 AM, of the Children and Adolescent food service line revealed a thick unknown film substance and multiple food particles located underneath the food service line.

Observation on March 9, 2015, at 10:10 AM, of the Children and Adolescent food dining area revealed a thick unknown film substance and multiple food particles located underneath the beverage station.

Observation on March 9, 2015, at 10:15 AM, of the Adult food dining area revealed a thick unknown film substance and multiple food particles located underneath the beverage station.

Observation on March 9, 2015, at 10:20 AM, of the Adult food service line revealed a thick unknown film substance and multiple food particles located underneath the food service line.

Interview on March 9, 2015, at 10:20 AM, with EMP27 confirmed that there was thick unknown film substances and multiple food particles located in the Children and Adolescent food services line and dining areas; and in the Adult food service lines and dining areas.

Observation on March 9, 2015, at 10:30 AM, of the Kitchen's Dry Storage Room revealed a thick unknown film substance located on the shelving units.

Interview on March 9, 2015, at 10:30 AM, with EMP27 confirmed that there was thick unknown film substance located on the shelving units.

Observation on March 9, 2015, at 10:45 AM, of the Kitchen's storage racks revealed on the bottom of three of the storage racks metal trays, pots, and pans were being stored, where the bottom of racks were open shelves, which allowed for contamination when wet mopping.

Interview on March 9, 2015, at 10:45 AM, with EMP27 confirmed that the bottom of racks were open shelves, which allowed for contamination when wet mopping.

Observation on March 9, 2015, at 10:50 AM, of the Kitchen's loading dock revealed various amounts of food related items, unknown packages, and garbage located around the dumpsters.

Interview on March 9, 2015, at 10:50 AM, with EMP27 confirmed the Kitchen's loading dock revealed various amounts of food related items, unknown packages, and garbage located around the dumpsters.

2. N4 Patient Care Unit

Observation on March 9, 2015, at 11:15 AM, of the N4 Psychiatric Unit's patient refrigerators revealed a thick unknown film substance located on the refrigerator shelving units.

Interview on March 9, 2015, at 11:15 AM, with EMP15 confirmed the N4 Psychiatric Unit's patient refrigerators revealed a thick unknown film substance located on the refrigerator shelving units.
3. D and E Pod Nursing Care Unit
Observation on March 9, 2015, at 11:00 AM, of D Pod nourishment room revealed the following: a black substance along the baseboards, under the refrigerator and around the base of the trash can, an unlabeled and uncovered salad and an unlabeled Styrofoam container of food in the refrigerator, a towel with a large orange stain on the bottom shelf of the refrigerator, and an orange sticky substance on the bottom shelf of the refrigerator, as well as in the bottom drawers. The cabinet under the sink had a broken handle and no laminate noted on the edges of the cabinet door.
Interview on March 9, 2015, at 11:30 AM, with EMP2 confirmed the above findings.
Observation on March 9, 2015, at 11:35 AM, of E Pod nourishment room revealed the following: an unlabeled Styrofoam container of food, an unlabeled and uncovered bowl of cereal on the counter, a black substance around the bottom of the ice/water dispenser, an orange sticky substance on the bottom shelf of the refrigerator, as well as in the bottom drawers, and a trash can with a broken lid and dried substances located on the outside of the trash can.

Interview on March 9, 2015, at 11:35 AM, with EMP2 confirmed the above findings.

Observation on March 9, 2015, at approximately 11:45 AM of D and E Pod's dining area revealed a black substance around the bottom of the milk dispenser, a black substance along the baseboards and along the bottom of all doors and black substance around a broken drain located below the serving line.

Interview on March 9, 2015, at 11:45 AM, with EMP2 confirmed the above findings.

4. N1 Patient Care Unit
Observation on March 9, 2015, at 10:00 AM, of N1 Patient Care unit revealed the entrance hallway was splattered with a dried substance. The hallway located between patient rooms 200 and 232 had a heavy layer of a dark gray substance along the floor baseboard. The flooring of the hallway was splattered with a dried light brown-gray substance throughout the unit.
In patient rooms the following was observed: Room 200- bathroom with a malodor and no hand soap,Room 201- bathroom flooring has a light gray haze and a heavy build-up of brown/white debris around base of toilet, Room 203- the bed frame had a shiny dried substance on the two side panels of the bed, Room 204- there was splatters of a dried red substance observed on the hallway wall outside of the room, Room 205- there was a broken bathroom tile and the bedroom wall had peeling paint and scratch marks, Room 206- plumbing fixture is heavily soiled with a white/reddish brown substance, Room 232- the floor had a light gray haze between the bathroom door and the bedroom entry door.
Observation of the N1 medication room revealed the floor and counter work space was heavily cluttered with books and non-clinical supplies. Floor is heavily soiled with splatters of unidentified substances. Medication cart cassettes are heavily soiled with a gray substance and covered with tape.
Observation of the Mechanical room revealed three metal shelving units with linen stored on the shelves and four large gray laundry bins. Further observation revealed a ceiling access panel that was open and an attached ladder that extended from the floor to the opening in the ceiling. The ladder was blocked with the four laundry bins.
Interview on March 9, 2015, 10:25 PM, with EMP4 confirmed the mechanical room is also the storage room for the laundry.
Interview on March 9, 2015, at 10:45 AM, with EMP9 confirmed housekeeping is on the unit daily performing housekeeping duties.

5. A and B Pod Nursing Care Units

Observation on March 9 and 10, 2015, of A Pod, revealed that in Room 1, 2 and 3 there was large amounts of grey dust and paper debris between the headboard and wall of the beds.

Observation on March 9 and 10, 2015, of B Pod revealed that in Room 2, 4 and 5, there was large amounts of grey dust and paper debris between the headboard and wall of the beds.

Interview on March 10, 2015, at 9:30 AM, with EMP15 confirmed that the dust and paper debris was present. Further interview at 10:52 AM, with EMP15 confirmed that to adequately clean the areas that the beds would need to be unfastened from the wall and caulk applied in the joint between the bed and wall and there was no documentation that proved that had been done.

6. D Pod Nursing Care Unit

Observation on March 9, 2015, at 11:15 AM, of room number 190, revealed a black substance on the floors, especially along the baseboards.

Observation March 9, 2015, at 11:20 AM, of the seclusion/quiet room revealed a two inch hole in the mattress and dust on the floor. A broken lock was noted on the door to the seclusion room as well.

Observation on March 9, 2015, at 11:25 AM, of the D Pod patient laundry room revealed loose dust on the floor between the washer and dryer.

Observation on March 9, 2015, at 11:30 AM, of the D Pod hallway revealed a water fountain with a white/green substance build up noted around the base of the water dispenser.

Interview on March 9, 2015 at 11:30 AM, with EMP2 confirmed the above findings.

Interview on March 10, 2015, at approximately 2:00 PM, with EMP28 indicated that the laundry area was cleaned daily.

7. N2 Patient Care Unit

Observations on March 9, 2015, at 11:30 AM, of N2 Patient Care Unit revealed Rooms 154 through 157 included black marks on the floors in the bedrooms and bathrooms, paint chips with exposed wallboard, soap dispensers were empty, sharp wood was exposed on doors and the shower entrance was black at corners. Observation of Rooms 186 through 188 included blackened areas on the floor and entrance to shower at the corners.

Interview on March 9, 2015, at 12:00 PM, with EMP4 confirmed the above findings.

8. N5 Patient Care Unit

Observation on March 9, 2015, at 12:30 PM, of N5 Patient Care Unit revealed Room 122, 123, 125, 127, 129, 131, 133 included blackened ares on the bedroom and bathroom floors and shower entrance, mildew on shower curtains, water puddles on BR floors, paint chippings along doorways. Room 133 was observed to have orange tinged areas in the ADA shower.

Observation on March 9, 2015, at 12:30 PM, revealed rooms 124, 126, 128, 130 included light black residue on shower curtains, around the sink faucets, and the base of the toilets.

Interview on March 9, 2015, at 1:00 PM, with EMP17 revealed that Room 133 had been cleaned and mopped.

Further observation of Room 133, after EMP17 confirmed the room was cleaned, revealed dirt and debris remained around the bedside table next to the bed where a patient was sleeping.

Observation of the N5 Housekeeping closet revealed that there was a ceiling tile not intact near the vent. The floor sink was heavily soiled with a thick black substance. Further observation revealed the shelving in the area was covered in a heavy accumulation of dust.

Observation of the N5 patient hallway revealed black scuff marks along the entire baseboard on both sides of the hallway between rooms 125 and 127 and that there was a black substance surrounding the individual tiles and where the tile meets baseboard.

Interview on March 9, 2015, at 12:50 PM, with EMP4 confirmed the above findings.

9. N3 Patient Care Unit

Observation on March 11, 2015, at 9:30 AM, of the N3 Psychiatric Nursing Unit's room 183, revealed a thick black buildup of unknown substances around the baseboards of the room.

Interview on March 11, 2015, at 9:30 AM, with EMP5 confirmed room 183 had a thick black buildup of unknown substances around the baseboards of the room.

10. N5 Nursing Care Unit

Observation on March 11, 2015, of room 133B revealed the bottom shelf of a cabinet contained dust. The floor had visible loose dirt and debris. The perimeter of the baseboards had an accumulation of dirt and there was a black/brown substance in the corners of room.
Interview on March 10, 2015, at 2:, with EMP26 confirmed the patient was discharged from 133B and the room was cleaned. EMP26 confirmed that above findings and that the room was not properly cleaned.

Interview on March 10, 2015, at 11:00AM, with EMP25 revealed that EMP25 only worked in the facility approximately 20 hours a week; and does not participate in environmental rounds. There was no evidence that EMP25 implemented or maintained a hospital-wide infection prevention and control program in order to reduce the risk of infection and ensure a sanitary environment.
Cross Reference:
482.28(a)(1) Food and Dietetic Services
482.41(a) Physical Environment

Based on review of facility documents and interview with staff (EMP), it was determined that the facility failed to ensure the adequate implementation of a hospital-wide quality assessment and performance improvement programs targeted to track hand-washing compliance throughout the facility; and failed to implement a corrective action plan to address and reduce incidences of hand-washing non-compliance, in order to improve quality outcomes.

Findings include:

Review on March 10, 2015, of facility "Amended and Restated Bylaws of the Board of Governors of Fairmount Behavioral Health System," approved February 10, 2015, revealed "Article IV Purpose of the Facility ... The Board shall be accountable for the safety and quality of care, treatment and services of the Facility ... Article V 5. Ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the Facility ... "

Review of the "Medical Executive Meeting Minutes," January 2015, revealed that handwashing was a quality initiative focus for 2014. Review of the "2014 Annual Report," revealed the following outcomes: "After touching patient" Quarter (Q) 3 - 49% compliant (C) and Q4 - 83% C; "After taking off gloves" Q3 - 52% C and Q4 - 50% C; "After touching something dirty" Q3 - 52% C and Q4 -50% C; "Before starting medication pass" Q3 - 45% C and Q4 - 100% C.
Review of "Infection Control Hand Washing Data Collection," revealed no hand washing data was collected in September, October and December 2014. Further review revealed that in November only 20 staff were observed with an 80% compliance rate on A-B-C Pods. EMP25 was unable to provide any hand-washing data collection for Pod N1, N2/3, N4, D-E and C-D.
Review of August collection data revealed that only 20 staff were observed Pod N1 with 75% compliance rate and only 20 staff were observed in Pod N4 with a 70% compliance rate. EMP25 was unable to provide hand-washing data collection for Pod N2/3, N4, D-E and C-D.
Review of July collection data revealed that only 20 staff were observed on Pod C-D with a 60% compliance rate. EMP25 was unable to provide hand-washing data collection for Pod N1, N2/3, N4, and D-E.
Interview on March 10, 2015, at 10:30 AM, with EMP26 revealed that they did not collect any the hand-washing data for their pod.
Interview on March 11, 2015, at 9:30 AM, with EMP3 revealed that the facility should have observed at least 50 personnel monthly in order to determine compliance with the quality indicator, hand-washing.

Review of facility documentation revealed no documented evidence that the facility addressed the issue of limited participation of units responsible for tracking and monitoring hand-washing non-compliance; nor was there evidence that the facility implemented a corrective action plan to address and reduce identified incidences of hand-washing non-compliance in order to improve quality outcomes.

Cross Reference:
482.21(a),(b)(1),(b)(2)(i),(b)(3) Qapi

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

I. Ensure that the Master Treatment Plans (MTP) for two (2) of eight (8) active sample patients (C7 and C11) were revised based on the patient's lack of response to treatment. These patients refused to participate in the prescribed group therapies and spent long periods of time alone in their rooms. The MTPs were not revised to include modalities from which these patients might benefit. Failure to revise MTPs impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

II. Ensure that active treatment measures, such as individual treatment and other therapeutic activities, were available for two (2) of eight (8) active sample patients (C7 and C11) who were unwilling or unable to attend group therapies. Specifically, these patients spent many hours in their rooms without any appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125 I)

III. Assess and treat the medical problems of 1 of 1 active patient (Patient C14) reviewed for medical care in order to potentially avoid medical complications. Failure to address medical issues results in a potential risk to patients' lives/health. (Refer to B125 II)

IV. Provide necessary interpretive services for 1 of 1 active patient (Patient C3) not proficient in the English language. This failure compromised the patient's ability to participate in assessments and treatment. As a result, patients are not able to benefit from group therapies, medication education, verbal interventions, or other treatments or interventions that require the understanding of the English language in order to address the psychiatric problems that led to their hospitalization. (Refer B125 III)

Based on record review and interview, the facility failed to provide social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions, and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (B7, B10, C7, C11, F1, F3, G9 and G18). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions.

Findings include:

A. Record Review

The following Psychosocial Assessments (dates in parentheses) failed to include an evaluation of psychosocial issues, conclusions and recommendations, or a description of the social worker's role in treatment and discharge planning: Patient B7 (2/18/15), Patient B10 (1/2/15), Patient C7 (2/27/15), Patient C11 (2/26/15), Patient F1 (2/22/15), Patient F3 (2/24/15), Patient G9 (3/6/15) and Patient G18 (2/25/15).

B. Staff Interview

1. During an interview with the Social Work Coordinator on 3/11/15 at 9:00 a.m., she acknowledged that the Psychosocial Assessments lacked an evaluation of the psychosocial issues, conclusions and recommendations, or a description of the social work role in treatment or discharge planning. She stated, "Our assessment form is limited. It does not allow us to elaborate. It would be important to have a conceptualization at the end of the psychosocial assessment. We need to really capture what is going on with the patient."

2. During an interview with the Medical Director on 3/10/15 at 2:50 p.m., she acknowledged that the Psychosocial Assessments did not contain an integration of the psychosocial information. The Medical Director stated that she had identified this as a problem and communicated her concerns to the supervisor of social work services.

Based on interview and record review, the facility failed to ensure that the Master Treatment Plans (MTP) for two (2) of eight (8) active sample patients (C7 and C11) were revised based on the patient ' s lack of response to treatment. These patients refused to participate in the prescribed group therapies and spent long periods of time alone in their rooms. The MTPs were not revised to include modalities from which these patients might benefit. Failure to revise MTPs impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Patient C7

1. Patient C7 was admitted 2/26/15 with the diagnoses of "Unspecified depressive d/o [disorder]" and "R/o [rule out] unspecified schizophrenic d/o." A review of the MTP dated 2/27/15 indicated that the treatment interventions for the Problem of "Depression," "Not eating/lost weight/hasn't changed clothes in days," and "Depressed mood/hopeless & helpless" included "SW will encourage pt [patient] to...attend groups" and "AT [activities therapist]: will offer group therapy 2x daily."

2. A review of the Group Therapy notes from 2/27/15 to 3/9/15 indicated that Patient C7 attended only two (2) groups as follows: on 2/27/15 at 9:30 a.m., "Process" group, "[Patient C7] sat quietly and listened as others shared, although [s/he] declined to participate when prompted by staff and left group after 20 minutes" and on 2/27/15 at 3:00 p.m., "Process" group, "Patient presented very depressed and soft spoken with prompting [s/he] engaged in activity, but needed continuous support throughout the group."

3. As of 3/9/15, the MTP for Patient C7 had not been revised to address noncompliance with the prescribed group therapy to develop alternative interventions.

B. Patient C11

1. Patient C11 was admitted 2/23/15 with a diagnosis of "Schizophrenia." A review of the MTP dated 2/27/15 indicated that the treatment interventions for the Problem of "Psychosis Related to Presented Complaints of Responding to Internal Stimuli" included "SW will encourage pt [patient] to...attend groups" and "AT [activities therapist] will offer group therapy 2x daily."

3. A review of the Group Therapy notes from 2/24/15 to 3/9/15 indicated that Patient C11 attended only one treatment group on 3/8/15 at 3:00 p.m. for "the last 20 minutes of group..." and attended only five educational groups.

4. As of 3/9/15, the MTP for Patient C11 had not been revised to address noncompliance with the prescribed group therapy to develop alternative interventions.

C. Staff Interviews

1. During an interview with the Director of Psychological Services and Adult Clinical Services on 3/10/15 at 4:00 p.m., he acknowledged that the MTPs for Patients C7 and C11 had not been revised when these patients did not attend the prescribed group treatments.

2. During an interview with the Medical Director on 3/10/15 at 2:50 p.m., she acknowledged that the MTPs for Patients C7 and C11 were not revised to address the lack of participation or provide alternative treatments when Patients C7 and C11 did not participate in group treatments.

Based on record review and interview, the facility failed to identify a substantiated diagnosis that served as the primary focus in the MTPs of eight (8) of eight (8) sample patients (B7, B10, C7, C11, F1, F3, G9 and G18). The absence of a substantiated diagnosis or diagnoses compromises that staff's ability to deliver clinically focused treatment.

Findings include:

A. Record Review

The following Master Treatment Plans (dates in parentheses) failed to include a substantiated diagnosis that served as the focus of treatment: Patient B7 (2/16/15), Patient B10 (12/31/14), Patient C7 (2/26/15), Patient C11 (2/23/15), Patient F1 (2/24/15), Patient F3 (2/25/15), Patient G9 (3/9/15), and Patient G18 (2/24/15).

B. Staff Interview

1. During an interview with the treatment team for Patients C3, C7, C11, and C14 including the Medical Director (and attending psychiatrist), SW 1, Mental Health Counselor Intern 1, and RN 1 on 3/10/15 at 10:30 a.m., they acknowledged that no diagnosis was included on the MTPs for Patients C3, C7, C11 and C14.

2. The Medical Director stated in an interview on 3/10/15 at 3:00 p.m., "There is no diagnosis in the treatment plan. We have been trying to revise the treatment plan to include a diagnosis."

Based on record review and interview, the facility failed to provide 8 of 8 active sample patients (B7, B10, C7, C11, F1, F3, G9 and G18) with Master Treatment Plans (MTPs) which included individualized interventions that stated specific treatment modalities with a specific focus of treatment based on each patient's individual problems and goals. Instead, the MTPs included routine discipline functions and generic statements of duties written as treatment interventions. These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Patient B7

a. For the problem of "Homicidal Ideations," the identified interventions were as follows: "MD: 5 min [minutes]/daily therapy [with] MSE [mental status examination]. Med-management. Assess risk [with] precaution. [increase] safety. [increase] reality," "RN: Will distribute medications as ordered and educate. Nsg [nursing] will monitor pt for safety and assess pt for coping skills," "SW: will encourage pt to focus on meds and treatment," and "AT: Pt will attend AT groups daily to address stressors & triggers of HI [homicidal ideation] & health ways to communicate with others."

b. For the problem of "Unstable Living Situation due to Homelessness," the identified interventions were as follows: "MD: Collaborate [with] social worker stabilize after care, for prevent relapse [sic]," "RN: Will facilitate treatment team and encourage pt to focus on medications and coping skills to enter housing group," "SW: will encourage pt to work on finding stable living environment prior to discharge," "AT: Pt will attend AT groups daily to address stressor and ways to [illegible]/problem solving skills."

2. Patient B10

For the identified problem of "Psychosis," the identified interventions were as follows: "MD: [psychiatrist] MD will monitor in response to Rx [prescription]," "RN: Nsg [nursing] will administer medications as ordered by MD," "SW: SW will encourage pt to engage in reality based interactions with peers and staff 3x daily," and "AT: AT will help orient pt to the unit and group therapy schedule to promote reality based engagement. 2x daily."

3. Patient C7

For the identified problem of "Depression/not eating/lost weight/hasn't changed clothes in days/Depressed mood hopeless & helpless," the identified interventions were as follows: "MD: Psychiatrist will meet [with Patient C7] daily x 15 minutes to monitor the changes in the severity of depression," "NSG: Nursing will monitor mood and medicate PRN MD order as needed," "SW [social worker]: SW will encourage pt [patient] to take all meds, comm [communicate] when feeling ill, attend groups, & interaction, participate, & invest," and "AT [activity therapist]: will offer group therapy 2x daily. AT will encourage patient to identify 1-2 healthy lifestyle skills."

4. Patient C11

a. For the identified problem of "Psychosis related to presented complaints of responding to internal stimuli," the identified interventions were as follows: "MD: Psychiatrist will meet [with Patient C11] daily x 15 min and assess mental status and response to medication," "NSG: Nursing will encourage patient be [sic] compliant with Tx [treatment], monitor patient for signs of psychosis and effectiveness of medications, daily during length of stay," "SW: SW will encourage pt to take all meds, comm. [communicate] when feeling ill, attend groups, [positive] interaction, practice reality based thinking, participate, & invest," and "AT: AT will offer group therapy 2x daily. AT will encourage [Patient C11] to identify 1-2 healthy selfcare skills."

b. For the identified problem of "Aggressive Behavior Presented Complaint," the identified interventions were as follows: " MD: Psychiatrist will meet [with Patient C11] daily x 15 min and explore at least 2 triggers Re [regarding] aggression," "NSG [nursing]: Nursing will monitor patient for signs of aggression - irritability, agitation - Q [every] shift during length of stay," "SW: SW will encourage pt to take all meds, comm. when feeling ill, attend groups, [positive] interaction, participate, & invest," and "AT: AT will offer group therapy 2x daily. AT will encourage [Patient C11] to identify 1-2 triggers for anger and teach anger management skills."

5. Patient F1

a. For the identified problem of "aggression," the identified interventions were as follows: "MD: Will meet with pt. [patient] 15' [15 minutes]/day to assess [herhis] response to Tx [treatment] (& Rx [medication] if consented to," "NSG: Staff will intervene early to diffuse potential crisis," "SW: Assist pt [patient] in identifying at least 3 - 5 effective coping skills to eliminate aggression," and "AT: Will provide gp. Tx [group treatment] 2 - 3x/wk to address aggression by identifying 1 - 2 + [positive] ways to manage anger."

b. For the identified problem of "trauma/psychosocial," "MD: Will meet with pt. [patient] 15' [15 minutes]/day to assess [her/his] response to Tx [treatment] (& Rx [medication] if consented to," "NSG: Staff will work with patient to identify coping skills to deal with psychosocial stressors," "SW: Assist pt [patient] in identifying triggers to psychosocial issues and most effective ways of dealing with issues," and "AT [Activity Therapy]: Will provide gp tx [group treatment] to address psychosocial stressors by identifying + [positive] ways to communicate needs."

6. Patient F3

a. For the identified problem of "SI" [suicidal ideation], the identified interventions were as follows: "MD: Will meet with patient 15' [15 minutes]/day to assess response to psychiatric treatment and adjust RX [medication] accordingly," "NSG: Staff will intervene early to prevent potential crisis," "SW: Will assist pt. 1 - 2 X/week to help identify + [positive] ways to replace SI [suicidal ideation]," and "AT [Activity Therapy]: will provide gp tx [group treatment] 2 - 3x/week to address + [positive] SI [suicide ideations] by identifying 1 - 2 + [positive] coping skills."

b. For the identified problem of "aggression," the identified interventions were as follows: "MD: Will meet with patient 15' [15 minutes]/day and assess bx [behavioral] level with respect to aggressive bx [behavior], then adjust accordingly tx [treatment] plans," "NSG: Staff will intervene early to prevent potential crisis," "SW: Will educate pt [patient] 1 - 2 x/week on the importance of maintaining + [positive] interactions without anger or aggression," and "AT: Will provide gp tx [group treatment] 2 - 3x/week to address aggression by identifying 1 - 2 + [positive] ways to manage anger."

7. Patient G9

a. For the identified problem of "psychosis," the identified interventions were as follows: "MD: Will meet with pt [patient] 1:1 daily to asses for changes in psychosis," "NSG: Will educate pt [patient] about medications upon starting, at d/c [discharge], and as needed," "SW: SW [Social Worker] and pt [patient] will focus on psychosis, sx [symptoms], tx [treatment], and compliance," and "AT [Activity Therapy]: Will encourage [patient ' s name] to attend 2 groups daily to develop interventions or 2 + [positive] coping skills to deal with hallucinations."

b. For the identified problem of "skin integrity," the identified interventions were as follows: "MD: Medication management, evaluation, and treatment," "NSG: Will assess skin integrity q shift and notify Dr. of abnormal findings," and "SW [Social Work]: Schedule aftercare appointment as recommended."

c. For the identified problem of "risk for dehydration due to decreased fluid intake," the identified interventions were as follows: "MD: Assess for medical stability. Refer to medical team," "NSG: Nurse will monitor input and output and encourage pt [patient] to drink fluids. Nursing will monitor pt's v.s. [patient's vital signs] q [each] shift," and "SW [Social Work]: Schedule aftercare appointment as recommended."

8. Patient G18

a. For the identified problem of "mood d/o[disorder], depression and suicide (sic) ideation," the identified interventions were as follows: "MD: Explore symptoms of depression. Assess risk of suicidality. Adjust medication regimen," "NSG: Will encourage [Patient's name] to verbalize any thoughts of suicide/depression to staff q shift and administer med per MD order," "SW [Social Work]: Will encourage going to 2 groups per day for the first week. Make referral for 1:1 therapist," and "AT [Activity Therapy]: Tx [Treatment] will explore the primary causes of [her/his] depression and SI [suicidal ideations] (grief and loss, etc.) and will attempt to identify sources of hope. 2 internal and 2 external resources/coping skills will be identified."

b. For the identified problem of "substance use," the identified interventions were as follows: "MD: Review mediations of substance abuse. Assess for withdrawal," "NSG: Will monitor [patient's name] for 2 withdrawal symptoms q shift and administer detox meds per MD order," "SW [Social Work]: Will encourage attending 1 meeting per week while in the hospital. Encourage identifying triggers that lead to [her/his] use," "AT [Activity Therapy]: Tx will focus on identifying triggers to substance use (cognitive, affective, behavioral) and also identify 3 alternative bxs [behaviors] to substance use."

B. Staff Interviews

1. During an interview with the Director of Clinical Services on 3/10/15 at 2:00 p.m., she acknowledged that interventions for group were generic. "This treatment plan document is a problem." "We are not hitting exactly what we need to hit...specificity."

2. During an interview with the Assistant Director of Nursing (ADON) on 3/10/15 at 5:10 p.m., he acknowledged that the interventions on the MTPs were general generic and not specific.

3. During an interview with the Director of Psychological Services and Adult Clinical Services on 3/10/15 at 4:00 p.m., he acknowledged that interventions on MTPs were not specific and vague.

4. During an interview with the Medical Director on 3/10/15 at 2:50 p.m., she acknowledged that interventions on MTPs were not specific and vague.

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

I. Ensure that active treatment measures, such as individual treatment and other therapeutic activities, were available for two (2) of eight (8) active sample patients (C7 and C11) who were unwilling or unable to attend group therapies. Specifically, these patients spent many hours in their rooms without any appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125 I)

II. Assess and treat the medical problems of 1 of 1 active patient (Patient C14) reviewed for medical care in order to potentially avoid medical complications. Failure to address medical issues results in a potential risk to patients' lives/health. (Refer to B125 II)

III. Provide necessary interpretive services for 1 of 1 active patient (Patient C3) not proficient in the English language. This failure compromised the patient ' s ability to participate in assessments and treatment. As a result, patients are not able to benefit from group therapies, medication education, verbal interventions, or other treatments or interventions that require the understanding of the English language in order to address the psychiatric problems that led to their hospitalization. (Refer B125 III)

Findings include:

I. Active Treatment

A. Patient C7

1. Patient C7 was admitted 2/26/15. The admission Initial Psychiatric Evaluation dated 2/26/15 stated Patient C7 was "depressed, [decreased] appetite, poor care to self & poor med [medication] compliance for psychiatric conditions & medical conditions. Poor care to self." The admission diagnoses included "Unspecified depressive d/o [disorder]" and "R/o [rule out] unspecified schizophrenic d/o." The interventions for the Problem of "Depression," "Not eating/lost weight/hasn't changed clothes in days," and "Depressed mood/hopeless & helpless" included "SW will encourage pt [patient] to...attend groups" and "AT [activities therapist]: will offer group therapy 2x daily."

2. During an observation of the "Process Group" on 3/10/15 at 9:30 a.m., Patient C7 was observed in her/his room lying in bed.

3. A review of the Group Therapy notes from 2/27/15 to 3/9/15 indicated that Patient C7 attended only 2 groups as follows: on 2/27/15 at 9:30 a.m., "Process" group, "[Patient C7] sat quietly and listened as others shared, although [s/he] declined to participate when prompted by staff and left group after 20 minutes" and on 2/27/15 at 3:00 p.m., "Process" group, "Patient presented very depressed and soft spoken with prompting [s/he] engaged in activity, but needed continuous support throughout the group."

4. During an interview with the treatment team for Patient C7 including the Medical Director (and attending psychiatrist), SW 1, Mental Health Counselor Intern 1, and RN 1 on 3/10/15 at 10:30 a.m., the Medical Director stated that the treatment for Patient C7 consisted of "pharmacotherapy," "encourage [her/him] to come to group," "collateral information," "encourage ADLs [activities of daily living]," and "monitoring [her/his] meds." The Medical Director acknowledged that no other alternative treatments were provided for Patient C7.

B. Patient C11

1. Patient C11 was admitted 2/23/15. The admission Initial Psychiatric Evaluation dated 2/23/15 stated Patient C11 was admitted for reportedly being "reclusive, laughing & crying randomly, attempting to destroy property - slammed the T.V., recently c/o [complained of] panic attacks, shaking, hyperventilation...not verbally responsive to questions." The admission diagnoses included "Schizophrenia." The interventions on the MTP, dated 2/25/15, for the identified Problem of "Psychosis related to presented complaints of responding to internal stimuli" included "SW will encourage pt [patient] to...attend groups" and "AT [activities therapist] will offer group therapy 2x daily."

2. During an observation of the "Process Group" on 3/10/15 at 9:30 a.m., Patient C11 was observed walking in the hallway. During an interview at that time, Patient C11 stated that s/he had only attended "a couple" of groups during that hospitalization. Patient C11 stated s/he "mostly stayed in bed and talked on the phone."

3. A review of the Group Therapy notes from 2/24/15 to 3/9/15 indicated that Patient C11 attended only one treatment group on 3/8/15 at 3:00 p.m. but only "attended the last 20 minutes of group..." and attended only five educational groups.

4. The only documentation provided by the facility of individual therapy was a session on 3/6/15 at 4:15 p.m., conducted by an activities therapy student.

5. During an interview with the treatment team for Patient C11 including the Medical Director (and attending psychiatrist), SW 1, Mental Health Counselor Intern 1, and RN 1 on 3/10/15 at 10:30 a.m., the Medical Director stated that group therapy was the "main form of treatment we have [at the facility]...unfortunately this patient [Patient C11] wouldn't attend." The Medical Director acknowledged that no other alternative treatments were provided for Patient C7.

C. Other Staff Interviews

1. During an interview with the Director of Clinical Services on 3/10/15 at 2:00 p.m., she stated that she would expect alternative treatments to be offered to patients who refuse or were unable to participate in group therapies. She stated that the treatment team should address the refusal of group therapies by patients.

2. During an interview with the Director of Psychological Services and Adult Clinical Services on 3/10/15 at 4:00 p.m., he stated that alternative treatments should be offered for patients not responding to prescribed group therapy.

3. During an interview with the Medical Director on 3/10/15 at 2:50 p.m., she acknowledged that no alternative treatments were provided for Patients C7 and C11 when they did not participate in group treatments.

II. Medical Treatment

A. Patient C14 was a 19 year old admitted 3/4/15 with the diagnoses of "Unspecified bipolar spectrum & related d/o [disorder]," "likely h/o [history of] intellectual disability (IQ [intellectual quotient] unknown," and "HTN [hypertension]." The "History and Physical" form reviewed on 3/10/15 at 12:15 p.m. indicated that a physical assessment had not been completed since admission. The documented reasons for not performing the examinations as follows: on 3/4/15 at 9:30 a.m., "Pt sleeping - won't respond," on 3/5/14 at 9:25 a.m., " 'No'," and on 3/6/15 at 1:45 p.m., "Pt not cooperating."

B. The nursing progress note for Patient C14 on 3/7/15 at 3:45 p.m. stated "Staff alerted by peer [patient initials] that pt. was vomiting. Pt. was laying [sic] down and vomiting profusely and was incontinent of urine...While pt. was sitting in shower became unresponsive and required additional staff to rouse...[physician name] alerted and Pt. sent [outside hospital] via ambulance...While waiting for ambulance pt. vomited again."

C. The "Medical Transfer Form" dated 3/7/15 stated Patient C14 was transferred to the emergency department for "vomiting, difficulty rousing, lethargic."

D. The nursing note dated 3/7/15 [no time] stated "Pt returned from [outside facility] at approximately 6:50 p.m."

E. The discharge summary from the outside facility emergency department dated 3/7/15 at 6:25 p.m. stated the only diagnosis as "Nausea and Vomiting."

F. A review of the medical record on 3/10/15 at 12:30 p.m. indicated that no physical examination or assessment of Patient C14's physical status by a physician or physician assistant had been documented since the return of Patient C14 on 3/7/15. A review of the "Vital Signs Flow Sheet" indication that no vital signs were obtained from 3/7/15 at 6:00 a.m. until 3/10/15 at 2:50 p.m. Patient C14 developed diarrhea on 3/10/14. A medical consultation was not ordered until 3/10/15 at 11:10 a.m.

G. During an interview with the treatment team including the Medical Director (and attending psychiatrist), SW 1, Mental Health Counselor Intern 1, and RN 1 on 3/10/15 at 10:30 a.m., the Medical Director stated that Patient C14 was treated at the local emergency department "over the weekend." She stated that the diagnosis from the emergency was only "nausea." We don't know anything else they did. It's been 3 or 4 days later."

H. During an interview with the Medical Director on 3/10/15 at 2:50 p.m., she stated that she did not know what the etiology of Patient C14's nausea and vomiting or diarrhea. The Medical Director stated that information had not been received from the emergency department evaluation on 3/7/15 and no further assessment had been completed. The Medical Director acknowledged that the medical condition of Patient C14 had not been assessed and she was concerned that an unknown serious condition might have existed.

III. Findings of failure to provide necessary interpreter services:

A. Patient C3 was a 28 year old non-English speaking, Hispanic male with diagnoses of "Unspecified Psychotic d/o [disorder]" admitted to the facility on 3/7/15.

B. A review of the MTP for Patient C11, dated 3/10/15, stated the goals of treatment included "Patient will identify alternative coping strategies to deal with anger and aggression - 3 days, prior to discharge" and "Patient will verbalize any thoughts of aggression to staff." Interventions included to "Psychiatrist were meet [with] [Patient C3] daily x 15 min and explore at least 2 triggers to aggression," "Nursing will encourage Patient to verbalize any thoughts of aggression to staff - Q [every]- shift during length of stay," "SW will encourage pt to take all meds, comm. When feeling ill, attend groups, [positive] interaction, participate, [and] invest," and "Will offer group therapy 2x. AT will encourage [Patient C3] to identify 1-2 triggers for anger and teach anger management skills." No strategies were documented to address how staff would implement these interventions without the presence of an interpreter or interventions to address the communication needs of Patient C3.

C. During an observation of the "Process Group" on 3/10/15 at 9:30 a.m., Patient C3 was observed entering the group for approximately 20 minutes. During this time Patient C3 was observed resting her/his head on the wall with her/his eyes closed. Patient C3 did not participate in this group.

D. During an interview with Interpreter 1 on 3/10/15 at 10:15 a.m., he stated that he had not met Patient C3 or been utilized to interpret for Patient C3 prior to that time.

E. During an interview with Interpreter 2 on 3/11/15 at 9:45 a.m., he stated that Patient C3 had "minimal" comprehension of English. Interpreter 2 stated that Patient C3 understood some words in English but did not understand any English phrases. Interpreter 2 stated that Patient C3 did not understand questions being asked in English and answered with "yes" when asked a question in English. Interpreter 2 stated that he had not met Patient C3 or been utilized to interpret for Patient C3 prior to that time.

F. During an interview with the Medical Director (and attending psychiatrist), SW 1, Mental Health Counselor Intern 1, and RN 1 on 3/10/15 at 10:30 a.m., SW 1 stated that, according to Patient C3's family, Patient C3 did not speak English. The Medical Director stated that she did not know if the initial psychiatric evaluation was completed with an interpreter. She stated that the physician did not speak Spanish and the psychiatric evaluation did not indicate that an interpreter was utilized. The Medical Director stated that Patient C3 "walked out" of her/his physical examination. Mental Health Counselor Intern 1 stated "yes, that [being approached for a physical examination] could be scary" [if Patient C3 did not understand English].

G. During an interview with the Social Work Coordinator on 3/11/15 at 9:00 a.m., she acknowledged that interpreter services were important for the assessment, treatment, and unit milieu with patients who did not understand English. She stated "treatment would not be productive at all."

H. During an interview with the Director of Clinical Services on 3/10/15 at 2:00 p.m., she stated that the faculty should have interpreters available to meet daily needs, group therapy, and to evaluate the status of non-English-speaking patients.

I. During an interview with the Medical Director on 3/10/15 at 2:50 p.m., she acknowledged that Patient C3 was unable to comprehend English with sufficient proficiency to participate in psychiatric, nursing, or social work assessments. She acknowledged that Patient C3 was unable to benefit from treatment interventions such as programming groups and individual therapy without an interpreter due lack of understanding the English language by Patient C3. She acknowledged that there was no documentation of an interpreter having been utilized for assessments, treatments, education, or routine unit activities since admission.

Based on observation, interview, and record review, the Medical Director failed to provide adequate medical oversight to ensure quality medical services. Specifically, the Medical Director failed to:

I. Ensure that the Master Treatment Plans (MTP) for two (2) of eight (8) active sample patients (C7 and C11) were revised based on the patient's lack of response to treatment. These patients refused to participate in the prescribed group therapies and spent long periods of time alone in their rooms. The MTPs were not revised to include modalities from which these patients might benefit. Failure to revise MTPs impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

II. Identify a substantiated diagnosis that served as the primary focus in the MTPs of eight (8) of eight (8) sample patients (B7, B10, C7, C11, F1, F3, G9 and G18). The absence of a substantiated diagnosis or diagnoses compromises that staff ' s ability to deliver clinically focused treatment.

III. Provide eight (8) of eight (8) active sample patients (B7, B10, C7, C11, F1, F3, G9 and G18) with Master Treatment Plans (MTPs) which included individualized interventions that stated specific treatment modalities with a specific focus of treatment based on each patient's individual problems and goals. Instead, the MTPs included routine discipline functions and generic statements of duties written as treatment interventions. These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective treatment.

IV. Ensure that active treatment measures, such as individual treatment and other therapeutic activities, were available for tow (2) of eight (8) active sample patients (C7 and C11) who were unwilling or unable to attend group therapies. Specifically, these patients spent many hours in their rooms without any appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125 I)

V. Assess and treat the medical problems of 1 of 1 active patient (Patient C14) reviewed for medical care in order to potentially avoid medical complications. Failure to address medical issues results in a potential risk to patients' lives/health. (Refer to B125 II)

VI. Provide necessary interpretive services for 1 of 1 active patient (Patient C3) not proficient in the English language. This failure compromised the patient's ability to participate in assessments and treatment. As a result, patients are not able to benefit from group therapies, medication education, verbal interventions, or other treatments or interventions that require the understanding of the English language in order to address the psychiatric problems that led to their hospitalization. (Refer B125 III)

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

I. Ensure that the Master Treatment Plans (MTP) for tow (2) of eight (8) active sample patients (C7 and C11) were revised based on the patient's lack of response to treatment. These patients refused to participate in the prescribed group therapies and spent long periods of time alone in their rooms. The MTPs were not revised to include modalities from which these patients might benefit. Failure to revise MTPs impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

II. Ensure that nursing interventions on the Master Treatment Plans of eight (8) of eight (8) sample records (B7, B10, C7, C11, F1, F3, G9 and G18) were individualized and specific to patient needs. The nursing interventions for the listed problems were generic and not individualized to patient needs. This deficiency results in failure to provide specific guidance for nursing staff to care for each patient based on each patient's individual psychiatric nursing needs. (Refer to B122)

Findings include:

A. Record Review

1. Patient B7 (MTP 2/16/15). The nursing intervention for the identified problem of "Homicidal Ideations" was "Will distribute medications as ordered and educate. Nsg [nursing] will monitor pt for safety and assess pt [patient] for coping skills." The nursing intervention for the identified problem of "Unstable Living Situation due to Homelessness" was "Will facilitate treatment team and encourage pt [patient] to focus on medications and coping skills to enter housing group."

2. Patient B10 (MTP 12/31/14, update 1/20/15). The nursing intervention for the identified problem of "Psychosis" was "Nsg [nursing] will administer medications as ordered by MD."

3. Patient C7 (MTP 2/26/15). The nursing intervention for the identified problem of "Depression/not eating/lost weight/hasn't changed clothes in days/Depressed mood hopeless & helpless" was "Nursing will monitor mood and medicate PRN MD order as needed."

4. Patient C11 (MTP 2/23/15). The nursing intervention for the identified problem of "Psychosis related to presented complaints of responding to internal stimuli" was "Nursing will encourage patient be [sic] compliant with Tx [treatment], monitor patient for signs of psychosis and effectiveness of medications, daily during length of stay." The nursing intervention for the identified problem of "Aggressive Behavior Presented Complaint," was "Nursing will monitor patient for signs of aggression - irritability, agitation - Q [every] shift during length of stay."

5. Patient F1 (MTP 2/24/15). The nursing intervention for the identified problem of "aggression" was "Staff will intervene early to diffuse potential crisis." The nursing intervention for the identified problem of "trauma/psychosocial," was "Staff will work with patient to identify coping skills to deal with psychosocial stressors."

6. Patient F3 (MTP 2/25/15). The nursing intervention for the identified problem of "SI" [Suicidal Ideation] was, "Staff will intervene early to prevent potential crisis." The nursing intervention for the identified problem of "aggression" was "Staff will intervene early to prevent potential crisis."

7. Patient G9 (MTP 3/9/15). The nursing intervention for the identified problem of "psychosis," was "Will educate pt [patient] about medications upon starting, at d/c [discharge], and as needed." The nursing intervention for the identified problem of "skin integrity," was "Will assess skin integrity q shift and notify Dr. of abnormal findings." The nursing intervention for the identified problem of "risk for dehydration due to decreased fluid intake" was "Nurse will monitor input and output and encourage pt [patient] to drink fluids. Nursing will monitor pt's v.s. [vital signs] q shift."

8. Patient G18 (MTP 2/24/15). The nursing intervention for the identified problem of "mood d/o [disorder], depression and suicide (sic) ideation" was "Will encourage [Patient's name] to verbalize any thoughts of suicide/depression to staff q shift and administer med per MD order." The nursing intervention for the identified problem of "substance use" was "Will monitor [patient's name] for 2 withdrawal symptoms q shift and administer detox meds per MD order."

B. Staff Interview

1. The ADON stated on 3/10/15 at 3:30 p.m., "The treatment plans don't capture the treatment correctly and are not always amended correctly. We are discussing individualization of treatment plans with the staff."

2. The DON stated on 3/10/15 at 3:45 p.m., "We will be doing training with the nurses about how to improve the treatment plans."

III. Ensure that active treatment measures, such as individual treatment and other therapeutic activities, were available for two (2) of eight (8) active sample patients (C7 and C11) who were unwilling or unable to attend group therapies. Specifically, these patients spent many hours in their rooms without any appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125 I)

IV. Provide necessary interpretive services for 1 of 1 active patient (Patient C3) not proficient in the English language. This failure compromised the patient's ability to participate in assessments and treatment. As a result, patients are not able to benefit from group therapies, medication education, verbal interventions, or other treatments or interventions that require the understanding of the English language in order to address the psychiatric problems that led to their hospitalization. (Refer B125 III)

Based on record review and interview, the facility failed to provide social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions, and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (B7, B10, C7, C11, F1, F3, G9 and G18). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Refer to B108)