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Based on staff interview and, medical record review, it was determined that there is a systematic failure of the facility to provide medical records that document the treatment given to patients and the facility staff who provided the services.

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 four (4) of eight (8) sample patients (B7, B10, D7 and E8). 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 (5/27/15), Patient B10 (5/29/15), Patient D7 (5/25/15), and Patient E8 (5/20/15).

B. Staff Interview

1. During an interview with the Director of Clinical Services on 6/2/15 at 3:00 p.m., she acknowledged that these 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.

2. During an interview with the Social Work Coordinator on 6/2/15 at 1:10 p.m., she acknowledged that these 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.

Based on record review and interview, the facility failed to provide eight (8) of eight (8) active sample patients (B7, B10, C2, C5, D7, D9, E7 and E8) 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 for nurses and psychiatrists. 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 (date of MTP in parentheses)

1. Patient B7 (5/24/15)

a. For the problem of "aggression," the identified MD and nursing interventions were as follows: "Psychiatrist will meet with [Patient B7] daily x 15 minutes and [illegible] at least two (2) triggers to aggression." "Nursing staff will monitor patient for signs of aggression, agitation, irritability and redirect as appropriate."

b. For the problem of "self-injury," the identified MD and nursing interventions were as follows: "Psychiatrist will meet with [Patient B7] daily and assess for evidence of self injury." Nursing: "Implement staff observation and safety measures: 1:1 observation, place in area close to nursing station, provide check-ins with [Patient B7] regarding mood and thoughts of self-harm."

c. For the problem of "psychosis," the identified MD and nursing interventions were as follows: "Psychiatrist will meet with [Patient B7] daily x 15 minutes. Rx [prescribe] medication and adjust dosages based on clinical response." "Nursing will assess pts [patient's] mood, monitor for psychosis, and assess effectiveness of medications."

2. Patient B10 (5/27/15)

a. For the problem of "Depression; Suicidal Ideations," the identified MD and nursing interventions were as follows: "Psychiatrist will meet with [Patient B10] daily x 15 minutes. Rx [prescribe] antidepressant and adjust dosages based on clinical response." "RN will assess for SI [suicidal ideations] and educate [Patient B10] on medications prescribed for depression."

b. For the problem of "Substance Abuse," there were no identified MD interventions. The nursing intervention was as follows: "RN will encourage [Patient B10] to use new coping skills to manage triggers/urges and cravings."

3. Patient C2 (5/22/15)

a. For the problem of "Treatment non-compliance," the identified MD and nursing interventions were as follows: MD: "Educate pt [patient] with meds [medications] benefit (sic). Adjust meds to his/her lifestyle for increased compliance." "Nursing will monitor treatment compliance and educate [Patient C2] to importance of treatment compliance."

b. For the problem of "Postpartum," the identified MD and nursing interventions were as follows: MD: "Collaborate with N.S. [nursing staff] and med-team, with f/u [follow-up], OB/GYN, stabilize sx [symptoms]." "Nursing will monitor [Patient C2] for complications related to post-partum."

c. For the problem of "Aggression," the identified MD interventions were as follows: MD: "1:1 15 min [minutes] daily, with MSE [mental status exam] and therapy with med-management. [Decrease] aggression with [increase] coping skill, [increase] safety, [decrease] impulsivity.

d. For the problem of "Depression," the identified MD interventions were as follows: "1:1 15 min/daily therapy with MSE and med-management [increase] coping skills [increase] mood."

4. Patient C5 (5/28/15)

a. For the problem of "SI," the identified MD and nursing interventions were as follows: "MD:" "1:1 15 min/daily therapy with MSE with med-management also. Assess risk with precaution. With [increase] safety, [increase] functioning." "Nursing will provide check-ins with patient regarding mood and thoughts of self harm."

b. For the problem of "HI" [homicidal ideation], the identified MD and nursing interventions were as follows: "MD:" "1:1 15 min/daily therapy with MSE. Assess risk with precaution with RX [medication] mgt. [management]. [Increase] safety, [increase] coping skills." Nursing: "Educate pt re: the benefits of taking meds for control of aggressive thoughts and behaviors."

c. For the problem of "Treatment non-compliance," the identified nursing interventions were as follows: "Nursing will monitor pt's compliance with medication and groups."

5. Patient D7 (5/29/15)

For the problem of "Depression & SI," the identified nursing interventions were as follows: "Educate patient regarding symptoms of depression and importance of compliance with treatment. Provide check-ins with patient regarding mood, negative thoughts and significant behavioral changes in condition."

6. Patient D9 (5/29/15)

For the problem of "Anxiety," the identified MD and nursing interventions were as follows: "MD:" "Assess patient's response, prescribe medication & monitor patient's behavior & any side effects to prescribed medications: TBD [to be determined] and initiate dosage to reduce panic and/or anxiety attacks," "MD/RN/LPN:" "Provide education for TBD: risks, benefits, side effects and need to continue meds after discharge," and "RN/LPN:" "Monitor and educate on anti-anxiety medication."

7. Patient E7 (5/27/15)

a. For the problem of "Depression [with] SI," the identified MD and nursing interventions were as follows: "MD will assess pt's [patient's] response, prescribe medications and monitor pts behavior & any side effects [secondary to] prescribed meds [medications]" and "Nurse will educate [Patient E7] about symptoms of depression & the importance of compliance [with] treatment/meds."

b. For the problem of "Paranoia," the identified intervention for the MD was as follows: "MD will prescribe medication & monitor [Patient E7's] response daily."

c. For the problem of "Medication non-compliance," the identified intervention for the MD was as follows: "MD will evaluate [Patient E7's] perception of medication effectiveness daily."

8. Patient E8 (5/21/15)

a. For the problem of "Depression [with] SI," the identified MD and nursing interventions were as follows: "MD will assess pt's response, prescribe medications and monitor pts behavior & any side effects [secondary to] prescribed medications" and "Nurse will educate [Patient E8] about symptoms of depression & the importance of compliance [with] treatment/meds."

b. For the problem of "Psychosis - Auditory Hallucinations," the identified MD and nursing interventions were as follows: "MD will prescribe medication & monitor [Patient E8's] response daily" and "Nursing will educate [Patient E8] of the risks of non-compliance."

c. For the problem of "Substance Abuse," the identified MD intervention was as follows: "MD will educate [Patient E8] on the negative effects that D&A [drug and alcohol] have on the body."

d. For the problem of "Psychosocial," the identified MD and nursing interventions were as follows: "MD will meet [with] [Patient E8] daily & team daily to explore safe D/C [discharge] plans" and "Nursing will educated [sic] [Patient E8] on the consequences of D/C plan noncompliance."

Based on interview and record review, the facility failed to assess and treat the medical problems of one (1) of eight (8) sample patients (B10) and one (1) of two (2) non-sample active patients (D19) 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.

Findings include:

A. Patient B10

1. Patient B10 was a 21 year-old admitted 5/27/15 with a diagnosis of "unspecified bipolar disorder." The "Medical Diagnosis" section stated "[nothing] acute." When the Patient B10 presented to the psychiatric facility for admission on 5/26/15, Patient B10 was referred to the emergency department at a local hospital for medical clearance related to a burn wound to the right leg. Patient B10 was medically cleared with the recommendation for daily treatment and dressing changes and returned to the facility for admission.

2. The Psychiatric Evaluation dated 5/26/15 at 11:38 a.m. stated in the "Significant Medical History" section that Patient B10 had no current medical conditions.

3. The History and Physical examination dated 5/27/15 at 10:30 a.m. stated that there was a "burn (~3 cm diameter) on right anterior shin with subcutaneous tissue visible."

4. The Physician's Inpatient Admission Order on 5/27/15 at 12:08 p.m. stated "silver sulfadiazine cream 1% to affected area over left [wrong site] shin twice daily X 7 days." A physician order on 5/27/15 at 12:40 p.m. stated "MRSA [methicillin-resistant Staphylococcus aureus] swab on right lower extremity burn site."

5. The Master Treatment Plan dated 5/27/15 identified the problem of "Burn on R (right) leg." The psychiatrist intervention was as follows: "Psychiatrist will meet with [Patient B10] daily X 15 minutes and assess medical aspect of right leg burn and determine need for medical consult." The nursing intervention was as follows: "RN will educate [Patient B10] regarding importance of medication compliance and wound care."

6. A review of the Physician Progress Notes, Multidisciplinary Notes, and Nursing Progress Notes for Patient B10 on 6/1/15 at 11:30 a.m. indicated no assessment or treatment of Patient B10's burn wound was documented since the time of admission. There were no progress notes or treatment notes indicating that the Patient B10 received treatment of the burn wound or that the physician had assessed the healing process of the burn wound.

7. During an interview on 6/1/15 at 11:30 a.m., RN4 stated that the burn wound was dressed daily by nursing staff and documented on Medication Administration Record but that the doctor had not assessed the burn wound since the patient's day of admission.

8. During an interview on 6/1/15 at 2:00 p.m., Patient B10 stated that the doctor looked at the burn wound on the day of admission but had not looked at the burn wound since admission.

9. During an interview on 6/2/15 at 12:10 p.m., MD 1, the physician for Medical Services, stated that, in order to "assess" a wound, a doctor would need to visually observe the wound. She acknowledged that there was no documentation in the medical record for Patient B10 that indicated that the burn wound had been assessed by a physician between 5/27/15 and 6/1/15.

10. During an interview with the Medical Director (and attending psychiatrist) on 6/2/15 at 12:10 p.m., she stated that the attending psychiatrist was responsible for both psychiatric and medical care for the patients in the facility. She stated that there was no mechanism for medical providers to follow-up medical problems unless consulted by the attending psychiatrist. She acknowledged that there was no documentation of an assessment of the burn wound by the emergency department prior to admission, only recommendations for treatment. She stated that she would expect a medical provider to assess the wound "every couple of days."

B. Patient D19

1. Patient D19 was a 46 year-old admitted 5/30/15 with the diagnoses of "Unspecified Depressive Disorder," "Pervasive developmental disorder," "Diabetes Mellitus," and "HTN [hypertension]." The "Initial Plan for Treatment" section did not include a plan for further assessments or treatments for the identified medical conditions.

2. The Medication Reconciliation form dated 5/30/15 at 1:00 a.m., indicated that Patient D19 had been receiving "Insulin 70/10 20 units HS [bedtime] 15 units AM [morning]" prior to admission.

3. The initial Nursing Assessment dated 5/30/15 at 12:15 p.m. stated in the "Medical/Surgical" section, "7 weeks - [right] foot surgery. Now has nickel sized ulcer." The "Admission Screening for MRSA" dated 5/30/15 at 2:00 p.m. completed by nursing staff indicated that Patient D19 had "an open wound." The "Multidisciplinary Progress Notes" on 5/30/15 at 2:00 p.m. by nursing stated "[positive] for open area on bottom of [right] foot."

4. The Initial Psychiatric Evaluation dated 5/30/15 at 11:00 a.m. stated in the "Surgical Hx [history]" that Patient D19 had a "R [right] toe amputation 6 weeks ago - diabetes complication." The "Initial Plan for Treatment" section did not document the ulcer on the foot of Patient D19 or any treatment interventions for diabetes assessment and treatment.

5. The History and Physical Examination dated 5/31/15 at 9:15 a.m. indicated that there were no findings in the section "Integumentary" section of the examination with the skin "warm, dry, good color, skin intact without rash, lesions, normal hair texture, no clubbing of fingers." There were no findings in the "Extremities" section with "no discoloration, edema, impairment or deformity, Pedal pulses 2+ BL [bilaterally]." The History and Physical Examination did not indicate that Patient D19 suffered from a diabetic ulcer on his foot or that his right foot was edematous.

6. The "Physician Progress Notes" dated 5/31/15 at 2:00 p.m. and 6/1/15 at 4:45 p.m. indicated in the section "Review of Diagnostic Tests and Medical Status," "none."

7. The Physician's Admission PRN Order Sheet stated "Blood Sugar Checks:" "Regular Insulin Sliding Scale (Call MD/DO if BS [blood sugar] [less than] 60 or [greater than] 400)" "BS 150-200 2 units," "BS 201-250 4 units," "BS 251-300 6 units," "BS 301-350 8 units," "BS 351-400 10 units." A review of the Physician's Order sheets indicated that a physician was called by nursing staff due to blood sugars exceeding the ordered parameter (400 milimoles/liter) on 5/30/15 at 5:00 p.m., 5/30/15 at 10:30 p.m., 5/31/5 at 6:00 p.m., 5/31/15 at 9:30 p.m., 6/1/15 at 6:20 a.m., and 6/1/15 at 9:30 p.m.

8. A review of the Physician's Order sheets indicated that Patient D19 was not restarted on a standing order for insulin, "Novolin 70/30 - 15 units SQ [subcutaneous] in A.M., 20 units SQ in PM," until 6/1/15 at 2:50 p.m. The "Medical Consultation" dated 6/1/15 at 2:55 p.m. stated "DM [diabetes mellitus] - 70/30 was never ordered upon admission. Will start 20 units in PM & 15 units in AM as pt had been taking prior to admission."

9. A review of the medical record on 6/2/15 at 9:30 a.m. indicated that an assessment of the ulcer had not been documented by a physician or medical provider during this admission.

10. During an interview with Patient D19 on 6/2/15 at 9:40 a.m., Patient D19 stated that no physician or medical provider had examined the ulcer during this hospitalization.

11. The "Medical Consultation" dated 6/2/15 at 10:10 a.m. stated "Pt [with] uncontrolled DM [diabetes mellitus] - ACCU [check mark] reading high...Pt also reports ulcer on bottom of [right] foot which he has been seeing outpt [outpatient] wound care for weekly follow-ups."

12. The "Medical Consultation" dated 6/2/15 at 2 p.m. stated that the physical examination included "app [approximately] 2 cm [centimeter] size circular ulcer on bottom of Rt [right] foot" and "3 + edema. Rt foot with feeble pulse +." The "Impression/Plan" section stated "Diabetic ulcer."

13. During an interview with the Medical Director on 6/2/15 at 12:10 p.m., she stated that the admitting nurse should have communicated the finding of the ulcer to the attending psychiatrist and that the attending psychiatrist for Patient D19 should have requested a medical consultation for Patient D19. She acknowledged that these actions did not occur. She stated that Patient D19's blood sugars being "all over the place" should have been "a red flag." The Medical Director acknowledged that not addressing the ulcer in the context of uncontrolled diabetes was potentially dangerous for Patient D19.

Based on 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. Provide eight (8) of eight (8) active sample patients (B7, B10, C2, C5, D7, D9, E7 and E8) with Master Treatment Plans (MTPs) which included individualized interventions to be provided by the physician 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 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. (Refer to B122)

II. Assess and treat the medical problems of one (1) of eight (8) sample patients (B10) and one (1) of two (2) non-sample active patients (D19) 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)

Based on 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 provide eight (8) of eight (8) active sample patients (B7, B10, C2, C5, D7, D9, E7 and E8) with Master Treatment Plans (MTPs) which included individualized interventions to be provided by the nurse 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 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. (Refer to B122)

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 four (4) of eight (8) sample patients (B7, B10, D7 and E8). 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)