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

I. Ensure that all members of the interdisciplinary team included their interventions on patients' Master Treatment Plans (MTPs). Specifically, the MTPs for 4 of 8 active sample patients (A3, A8, A21 and A30) had no interventions by physicians. The MTPs of 2 of 8 active sample patients (A3 and A8) had no professional nursing interventions, and the MTPs of 3 of 8 active sample patients (A10, A12 and A21) had no interventions by rehabilitation therapists .n addition, the facility had nursing staff develop the Master Treatment Plans for patients on the day of admission instead of assuring that the plans were developed by the interdisciplinary team after review/discussion of all assessments. Failure to include MTP interventions by all members of the multidisciplinary team hampers the staffs' ability to provide coordinated treatment and potentially results in patients not receiving all needed treatment to address their problems. (Refer to B118)

II. Develop Master Treatment Plans (MTPs) that included short term goals (STGs) that were stated in measurable behavioral terms for 4 of 8 active sample patients (A10, A12, A16 and A30). In addition, the MTPs for 5 of 8 active ample patients (A3, A8, A12, A18 and A21) incorrectly listed staff interventions rather than patient outcome behaviors as patient goals. These deficiency practices hamper the ability of the treatment team to provide goal directed treatment and determine effectiveness of interventions based on changes in patient behaviors. (Refer to B121)

III. Develop Master Treatment Plans (MTPs) that documented individualized interventions based on the assessed needs of 8 of 8 active sample patients (A3, A8, A10, A12, A16, A18 and A30). Instead, interventions on the plans were generic discipline functions which frequently lacked a focus for treatment. This deficiency results in lack of guidance for staff in providing individualized treatment that is purposeful and goal-directed. (Refer to B122)

IV. Provide active treatment, including alternative interventions for 1 of 8 active sample patients (A18) who was not motivated to attend the groups offered. Approximately half of 26 non-sample patients on the unit (census=26) also did not consistently attend unit groups. Rather than providing individualized treatment for these patients, staff expected them to attend all groups listed on the unit activity schedule. When patients declined to attend the scheduled programming, they were allowed to do whatever they wished to do, such as go to their rooms and lie down or sit in the Dayroom or dining room. Failure to provide active treatment for patient A18 and not seeing that all patients take advantage of groups offered results in patients being hospitalized without all interventions for recovery being provided for them, potentially delaying their improvement. (Refer to B125-I)

V. Assure that staff used and documented proper procedures for seclusion/restraint for 3 of 4 non-sample patients (C1, C2 and C4) whose records were reviewed for seclusion and restraint procedure compliance. For sample patients C1 and C2, "therapeutic holds" were employed for administration of medications without documented physician orders. For patient C4, a seclusion episode was documented approximately 5 hours after initiation of the seclusion. The physician progress note said that the patient had been in seclusion, but did not mention a face to face evaluation. These failures violate the patients' rights to be free from unnecessary restraints without sufficient justification, and potentially endanger the patients' life and well being. (Refer to B125-II)

Based on record review and interview, it was determined that for 3 of 3 active sample patients (A3, A8 and A16), who had been hospitalized over 72 hours (policy deadline for psychosocial assessment completion), the facility failed to provide a social work assessment in a timely fashion or failed to provide psychosocial assessments that included conclusions and recommendations, describing anticipated social work roles in treatment and discharge planning. This failure results in a lack of professional social work input for treatment planning and potentially leads to lack of needed social work services.

Findings include:

A. Record review

1. Patient A3 (admitted 8/27/11). The Psychosocial Assessment dated 8/30/11 contained no recommendations that described anticipated social work roles in treatment and discharge planning.

2. Patient A8 (admitted 8/27/11). The Psychosocial Assessment dated 8/30/11 contained no recommendations that described anticipated social work roles in treatment and discharge planning.

3. Patient A16 (admitted 8/17/11). A Psychosocial Assessment note dated 8/26/11 reported that patient refused the assessment. On 9/29/11, the record documented a second refusal. The first attempt Psychosocial Assessment took place beyond the 72 hr time limit required by hospital policy.

B. Staff Interview

In an interview on 8/29/11 at 3p.m., the above findings were acknowledged by the Assistant Director of Social Services who was in charge of the social work activities on the Adult Psychiatric unit.

Based on record review and interview, the facility failed to ensure that the Master Treatment Plans (MTPs) for 6 of 8 active sample patients (A3, A8, A10, A12, A21 and A30) included interventions by all members of the interdisciplinary team. Specifically, the MTPs for patients A3, A8, A21 and A30 had no physician interventions; the MTPs for patients A3 and A8 had no professional nursing interventions; and the MTPs for patients A10, A12 and A21 had no rehabilitation therapist interventions. In addition, the facility had nursing staff develop the Master Treatment Plans for patients on the day of admission instead of having plans developed by the interdisciplinary team after review/discussion of all assessments. These failures hamper the staffs' ability to provide coordinated treatment, potentially resulting in patients not receiving all needed treatment to address their problems.

Findings include:

A. Record Review

1. The following MTPs did not have physician interventions (dates of MTP in parenthesis): A3 (8/27/11), A8 (8/27/11), A21 (8/29/11), and A30 (8/25/11).

2. The following MTPs did not have any professional nursing interventions: A3 (8/27/11), and A8 (8/27/11).

3. The following MTPs did not have any rehabilitation therapist interventions: A10 (8/28/11), A12 (8/27/11), and A21 (8/29/11).

B. Policy Review

4. In this facility, the professional nurses are responsible for developing the MTP for all disciplines. The facility's policy/procedure, titled "Treatment Planning", #903, last reviewed 3/11/09, states, "The nurse will list at least two main problems, interventions, measurable goals and target dated"... "The nurse will list who is responsible for overseeing"... "particular interventions,"... "Membership [on treatment plan teams] will include, but is not limited to a physician, RN [registered nurse], case manager [bachelor level people who, complete the psychosocial assessment and do discharge planning]."

B. Interview

In an interview on 8/29/11 at 9:50a.m., RN #1 was asked who was responsible for treatment plan development. She stated that the registered nurse [RN] who admits a patient, develops the initial/Master Treatment plans for the treatment team, based on information obtained from the admitting psychiatrist's assessment and progress notes written by the case managers and nurse practitioners who do all the history and physicals. When asked why the nurses develop all the treatment plans, RN #1 stated, "We operate under a medical model, you know." She meant that in a medical/surgical setting, nursing staff develop treatment plans for patients.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that included short term goals (STGs) that were stated in measurable behavioral terms for 4 of 8 active sample patients (A10, A12, A16 and A30). In addition, the MTPs for 5 of 8 active ample patients (A3, A8, A12, A18 and A21) incorrectly listed staff interventions (rather than patient outcome behaviors) as patient goals. This deficient practice hampers the ability of the treatment team to provide goal directed treatment and determine effectiveness of interventions based on changes in patient behaviors.

Findings include:

A.Record Review (MTP dates in parentheses)


1. Unmeasurable Goals

a. Patient A10. A non-measurable patient goal on the MTP (8/28/11) was "[name of patient] will no longer pose a threat to self & [and] others & will develop coping skills."

b. Patient A12. A non-measurable patient goal on the MTP (8/27/11) was "[name of patient] will no longer be suicidal & will develop insight & coping skills."

c. Patient A16. A non-measurable patient goal on the MTP (8/16/11) was "[name of patient] will experience cleaner thought processes and will exhibit no psychosis within 7 days."

d. Patient A30. A non-measurable patient goal on the MTP (8/25/11) was "[name of patient] will remain medically stable until discharged."

2. Staff interventions stated as patient goals

a. Patient A3. Staff goals on MTP (8/27/11) were, "to maintain her safety & the safety of others from admission to discharge." "Educate her regarding her illness & teach newer coping skills."

b. Patient A8. Staff goals on the MTP (8/27/11) were, "maintained his safety from admission to discharge." "Educate regarding his illness & teach new coping skills." "Maintain medical stability while here."

c. Patient A12. A staff goal on the MTP (8/27/11) was "[name of patient] will have a safe detox & F/U c [follow up with] a tx [treatment] program."

d. Patient A18. A staff goal on the MTP (8/27/11) was "maintain his safety from admission to discharge."

e. Patient A21. A staff goal on the MTP (8/29/11) was "[after] medical clearance F/U [follow-up] [with] rehab [rehabilitation] program."

B. Interview

In an interview on 8/30/11 at 4p.m., the unmeasurable goals and the incorrectly listed staff interventions as patient goals on the active sample patients' MTPs were discussed with the Medical Director. He acknowledged the findings.

Based on record review and interview, it was determined that the facility failed to develop Master Treatment Plans (MTPs) that documented individualized interventions based on the assessed needs of 8 of 8 sample patients (A3, A8, A10, A12, A16, A18, A21 and A30). Instead, the listed interventions on the patients' MTPs were generic discipline functions. This failure results in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and fail to provide guidance to staff regarding the specific modalities needed and the purpose for each modality/intervention.

Findings include:

A. Record Review

1. Patient A3 (admitted 8/27/11). The MTPdated 8/27/11 listed "Recovery/Treatment Issues" as "(Patient name) is here voluntarily due to homicidal ideation. She reports hearing voices telling her to harm. She had a verbal altercation with her grandmother over not knowing who her child's father is." Staff Interventions were listed as: "Patient is on close observation, suicide precautions, and homicide precautions-15 min [minute] checks" These are generic staff functions. "Provide groups-3-4 X [times] daily." The specific focus of the group for the patient was not noted.

2. Patient A8 (admitted 8/27/11). The MTP dated 8/27/11 listed Recovery/Treatment Issues as "(Patient name) is here on a voluntary basis due to depression with suicidal thoughts, (Patient name) reports having COPD [chronic obstructive pulmonary disease], NIDDM [non- insulin dependent diabetes mellitus], and hypertension." Staff Interventions were listed as: "Patient is on close observation and suicide precautions-15 min checks." These are generic staff functions. "Provide groups-3-4xdaily." The specific focus of the group for the patient was not noted. "Physical assessment." This was a generic activity.

3. Patient A10 (admitted 8/28/11). The MTP dated 8/28/11 listed "Recovery/Treatment Issues" as "(Patient name) admitted...Allegedly made threats to kill self and 6 month old baby." Staff Interventions were listed as: "Provide group therapy-daily." The specific focus of the groups for the patient was not noted. "Individual therapy with MD daily." The specific focus of therapy was not noted.

4. Patient A12 (admitted 8/27/11). The MTP dated 8/27/11 listed "Recovery/Treatment Issues" as "(Patient name) got drunk and was trying to jump in front of cars. Says she wants to die." "(Patient name) uses ETOH [alcohol]." Staff Interventions were listed as: "Daily group therapy." (no noted focus of the group). "Individual therapy with MD daily." The focus of the Individual therapy was not noted.

5. Patient A16 (admitted 8/16/11). The MTP dated 8/16/11 listed "Recovery/Treatment Issues" as "(Patient name) was Baker Acted at [name of facility] for psychosis, does not appear to be in touch with reality. She has been hospitalized for 12 days at [name of facility] for septic shock." (Patient name) has medical concerns of CAD [coronary artery disease], non insulin dep. diabetes mellitus, thrombocytopenia, hyperlipidemia, and UTI [urinary tract infection] (on antibiotics)." Staff Interventions were listed as: "on fall and close observation precautions" (generic functions); "evaluation by Psychiatrist" (generic function); "encourage physical participation 3x daily" (non-specific); "administer medications as prescribed for anxiety, psychosis 1-3x daily prn [as needed]" (generic function); "Monitor response to medications every shift" Generic function, "1; 1 therapy-as needed" (non-specific); "family therapy-as needed" (non-specific); "evaluation by doctor/ARNP [nurse practitioner]-upon admission"; "medications, laboratory studies as needed" (generic functions).

6. Patient A18 (admitted 8/27/11). The MTP dated 8/27/11 listed Recovery/Treatment Issues as "(Patient name) presents voluntarily due to suicidal thoughts by overdose or suffocation: Staff Interventions were listed as: "Evaluate medically-on admit" (generic function); "provide group therapy-tid [three times a day]" (no focus or type of group specified); "monitor vital signs-qid [four times a day]" (generic function); "Monitor progress and document-bid [twice a day]" (generic function); "administer medications-as directed" (generic function).

7. Patient A21 (admitted 8/29/11). The MTP dated 8/29/11 listed Resource/Treatment Issues as "(patient name) was on ART x 4 day. For ETOH (alcohol) program [sic]. On 8/28/11 he had a grand mal seizure, sent to [name of facility] ER [emergency room] for clearance. (Patient name) has a past med. Hx [medical history] of seizures, recent grand mal seizures." Staff interventions were listed as: "Monitor for S/S q4h [signs and symptoms every 4 hours] withdrawal and document" (generic); "Encourage to attend groups-daily" (nonspecific focus and type of group); "Monitor vitals" (generic task); "Provide Neurontin as ordered" (generic task); "evaluate medically-PRN daily" (generic task).

8. Patient A30 (admitted on 8/25/11). The MTP dated 8/25/11 listed recovery/treatment issues as "(Patient name) presents to access to detox from polysubstance dependence; hypertension; cancer. Staff Interventions were listed as "Provide safe therapeutic milieu for safety-q15 min. [every 15 minutes]." (generic function); "Provide 1:1 and group therapy to discuss alternative coping skills 3-4x Daily" (nonspecific focus and type of group or nature of "coping skills"); "evaluate medical issues-within 24 hours" (generic function).

B. Interviews

1. In an interview on 8/30/11 at 11:45a.m., the generic interventions on the Master Treatment Plans were discussed with the Nursing Director. The DON agreed with the findings.

2. During an interview with the Medical Director on 8/30/11 at 4p.m., the above findings were reviewed. The Medical Director acknowledged the findings.

Based on record review and interview, it was determined that the facility failed to identify the responsible team member by name and discipline for the modalities listed in the Master Treatment Plans (MTPs) of 7of 8 active sample patients (A3, A8, A10, A12, A18, A21 and A30). Instead, either the first names and initials of the discipline were used or just the discipline initials without a name. This failure compromises the facility's ability to determine what staff member is responsible for ensuring compliance with the various aspects of treatment, potentially hampering the effective coordination of treatment modalities.

Findings include:

A. Record Review

1. Patient A3 (admitted 8/27/11). The Master Treatment Plan) dated 8/27/11 listed as "Responsible Party" for listed modalities as "Brian MHT, Troy MHT, Connie MHT, Tara MHT, Kari MHT, Nina MHT." No full names were recorded anywhere on the MTP.

2. Patient A8 (admitted 8/27/11). The MTP dated 8/27/11 listed as "Responsible Party" for listed modalities as "Brian MHT, Connie MHT, Nina (No discipline), Tara (No discipline), Kari (No discipline), and Philip PA." No full names were recorded anywhere on the MTP.

3. Patient A10 (admitted 8/28/11). The MTP dated 8/28/11 listed "Responsible Party" for listed modalities as "Fred RN." No full name was recorded

4. Patient A12 (admitted 8/27/11). The MTP dated 8/27/11 listed for listed "Responsible Party" for modalities as "Fred RN" No full name was recorded anywhere on the MTP

5. Patient A18 (admitted 8/27/11). The MTP dated 8/27/11 listed "Responsible Party" for listed modalities as "MD/ARNP, Therapists, BHT (Behavioral Health Tech)/Nurses, Bryson, Connie, MHTs..." No full names were recorded anywhere on the MTP.

6. Patient A21 (admitted 8/29/11). The MTP dated 8/29/11 listed "Responsible Party" for listed modalities as "Fred RN, Therapist, Ashby MHT, Kevin MHT, Cury MHT, Heather LPN, Kay RN." No full names were recorded anywhere on the MTP.

7. Patient A30 (admitted 8/29/11). The MTP dated 8/29/11 listed "Responsible Party" for listed modalities as "Sarah BHT, Connie BHT, Kevin BHT, Kari ACSW, Nina CRT (Certified Recreational Therapist), Justin RN, Patty ARNP" No full names were recorded anywhere on the MTP.

B. Interview

1. In an interview on 8/30/11 at 11:45a.m., the lack of full nursing names responsible for nursing interventions on the Master Treatment Plans was discussed with the Director of Nursing. She did not dispute the findings.

2. During an interview on 8/30/11 at 4p.m, the above findings were reviewed with the Medical Director. He acknowledged the findings.

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

I. Provide active treatment, including alternative interventions for 1 of 8 active sample patients (A18) who was not motivated to attend the groups offered. Approximately half of 26 non-sample patients on the unit (census=26) also did not consistently attend unit groups. Rather than providing individualized treatment for these patients, staff expected them to attend all groups listed on the unit activity schedule. When patients declined to attend the regular programming, they were allowed to do whatever they wished to do, such as go to their rooms and lie down or sit in the Dayroom, dining room, or one or the other rooms. Failure to provide active treatment for patients results in patients being hospitalized without all interventions for recovery being provided for them, potentially delaying their improvement.

II. Assure that staff used proper procedures for seclusion/restraint for 3 of 4 non-sample patients (C1 C2 and C4) whose records were reviewed for seclusion and restraint policy/procedure compliance. For patients C1 and C2, "therapeutic holds" were employed for administration of medications without documented physician orders. For patient C4, a seclusion episode was documented approximately 5 hours after initiation of the seclusion. The physician's progress note documented that the patient had been placed in seclusion but did not mentioned a face to face evaluation. These failures violate patients' rights to be free from unnecessary restraints without adequate justification. They also potentially endanger the patient's life and well being.

Findings include:

I. Lack of active treatment

A. Observation on the unit on 8/29/11 and 8/30/11 revealed that patients were free to attend any group they desired. All groups on the unit's activity schedule were open to all patients, with exception of patients with substance abuse who were expected to attend an addiction group 3 times per week for one hour on Mondays and Wednesdays at 11a.m. and Fridays at 9a.m. Observation of patient/staff interactions revealed that the groups were announced as scheduled, and patient A18 and many non-sample patients who did not immediately get up and go to the group room were asked if they were going to the groups. When patients said "No," they were free to wander about the unit or lie on their beds. Many patients did this.

B. In an interview on 8/29/11 at 12:15p.m., the Clinical Manager (who also serves as the Assistant Social Work Director), stated that there were only 3 therapeutic groups held daily. She stated that with exception of the addiction group held for the patients with substance abuse, all patients were expected to attend these 3 groups. The three major therapeutic groups focused on the following topics - self awareness, wellness plan, self advocacy, disease concept, decision making, nutrition, and stress reduction. The Clinical Manager stated that these therapy groups were only held from 9a.m.to 2p.m., and that the only group held after that time was a "wrap-up" group run by mental health technician at 8p.m. daily.

C. Specific patient findings

1. Patient A18 was admitted on 8/27/11. The Psychiatric Evaluation dated 8/27/11 stated that the diagnoses were "schizoaffective D/O [disorder] bipolar type" and "polysubstance dependence." Additional information on the Psychiatric Evaluation included "relapsed on cocaine."

2. In an interview on 8/29/11 at 11:35a.m., patient A18, who was found in his/her room in bed during the "Addiction Group" offered from 11a.m. - 12p.m., stated that s/he had only attended one group since his/her admission on 8/27/11. When asked why s/he had not been attending groups, s/he stated, "I like to sleep."

3. On patient A18's Master Treatment plan dated 8/27/11, the identified problem was "[name of patient] presents voluntarily due to suicidal thoughts by overdose or suffocation." Goals - "CL [client] will attend group therapy within 24 hours, maintain his safety from admission to discharge." The listed intervention was "Evaluate medically, provide group therapy, monitor vital signs, monitor behavior & [and] appearance, administer medications. He's ordered on close observation & suicide precautions." There was nothing on the patient's treatment plan to suggest any alternative programming if s/he did not attend assigned groups.

4. A review of group progress notes documented that patient A18 did not attend the following groups on 8/27/11: "Hospital Wellness" from 9a.m. - 10a.m., "Hospital Decision Making" from 11a.m. - 12p.m., and "Stress Management" from 1p.m. - 2p.m.

5. In an interview on 8/29/11 at 11:45a.m., MHT #1 [Note: mental health technicians are also known as Behavioral Health Technicians or BHTs at this facility] was asked why patient A18 was in bed and not in the addiction group currently being held from 11a.m.to 12p.m. MHT #1 stated, "This patient does not go to groups. He stays in bed." When asked if patient A18 was encouraged to go to groups, MHT #1 stated, "Yes, but you can't force them."

D. Additional information on group attendance

1. The Attendance Sheet for the "Community Meeting" held on 8/19/11 at 8a.m. listed 18 of 26 patients at the meeting.

2. The Attendance Sheet for the "Self Awareness" group held on 8/29/11 at 9a.m., listed14 of the 26 patients in the session.

3. The "Occupational Therapy" group on 8/29/11 at 11a.m. had 8 of 16 available patients attending. Note: The "Addiction" group was also being held in another room for the other 10 patients on the unit.

II. Failure to follow seclusion/restraint policy/procedures

A. Failure to treat therapeutic holds as restraint

1. Patient C1.

A nursing progress note dated 7/29/11 at 5p.m. documented that patient C1 was "screaming up the hall saying that another client had raped her and propositioned her and the [other] patient was wandering around the hall nude. She (C1) was very psychotic and continued to make accusations" ---- "When staff approached her to give the injection, she became combative and was held in a therapeutic hold and the medication was given." There was a physician's order in the patient's record, dated 7/24/11 at 3:30p.m for the medication, but there was no order for the Hold or documentation on the progress note of a face to face evaluation of the patient by the physician.

2. Patient C2

A nursing progress note on 7/23/11 at 5:11p.m. stated that the patient was "visible on unit, continues to threat and make inappropriate gestures. [Name of physician] was present when the incident @ [at] 12:30p.m. occurred with pt. [patient] becoming aggressive, refused po [by mouth] meds [medication], an im [intramuscular injection] was required for pt to get under control." There was no order for the Hold or documentation in the progress notes of a face to face evaluation of the patient by the physician.

3. RN #2, who was assisting the surveyors with review of seclusion/restraint documentations on 8/30/11 at 9:55a.m., stated that the facility only used therapeutic holds for administration of medications and did not follow the facility's policy and procedures utilized for other restraints such as 4-point restraints.

4. Review of the facility's policy/procedure titled "Physician Orders for Seclusion or Restraints", #1103, last revised 12/10, revealed the following statement regarding therapeutic holds - "Therapeutic restraint hold is identified as the act of staff putting their hands on a patient in order to administer im medication as ordered by the physician. A physician order is needed for therapeutic hold and it must specify justification under which it is used." There was nothing in the policy about the need for a physician to do a face to face evaluation of the patient after a therapeutic hold for medication administration.

B. Failure to document a face to face evaluation of a patient within 1 hour of initiation of seclusion.

1. The facility policy/procedure on seclusion/restraints (cited in #4 above) states, "A physician must see and evaluate the need for restraint or seclusion within one hour after the initiation of this intervention."

2. A Nursing Progress Note, dated 6/15/11 at 8:33a.m., stated, "Pt [C4} standing in front of desk, spitting on desk, at staff and on food. He had disrobed and would not get dressed, verbally abusive and threatening, tore survey box off the wall and threw it, broke both portable phones. [Name of doctor] was called and ordered seclusion"... "He was placed in seclusion at 8:00a.m. and door was unlocked at 8:15a.m. The facility's log book for seclusion/restraint stated that the doctor arrived on the unit at 8:15a.m. However the physician's progress note on 6/15/11 at 1:40p.m.stated, "pt seen and discussed patient in seclusion"... "Given ETO [emergency treatment order]." There was nothing in the progress note to indicate if and when the physician had done a face to face evaluation of the patient within an hour after initiation of the seclusion.

Based on observation, record review and interview, the Medical Director failed to adequately assure quality and appropriateness of services provided by the medical staff and other disciplines. Specifically the Medical Director failed to:

I. Ensure that all members of the interdisciplinary team included their interventions on patients' Master Treatment Plans (MTPs). Specifically, the MTPs for 4 of 8 active sample patients (A3, A8, A21 and A30) had no interventions by physicians; the MTPs of 2 of 8 active sample patients (A3 and A8) had no professional nursing interventions, and the MTPs of 3 of 8 active sample patients (A10, A12 and A21) had no interventions by rehabilitation therapists. In addition, the facility had nursing staff develop the Master Treatment Plans for patients on the day of admission instead of having the plans developed by the interdisciplinary team after review/discussion of all assessments. These failures hamper the treatment team's ability to provide coordinated treatment, potentially results in patients not receiving all needed treatment to address their problems. (Refer to B118)

II. Ensure that staff developed Master Treatment Plans (MTPs) that included short term goals (STGs) stated in measurable behavioral terms for 4 of 8 active sample patients (A10, A12, A16 and A30). In addition, the MTPs for 5 of 8 active ample patients (A3, A8, A12, A18 and A21) incorrectly listed staff interventions rather than patient outcome behaviors as patient goals. These deficiency practices hamper the ability of the treatment team to provide goal directed treatment and determine effectiveness of interventions based on changes in patient behaviors. (Refer to B121)

III. Ensure that staff developed Master Treatment Plans (MTPs) that documented individualized interventions based on the assessed needs of 8 of 8 active sample patients (A3, A8, A10, A12, A16, A18 and A30). Instead, interventions on the plans were generic discipline functions which frequently lacked focus for treatment. This deficiency results in lack of guidance for staff in providing individualized treatment that is purposeful and goal-directed. (Refer to B122)

IV. Ensure that staff provided active treatment, including alternative interventions for 1 of 8 active sample patients (A18) who was not motivated to attend the groups offered. Approximately half of 26 non-sample patients on the unit (census=26) also did not consistently attend unit groups. Rather than providing individualized treatment for these patients, staff expected them to attend all groups listed on the unit activity schedule. When patients declined to attend the scheduled programming, they were allowed to do whatever they wished to do, such as go to their rooms and lie down or sit in the Dayroom or dining room. Failure to provide active treatment for patients results in patients being hospitalized without all interventions for recovery being provided for them, potentially delaying their improvement. (Refer t0 B125-I)

V. Assure that staff used and documented proper procedures for seclusion/restraint for 3 of 4 non-sample patients (C1, C2 and C4) whose records were reviewed for seclusion/restraint procedure compliance. For patients C1 and C2, staff employed "therapeutic holds" for administration of medications without documented physician orders. For patient C4, a seclusion episode was documented approximately 5 hours after initiation of the seclusion. The physician progress note said that the patient had been in seclusion but did not mention a face to face evaluation. These failures violate the patients' rights to be free from unnecessary restraints without sufficient justification, and potentially endanger the patients' life and well being. (Refer to B125-II)

VI. Additional Interview

In an interview on 8/30/11 at 8/30/11 at 4p.m., the problems cited above were discussed with the Medical Director. He acknowledged the findings.

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

I. Ensure that nursing staff included their treatment interventions on the Master Treatment Plans (MTPs) for 2 of 8 active sample patients (A3 and A8). The MTPs for these patients had no listed nursing interventions. The DON also allowed nurses to develop patients' Master Treatment Plans for all the involved disciplines. These failures hamper the treatment team's ability to provide coordinated treatment, potentially resulting in patients not receiving all needed treatment to address their problems.

Findings include:

1. The following MTPs did not have any professional nursing interventions: A3 (8/27/11) and A8 (8/27/11).

2. In this facility, the professional nurses are responsible for developing the MTP for all disciplines.

The facility's policy/procedure, titled "Treatment Planning", #903, last reviewed 3/11/09, stated, "The nurse will list at least two main problems, interventions, measurable goals and target dated"... "The nurse will list who is responsible for overseeing"... "particular interventions,"... "Membership [on treatment plan teams] will include, but is not limited to a physician, RN [registered nurse], case manager [bachelor level people who, complete the psychosocial assessment and do discharge planning]."

In an interview on 8/29/11 at 9:50a.m., RN #1 was asked who was responsible for treatment plan development. She stated that the registered nurse [RN] who admits a patient, develops the initial treatment plans and the Master Treatment plans for the treatment team, based on information obtained from the admitting psychiatrist's assessment and progress notes written by the case managers and nurse practitioners who do all the history and physicals. When asked why the nurses develop all the treatment plans, RN #1 stated, "We operate under a medical model, you know." She meant that in a medical/surgical setting, nurses write the patient's treatment plan.

II. Ensure that the Master Treatment Plans (MTP) for 7 of 8 active Sample patients (A3, A8, A12, A16, A18, A21 and A30) included nursing interventions individualized for the patient. The nursing interventions on the MTPs consisted of generic nursing functions or routine patient observations. This failure results in treatment plans that fail to reflect an individualized approach to patient care and that fail to provide guidance to regarding the specific modalities needed and the purpose for each.

Findings include:

A. Record Review

1. Patient A3. The MTP dated 8/27/11 had the following generic nursing interventions: "She is on close observation, suicide precautions & [and) homicide precautions-15 min checks."

2. Patient A8. The MTP dated 8/27/11 had the following generic nursing interventions: "He is on close observation, suicide precautions-15 min checks."

3. Patient A12. The MTP dated 8/27/11 had the following generic nursing intervention: "Monitor vsq4hrs [vital signs every 4 hours} for s/s w/d [signs and symptoms} of withdrawal q4h [every 4 hours]."

4. Patient A16. The MTP dated 8/16/11 had the following generic nursing interventions: "Place [name of patient] on fall and close observation precautions as needed, Administer medications as prescribed for anxiety, monitor patient's response to medication and observe for any changes in mood, behavior or mental status."

5. Patient A18. The MTP dated 8/27/11 had the following generic nursing interventions: "Administer medications, monitor vital signs, monitor behavior 7[and] appearance, monitor progress & document."

6. Patient A21. The MTP dated 8/29/11 had the following generic nursing intervention: "Monitor for s/s w/d q4hs & medicate."

7. Patient A30. The MTP dated 8/25/11 had the following generic nursing intervention: "Provide a safe therapeutic milieu for safety."

B. In an interview on 8/30/11 at 11:45a.m., the generic nursing interventions on the 7 active sample patients Master Treatment Plans were discussed with the Nursing Director. The Nursing Director agreed with the findings.

Based on record review and interview, it was determined that the hospital failed to provide a Director of Social Services who assured the quality and appropriateness of social work services. This failure resulted in a lack of professional social work assessments for 3 of 3 active sample patients (A3, A8 and A16) who had been hospitalized over 72 hours (policy deadline for psychosocial assessment completion), and potentially leads to lack of needed social work services.

Findings include:

A. Record Review

Review of the medical records of 3 of 3 active sample patients (A3, A8 and A16) who had been hospitalized over 72 hours (policy deadline for psychosocial assessment completion) revealed no psychosocial assessments for the patients or psychosocial assessments that included no conclusions and recommendations, describing anticipated social work roles in treatment and discharge planning.

B. Interview

During an interview on 8/30/11 at 3p.m., the Assistant Director of Social Services who is an LCSW [Licensed certified social worker) stated that she was the only social worker in the hospital, and that there was no department of Social Services. She stated that she supervises counselors and therapists, some of whom have BSW degrees. These staff members provide case management services, and therapies of various models such as Recreational and Occupational therapies. The Assistant Director of Social Services said that she is responsible for the quality of their services and that she meets with Recreational and Occupational therapists, using a peer review model and observation. She also acknowledged that the therapists were stretched to the limits in providing assessments and groups to all the patients on the inpatient unit.

Based on observation, interview and record review, the facility failed to plan and implement a structured program of therapeutic/leisure activities after 2p.m. on seven days per week for the inpatient population, including 2 of 8 active sample patients (A3, A10, A16 and A18). With the exception of a non-therapeutic "Wrap Up" group held daily by a mental health technician at 8p.m., there were no scheduled therapeutic activities from 2p.m. to bedtime at 11p.m. This resulted in long periods of idleness for patients A16 and A18) and in discontent and (regarding lack of structured activities), expressed by 2 of 8 active sample patients (A3 and A10). This failure also results in a lack of structured therapeutic groups/activities to assist the patients in meeting their treatment goals.

Findings include:

A. Observations

1. On 8/29/11 at 11a.m., the "Occupational Therapy" group was being conducted in the Dining room from 11a.m. to 12p.m. Active sample patient A16 was observed sitting at a table alone, cutting out paper letters and posting them on a rectangular sheet of colored paper. She got up and left the groups at 11:30a.m. OT 1 let the patient leave the group without asking the patient where she was going or why.

2. On 8//29/11 at 11:35a.m., the "Addiction Group" was taking place in the Dayroom as scheduled. Active sample patient A18, who had a diagnosis of "Etoh [alcohol] dependence" per Psychiatric Evaluation dated 8/28/11, was observed lying on his bed in his room. When asked what he was doing in his room during group, patient A18 stated "I like to sleep". "I don't have to go [to group] if I don't want to. I'm waiting to be discharged anyway."

3. During a community meeting held in the Dining room on 8/30/11 from 10:15a.m. to 10:45a.m. by a mental health technician (called BHT's or behavioral health technicians at the facility), 13 of 26 patients on the unit were in attendance. Three or four patients kept getting up, one at a time, and left the group. The group leader never asked any of them why they were leaving the group or where they were going.

4. On 8/30/11 at 10:50a.m. RN 1 reminded active sample patient A16 that the "Social Awareness Group" was being held in the Dining room at 11a.m. and that she (patient A16) should go. Patient A16 told RN 1 that she wanted to see her doctor again. "I don't want to go to group." Patient A16 walked away from RN1. RN 1 returned to the nurses' station without saying anything more to the patient about going to the group.

5. On 8/29/11 at 12:15p.m., following the occupational therapy group, OT 1, the group leader, was asked where 9 of 17 patients who did not attend the group were. She stated, "I can't keep track of where everyone is."

B. Interviews on patients discontent with groups

1. In an interview on 8/29/11 at 2p.m., active sample patient A3 was asked about groups on the unit. She stated, "When I was here one year ago the staff encouraged patients to go to groups. This time they tell you to go to groups but don't encourage you to go if you say 'No'."

2. In an interview on 8/29/11 at 2:15p.m., patient A10 stated that when she was here two years ago "the staff stressed the importance of the groups, but now you go if you want to and if not, it's okay."

C. Record/Document Review

1. A review of group attendance sheets showed approximately 50% of the total patient population on the unit went to groups during the period of 8/29-30/11

2. Attendance at the community meeting on 8/29/11 from 8a.m. - 9a.m. was provided by MHT2 on 8/30/11 around 2p.m. According to the attendance sheet, 18 of 26 patients on the unit, including active sample patients A12 and A30, attended the group. Active sample patients A3, A8, A10, A16 and A21 did not attend.

3. The attendance sheet for the "Self-awareness" group held on 8/29/11 at 9a.m. showed that 13 of 26 patients attended the group. Three of the 8 active sample patients (A16, A18 and A21) did not attend.

4. Thirteen of 26 patients on the Adult Psychiatric Unit attended the community meeting on 8/30/11 from 8:15a.m. to 8:45a.m. Four active sample patients did not attend. The missing patients were active sample patientsA3, A8, A16 and A21.

Based on record review and interviews, the facility failed to provide sufficient numbers of activity therapy staff to provide individual RT [recreational therapy] assessments for 8 of 8 active ample patients (A3, A8, A10, A12, A16, A18, A21 and A30) and Occupational Therapy assessments for 3 of 8 active sample patients (A12, A21 and A30). In addition, there were no rehabilitation therapists available for patients after 2 p.m., 7 days per week. These failures result in lack individual focused groups/activities in the afternoon and evening to assist the patients in meeting their treatment needs.

Findings include:

A. Record Review

The unit schedule, which was developed for all patients to attend, had ???3 therapeutic groups a day - one at 9a.m., one at 11a.m., and another at 1p.m. There were no scheduled groups from 2p.m. to the time the patients went to bed at 11p.m.

B. Interviews

1. In an interview 8/30/11 at 2:15p.m., RT #1 stated that she hasn't done a Recreational Therapy assessment on patients for about 6 months. RT #1 stated, "I just don't have the time." When asked if there was a shortage of staff, RT # 1 said, "I would say that. We are just stretched too thin."

2. In an interview on 8/30/11 at 3p.m., the Assistant Social Work Director, who supervises the four therapists on the unit, stated that OT Assessments were done on all psychiatric patients, but not on substance abuse patients. She stated that she is the only person in therapeutic activities that works full time, and that the four "therapists" who work on the Adult Unit only work part time. The scheduled staffing was as follows: RT and OT staff each work 12 hours/week, 2 counselors each work 10 hours per week. It was pointed out that the therapeutic interventions on the Master Treatment plans were generic. The Assistant Director was asked if she thought that the generic interventions had anything to do with the staff not being around enough to really get to know the patients and the fact that no therapeutic groups were offered after 2 pm., she stated, "We are stretched to the limits. We do the best we can."