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I. Based on record review, policy review and interviews, it was determined that for 2 of 8 active sample patients (A1 and A5), the facility failed to document required psychiatric evaluations. For one active sample patient, there was no updated annual psychiatric evaluation (A1); for another active sample patient a psychiatric evaluation was not done at all (A5). The absence of this patient information hinders the treatment teams' ability to formulate an appropriate problem list and plan appropriate treatment. (Refer to B110)

II. Based on policy/document review, record review and interview, the facility failed to ensure that physicians completed psychiatric evaluations within 60 hours for 6 of 8 active sample patients (A2, A3, A4, A6, A7 and A8). Review also revealed that the facility has consistently failed to provide psychiatric evaluations within 60 hours of admission for most patients over the three months prior to the survey. These failures place the treatment team at a disadvantage when developing the master treatment plan by not having psychiatric data readily available to help address patient needs and problems. (Refer to B111)

III. Based on record review, policy/document review and interview the facility failed to develop an individualized treatment plan for one non-sample patient (D6) who required locked seclusion for 44 continuous hours. This failure has the potential for patients to be restrained or secluded inappropriately without utilizing alternative strategies identified by the treatment team. (Refer to B118)

IV. Based on record review, policy/document review and interview the facility failed to provide 6 of 8 patients on the Evergreen unit (A1, A2, A4, A5, A6, A7) with an active therapeutic program for significant periods of time when they refused scheduled programming. In addition, the facility did not offer therapeutic activities/structure on the unit beyond 2:15PM Monday through Friday; offered only one structured activity (off the unit) on Saturdays; and offered no scheduled therapeutic activities on Sundays. Nursing staff provided no therapeutic group modalities at all. This lack of modalities to meet patient needs resulted in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125-II)

V. Based on observations, interviews and record review, the facility failed to ensure a consistent policy and procedure for patients who wish to request changes in care. One active sample patient (A5) had been asking for a change in attending physician since admission to the facility on 10/31/11 without response from care providers. Patient A5 attempted to contact the state patient advocate on 12/7/11 but was told that he/she could not contact the advocate; the patient threatened to harm the RN involved and the patient needed to be given a time-out and de-escalation by the nurse manager. The failure to provide for the patient's right to speak to a patient advocate can lead to increased frustration and acting out by a patient, thus delaying clinical improvement and placing the patient and others at unnecessary risk for harm. (Refer to B125-III)

Based on record review and interviews, it was determined that for 2 of 8 active sample patients (A1 and A5), the facility failed to document a psychiatric evaluation. For one active sample patient, there was no updated annual psychiatric evaluation (A1); for another active sample patient, there was no psychiatric evaluation at all (A5). The absence of this patient information hinders the treatment teams' ability to formulate an appropriate problem list and plan appropriate treatment.

Findings include:

A. Record Review

1. Patient A1: readmitted to the facility on 7/1/06, last had a psychiatric evaluation on 3/21/2000.

2. Patient A5: admitted on 10/31/11, had no psychiatric evaluation documented in the electronic record as of 12/7/11.

B. Interview

In an interview on 12/7/11 at 3:45pm, the Medical Director was informed of the findings and stated "we've been looking at this problem and we're not there yet. I agree we have compliance issues."

Based on policy/document review, record review and interview, the facility failed to ensure that physicians completed psychiatric evaluations within 60 hours for 6 of 8 active sample patients (A2, A3, A4, A6, A7 and A8). Review also revealed that the facility has consistently failed to provide psychiatric evaluations within 60 hours of admission for most patients on the inpatient unit over the three months prior to the survey. These failures place the treatment team at a disadvantage when developing the master treatment plan by not having psychiatric data readily available to help address patient needs and problems.

A. Policy/Document Review

1. Medical Staff Bylaws were amended on June 30, 2011 to clarify that psychiatric evaluations were to be "available on the patient record within 60 hours of admission."

2. Quality Improvement trending data for the months of July, August and September 2011, showed that psychiatric evaluations on the Evergreen unit were completed within the 60 hour timeframe 50%, 29% and 47% respectively.

B. Record Review

1. Patient A2: admitted on 11/15/11 had a psychiatric evaluation completed in the electronic record on 11/22/11. (4.5 days late)

2. Patient A3: admitted on 11/30/11 had a psychiatric evaluation completed in the electronic record on 12/6/11. (4.5 days late)

3. Patient A4: admitted on 10/25/11 had a psychiatric evaluation completed in the electronic record on 11/1/11. (4.5 days late)

4. Patient A6: admitted on 6/21/11 had a psychiatric evaluation completed in the electronic record on 6/27/11. (3.5 days late)

5. Patient A7: admitted on 11/2/11 had a psychiatric evaluation completed in the electronic record on 11/6/11. (1.5 days late)

6. Patient A8: admitted on 11/29/11 had a psychiatric evaluation completed in the electronic record on 12/2/11. (1.5 days late)

C. Interview

In an interview on 12/7/11 at 3:45pm, the Medical Director was informed of the findings and stated, "we've been looking at this problem and we're not there yet. I agree we have compliance issues."

Based on record review, policy/document review and interview the facility failed to update an individualized treatment plan for one non-sample patient (D6) who required locked seclusion for 44 continuous hours. This failure has the potential for patients to be restrained or secluded inappropriately without utilizing alternative strategies identified by the treatment team.

Findings include:

A. Record Review

Non-sample patient D6, admitted to Evergreen unit 7/26/11, required the use of continuous locked seclusion from 8/14/11 at 5:26PM through 8/16/11 at 1:22PM, at which time the patient was transferred to the Criminal Justice Program. A review of the six face to face evaluations completed by the physicians during that time revealed they did not include documentation of treatment recommendations for treatment plan updates as outlined in facility policy.

A review of the master treatment plan developed on 7/27/11, with updates and revisions completed 8/16/11, revealed it did not address the use of locked seclusion or alternative treatment strategies for management of the patient behavior.

B. Policy/Document Review

Facility policy titled, "Seclusion and Restraint Policy, Section 2.F.-Nonviolent Practices," last review/revision date of 8/19/11, states in Section IV. K: "the attending medical staff member must be consulted as soon as possible if the attending medical staff member did not order the restraint or seclusion to discuss suggested updates to the treatment plan. Documentation by the attending medical staff member of this consultation will be noted in the progress toward the objective section of the treatment plan."

C. Interview

During an interview with the Quality Coordinator at 3:00PM on 12/07/11, she reviewed the six face to face encounters for patient D6 documented between 08/14/11 and 08/16/11 and stated "These do not include recommendations for treatment planning as required in our policy. If they would have used the template for documentation that would prompt the physicians to include their recommendations for changes to the treatment plan to be incorporated at the next team meeting."

I. Based on policy/document review, record review and interview the facility failed to provide consistent documentation of seclusion and restraint events for patients residing on Evergreen (acute treatment) unit for one active sample patient (A5) and one discharged patient added to the sample (D6). For patient D6, there was one missing physician order for continuing seclusion and three late MD orders; for patient A5 the nursing progress note related to the initiation of seclusion was not recorded in the patient medical record. These failures resulted in patients being restrained or secluded without necessary physician orders and/or justification for the use of seclusion.

Findings include:

A. Policy/Document Review

Facility policy titled "Seclusion and Restraint Policy Section 2.F.-Nonviolent Practices" last reviewed/revised August 19, 2011, requires in Section IV. Procedures, E: "written and/or telephone orders for seclusion and restraint are time limited for up to 4 hours...."; section VI. Documentation, section A states: "use of seclusion or restraint is documented in the patient's medical record"; section B states: "the initiating RN must document in the patient's record the use of alternative strategies, including de-escalative [sic]and verbal intervention techniques prior to seclusion or restraint."

B. Record Review

1. Patient A5, admitted to Evergreen unit 10/31/11, required locked seclusion on 12/5/11, after being returned to the unit by the police after the patient went AWOL (Absent without leave). A review of the patient's medical record revealed that the patient was placed in locked seclusion by physician order at 1:45PM. There was no documentation in the record by the nurse (RN1) who initiated seclusion as the facility policy required.

2. Patient D6, admitted to Evergreen unit on 7/26/11, required seclusion from 8/14/11 at 5:26PM through 8/16/11 at 1:19PM when transferred off the unit. During this time a total of 14 physician orders were required. A review of the medical record revealed a total of four physician orders that were not completed timely: order dated 8/15/11 at 8:34AM was due at 8:30AM; order dated 8/15/11 at 12:38PM was due at 12:34PM; order dated 8/15/11 at 8:30PM was due at 8:22PM; order dated 8/16/11 at 7:21AM expired at 11:21AM, with no new order obtained until 8/16/11 at 1:19PM.

C. Interview

1. At 11:52 AM on 12/6/11, the Director of Nursing (DON) stated the "nurse should have written a progress note" on patient A5 "when the seclusion was initiated." The DON reviewed the record with the surveyor and confirmed there was "no nursing documentation."

2. During an interview on 12/6/11 at 12:20PM with RN 1 (nurse who initiated locked seclusion on patient A5 on 12/5/11), RN 1 stated, "I didn't put that note in yet, I think I have 24 hours to do that." The Unit Director, who was present during this interview, clarified the expectation that "the progress note is to be written immediately, per facility policy, by the nurse who initiates the restraint and/or seclusion."

II. Based on record review, policy/document review and interview the facility failed to provide 6 of 8 patients on the Evergreen unit (A1, A2, A4, A5, A6, A7) with an active therapeutic program for significant periods of time when they refused scheduled programming. In addition, the facility did not offer therapeutic activities/structure on the unit beyond 2:15PM Monday through Friday; offered only one structured activity (off the unit) on Saturdays; and offered no scheduled therapeutic activities on Sundays. Nursing staff provided no therapeutic group modalities at all. This lack of modalities to meet patient needs resulted in patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement.

Findings Include:

A. Record Review

1. Patient A1, admitted to Evergreen unit on 7/1/06 was scheduled to attend 24 therapeutic groups/activities, off the unit, during the week 11/27/11 through 12/3/11. When the patient did not attend those sessions assigned, off the unit, there was no documentation in the medical record that alternative activities were done with the patient.

2. Patient A6: admitted to Evergreen unit on 6/21/11, during the week 11/27/11 through 12/3/11 the patient was scheduled to attend 13 therapeutic groups/activities, off the unit. When the patient did not attend those sessions assigned, off the unit, there was no documentation in the medical record that alternative activities were done with the patient.

3. Patient A4:, admitted to Evergreen unit 10/25/11, during the week 11/27/11 through 12/3/11 the patient was scheduled to attend 22 therapeutic groups/activities, off the unit. When the patient did not attend those sessions assigned, off the unit, there was no documentation in the medical record that alternative activities were done with the patient.

4. Patient A5, admitted to Evergreen unit on 10/31/11, during the week 11/27/11 through 12/3/11 the patient was scheduled to attend one activity off unit on Sunday, 11/27/11, one evening activity off unit on Friday 12/2/11 and nothing on Saturday 12/3/11. Prior to this patient going AWOL (Absent without leave) from the unit on 12/5/11, all regular hour programming was done off the unit for this patient. After the patient went AWOL the patient was restricted to on unit program. This on unit schedule consisted of activities scheduled at 9:30AM, 10:30AM, 12:30PM and 1:30PM, Monday through Friday, no evening or weekend scheduled therapeutic programming. The patient's treatment plan stated, "will participate in 50% of assigned groups on a daily basis." The patient reported to the surveyor on 12/7/11 at 1:30PM that he/she does not go to the groups done on the unit "because they are not helpful."

5. Patient A7: admitted to Evergreen unit on 11/2/11, during the week of 11/27/11 through 12/3/11 the patient was scheduled to attend 17 therapeutic groups/activities off the unit. When the patient did not attend those sessions assigned off the unit, there was no documentation in the medical record that alternative activities were done with the patient.

6. Patient A2: admitted to Evergreen unit on 11/15/11, during the week of 11/27/11 through 12/3/11 the patient was scheduled to attend 16 therapeutic groups/activities off the unit. When the patient did not attend those sessions assigned off the unit, there was no documentation in the medical record that alternative activities were done with the patient.

B. Document Review

1.The Therapeutic Group Schedule-Winter Session, October 31, 2011 through January 20, 2012, for the Evergreen unit provided to the surveyors by the Unit Program Manager on 12/6/11 consisted of the following time slots for therapeutic activities on the unit: 9:30AM, 10:30AM, 12:30PM and 1:30PM for Monday through Friday only. There was no scheduled structured on unit programming during the evening hours or on weekends (Saturday or Sunday) provided by Activities Therapy Staff.

2. The facility has established a standard of a minimum of 20 hours active treatment per week to ensure that patients are receiving active treatment at the facility. However, the quality data provided by the Unit Program Manager on 12/7/11 at 2:00PM for the week of October 16-22, 2011 showed that the patients on the Evergreen unit participated on average 8.6 hours of therapeutic programming; for the week of November 13-19, 2011 the average was 12.56 hours.

C. Interview

1. Patient A5, during an interview on 12/6/11 at 2:00PM stated, "they don't offer anything on this unit that is helpful to me, so no I am not going to any of the activities now that I have a red card (unit restriction)."

2. During an interview on 12/6/11 at 3:30PM. Patient A1 stated "I've been here a long time; there's nothing to do."

3. In an interview on 12/6/11 at 3:40PM, Patient A4 was asked about evening and weekend programs on the Evergreen unit; Patient A4 replied, "We sleep in, have lunch and watch TV, that's it."

4. During an interview on 12/7/11 at 12:30PM with the Unit Program Manager for the Evergreen unit she stated, "the program is lacking since we have a number of vacant positions. The activities offered in the evening are unstructured and we don't have anything on the weekends."

5. During an interview on 12/7/11 at 1:00PM with the Director of Program Services (responsible for Social Work and AT services), he stated "I do not have the overall responsibility for programming on the unit, that responsibility is the unit program managers." At 3:00PM on 12/7/11 the Director of Program Services asked to speak to the surveyors to clarify his earlier statement. At this time he stated "I've talked to some people and I guess it is my responsibility overall to make sure programming is adequate."

6. During an interview on 12/7/11 at 2:00PM with the Discipline Coordinator for Recreational Therapy, she stated, "our programming has been reduced somewhat due to our vacancies. Some of our vacancies go back as far as two years ago. Currently no staff are dedicated to the DP only, they work throughout the facility covering all programs. We currently have a total of 10 positions approved, 9 recreation therapists and 1 technician but we only have 5 recreation therapists and 1 technician filled." She further stated, "there is no structured or formal therapeutic activity/group offered on the evening hours or weekends on the Evergreen unit for patients who are unable to attend off unit programming."

7. During an interview with the Director of Nursing on 12/7/11 at 3:50PM she stated, "nursing has not been assigned to do groups yet, because they have not been trained. But I am sure that will all change after this."

III. Based on observations, interviews and record review, the facility failed to ensure a consistent policy and procedure for patients who wish to request changes in care. One active sample patient (A5) had been asking for a change in attending physician since admission to the facility on 10/31/11 without response from care providers. Patient A5 attempted to contact the state patient advocate on 12/7/11 but was told that he/she could not contact the advocate; the patient threatened to harm the RN involved and the patient needed to be given a time-out and de-escalation by the nurse manager. The failure to provide for the patient's right to speak to a patient advocate can lead to increased frustration and acting out by a patient, thus delaying clinical improvement and placing the patient and others at unnecessary risk for harm.

Findings include:

A. Observations

1. During an observation on 12/7/11 at 10:50am, Patient A5 had been out in the unit hallway, and approached the surveyor and wanted to discuss changing attending physicians. Patient A5 stated that s/he wanted to call the patient advocate and ask for help. Patient A5 then approached the nurse's station and asked RN2 to use the telephone to call the patient advocate. RN2 replied to Patient A5, "No, you can't call the advocate, go to your room." Patient A5 then walked away from the nurse's room looking angry.

2. At 10:55AM on 12/7/11 the second surveyor walked onto the unit, while walking down the corridor with RN2, Patient A5 opened his bedroom door and came into the corridor and began to speak with the surveyor stating "I am not psychotic, I am only here because I am homeless. My doctor has decreased my medication to three quarters of what I should be taking. I have been telling them since I came in I want a new doctor." The patient was becoming increasingly louder with an angry tone of voice. When RN2 attempted to set limits on Patient A5, the patient began to threaten RN2, stating, "get away from me, I will kill you." Additional staff arrived in the area. The Unit Nurse Manager utilized de-escalation techniques to assist the patient in calming down. The patient agreed to a time out in the seclusion area (unlocked door) to continue to calm down until the lunch trays were brought to the unit.

B. Interviews

1. Both surveyors interviewed RN2 on 12/7/11 at 2:50PM regarding the denied request for use of the phone by Patient A5. RN2 stated "the patient was refusing to go to the group, when the patient asked to use the phone to call the patient advocate, I told him no. Patients are not allowed to use the phone during group time." This interview was done in the presence of the Unit Nurse Manager. The surveyor asked the Unit Nurse Manager if this was protocol to which the Nurse Manager replied, "no, that is not how most nurses would do it, they would either allow them to make the call or would tell the patient they would call the patient advocate."

2. On 12/8/11 at 9:30AM an interview with the Client Mediator (Patient Advocate) was done by both surveyors to validate when he first became aware of the patient's (A5) request for a new physician and what internal process is utilized to address this type of request/concern. The Client Mediator produced a written request submitted by Patient A5 dated 11/5/11. According to records maintained by the Client Mediator he met with the patient for the first time on 11/8/11 and informed the Medical Director of the patient's request. The Client Mediator stated, "informing the Medical Director of the request is usually in passing, nothing formal." He also stated, "once I do that communication there is not any other follow up unless the patient requests to see me again." On 12/8/11 the Client Mediator had received a second written request from the patient requesting a new physician but at the time of this interview had not yet seen the patient.

3. The Client Rights Representative was interviewed on 12/8/11 at 9:42AM to verify what information had been obtained from Patient A5 when he completed the debriefing following the locked seclusion event of 12/5/11. The Client Rights Representative produced documentation that the patient had identified "give me a doctor change, please" as what could be done in the future to prevent further use of seclusion or restraint. The Client Rights Representative stated this information "is recorded in the Avatar documentation system so everyone can see." He also stated that he did not do anything other than record the information because "the patient had told me the doctor was taking care of it by ordering a second opinion."

C. Record Review

1. Patient Advocate Request form dated 11/5/11 (6 days after admission): Patient A5 wrote "I am requesting a doctor change." No action was taken by the Client Rights Representative as of 12/8/11 at 10:00AM.

2. The physician progress note (MD1) documented for Patient A5 on 12/6/11 at 9:55PM stated "patient refused to talk to this writer. Addendum to yesterday's note, the patient continued to express dislike for this writer, at which point writer decided not to see patient while in seclusion or immediately after seclusion." In the section identified as "plan" MD1 wrote "certainly I will honor [A5's] request for change in-attending psychiatrist; will consult Medical Director for further action." No further information was noted on the chart as of 12/8/11 at 9:30AM.

3. Patient Advocate Request form dated 12/7/11 (37 days after admission): Patient A5 wrote "I am again asking for a new doctor." No action had been taken by the Client Rights Representative as of 12/8/11 at 10:00AM.

4. The nurse's progress note documented on Patient A5 by RN2 on 12/7/11 at 6:14PM related to the incident requiring the patient to take a time out stated, "patient stated at this time [while in time out) that [he/she ]was angry for being at WSH (Wyoming State Hospital), for [his/her] doctor not being changed, that [he/she ]has not had a second evaluation and that [he/she ]wants to read [his/her] chart"

Based on record review, policy/document review and interview the facility failed to ensure that nurses regularly recorded changes in patient condition, accurately recorded patient incidents such as absent without leave and seclusion initiation and/or nursing interventions implemented for 1 of 8 active sample patients (A5). This failure resulted in lack of evidence that nurses were actively involved in the care of patients.

Findings include:

A. Record Review

1. Patient A5 went AWOL (Absent without leave) on 12/5/11 at 12:45PM; incident reports reveal the patient pulled the fire alarm and escaped from the unit and was later returned to the unit by the police. There was no documentation in the medical record by RN1 working on the Evergreen unit at the time of the AWOL describing the incident, interventions taken or when the patient was returned to the unit. In addition, this same patient upon return to the unit after being AWOL was placed in locked seclusion by physician order; there was no documentation in the medical record by RN1 who initiated the locked seclusion procedure.

2. The nurse's progress note documented on Patient A5 by RN2 on 12/7/11 at 6:14PM related to the incident requiring the patient to take a time out after being restricted from making a telephone call to the patient advocate (refer to B125 section III above) was an inaccurate account of the details as observed by both surveyors and verified in an interview with RN2 on 12/7/11 at 2:50PM. The documented note stated, "refuses to attend scheduled groups. Asked to make a phone call during group/mall hours, hall rules do not allow patients to utilize the phone during this time. Patient was seen by the surveyors and became upset, stated that [he/she] was going to 'kill anyone.' It is [his/her] 'legal right.' Patient was asked to go to the seclusion area for a time out and to calm down. Remained angry and yelled. The Unit Supervisor de-escalated the patient by talking to the patient...."

B. Policy/Document Review

Facility policy titled "charting requirements", last review/revision date 1/09 section 3 states "any unusual incident or change in behavior will be noted in the progress notes, including the initiation of any restrictive treatment, as well as staff debriefing, patient debriefing and notification of family/guardian of the restrictive intervention."

C. Interview

1. During an interview on 12/6/11 at 11:52AM with the Director of Nursing (DON) she stated, "the requirement for documentation of a progress note by nursing was not met for the AWOL or seclusion initiation on patient A5

2. The nurse surveyor reviewed the progress note written by RN2 on 12/7/11 with the DON on 12/8/11 at 9:20AM. The DON acknowledged that "the progress note does not reflect the time out incident as described by both surveyors" in the meeting held on 12/7/11 at 4:15PM. The DON stated, "I will talk to that nurse again and this problem with nurses' notes will be fixed."

Based on record review and interview, the facility failed to provide a discharge summary for 1 of 5 discharge records reviewed (D4). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient.

Findings include:

A. Record Review

1. Patient D4 was discharged on 10/26/11. There was no written or electronic discharge summary present in the record as of 12/7/11.

B. Interview

In an interview on 12/7/11 at 3:45pm, the Medical Director agreed with the finding and stated "we've had trouble getting our doctors to document well."

I. Based on policy review, record review, document review and interview, the Medical Director failed to ensure that patient discharge summaries were completed by attending physicians in a timely manner in 4 of 5 discharged patient records reviewed (D1, D3, D4, and D5). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient.

Findings include:

A. Policy Review

Medical Staff Bylaws were changed on 6/30/11 to state: "Discharge summaries must be present on the patient record within 15 days of discharge." This new requirement related to 3 of the records reviewed (D3, D4 and D5). Prior to 6/30/11, according to the previous medical staff bylaws, the physicians had to dictate the discharge summary within 15 days; this requirement related to one record reviewed (D1).

B. Record Review

1. Patient D1 was discharged on 6/6/11. The discharge summary was dictated on 7/1/11 and signed off by the physician on 7/7/11.

2. Patient D3 was discharged on 7/21/11. The discharge summary was dictated on 8/25/11 and signed off by the physician on 8/26/11.

3. Patient D4 was discharged on 10/26/11 and as of 12/7/11 did not have a discharge summary in the record.

4. Patient D5 was discharged on 10/17/11. The discharge summary was dictated on 11/2/11 and signed off by the physician on 11/6/11.

C. Document Review

Quality Improvement data for 2011 noted the following for July, August and September: Discharge summary completion rates were 70%, 41% and 0% respectively for the Evergreen unit only.

D. Interview

In an interview on 12/7/11 at 4:00pm, the Medical Director agreed with the findings noted above and stated "it's been hard to get the doctors to complete their paperwork on time, this has been going on for a long time now."

II. Based on policy/document review, record review and interview, the Medical Director failed to ensure that physicians provided an authenticated history and physical examination in the patient record within 24 hours of admission for 4 of 8 active sample patients (A3, A6, A7 and A8). The failure to ensure that physician reports are completed in a timely manner places patients and treatment providers at risk to miss or ignore important information that may be provided from a medical history and physical examination.

A. Policy/Document Review

1. Medical Executive Committee minutes dated 6/30/11 noted that Medical Staff Bylaws were amended to read "History and Physicals available in the chart within 24 hours of admission." Prior to 6/30/11, history and physical examinations had to be completed within 24 hours of admission (without the requirement of being present in the record within 24 hours).

2. Review of Quality Improvement data for the Evergreen unit for the months of July, August and September 2011 showed that History and Physical examinations were completed in a timely manner 40%, 50% and 35% respectively.

B. Record Review

1. Patient A3, admitted 11/30/11, had a history and physical examination performed on 12/1/11 and transcribed into the record on 12/2/11. The report was authenticated on 12/5/11.

2. Patient A6, admitted 6/21/11, had a history and physical examination that was performed on 6/23/11 and transcribed on 6/24/11. The report was authenticated on 6/24/11.

3. Patient A7, admitted 11/2/11, had a history and physical examination that was performed on 11/3/11 and transcribed into the record on 11/4/11. The report was authenticated on 11/7/11.

4. Patient A8 admitted 11/29/11, had a history and physical examination that was performed on 11/29/11 and transcribed into the record on 11/30/11. The report was authenticated on 12/1/11.

C. Interview

In an interview on 12/7/11 at 4:00pm, the Medical Director agreed with the findings and stated, "I've had trouble getting physician reports on the chart in a timely manner for some time now."

Additionally, based on record review, policy/document review, interviews and observations, the Medical Director failed to:

III. Ensure that for 2 of 8 active sample patients (A1 and A5), there was documentation of a psychiatric evaluation. For one active sample patient, there was no updated annual psychiatric evaluation (A1); for another active sample patient, there was no psychiatric evaluation at all (A5). The absence of this patient information hinders the treatment teams' ability to formulate an appropriate problem list and plan appropriate treatment. (Refer to B110).

IV. Ensure that physicians completed psychiatric evaluations within 60 hours for 6 of 8 active sample patients (A2, A3, A4, A6, A7 and A8). This failure places the treatment team at a disadvantage when developing the master treatment plan by not having psychiatric data readily available to help address patient needs and problems. (Refer to B111)

V. Ensure that treatment team staff developed an individualized treatment plan for one non-sample patient (D6) who required locked seclusion for 44 continuous hours. This failure has the potential for patients to be restrained or secluded inappropriately without utilizing alternative strategies identified by the treatment team. (Refer to B118)

VI. Ensure that staff provided consistent documentation of seclusion and restraint events for patient residing on Evergreen (acute treatment) unit for one active sample patient (A5) and one discharged patient added to the sample (D6). Documentation of the number of seclusion/restraint episodes, missing or late MD orders, and nursing progress notes were either inconsistent or not recorded in the patient medical record. These failures resulted in patients being restrained or secluded without necessary physician orders and a lack of planning to prevent further occurrences. (Refer to B125-I)

VII. Ensure that staff provided 6 of 8 patients on the Evergreen unit (A1, A2, A4, A5, A6, A7) with an active therapeutic program for significant periods of time during the day. Specifically, the facility does not offer therapeutic activities/structure on the unit beyond 2:15PM Monday through Friday, only one structured activity on Saturday (off the unit) and no scheduled therapeutic activities on Sundays are offered. This lack of active therapies resulted in these patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125-II)

VIII. Ensure that patients were allowed phone contact with the patient advocate. One active sample patient (A5) had been asking for a change in attending physician since admission to the facility on 10/31/11without response from care providers. Patient A5 had been refusing to speak to the attending psychiatrist until a change in physician had been considered. Becoming increasingly frustrated with a lack of response by staff, Patient A5 attempted to contact the state patient advocate on 12/7/11. Patient A5 was told that he/she could not contact the advocate and proceeded to escalate aggressive behaviors to the point that Patient A5 threatened to harm the RN involved and needed to be given a time-out and de-escalation by the nurse manager. The failure to provide for the patient's basic right to speak to a patient advocate can lead to increased frustration and acting by a patient, thus delaying clinical improvement and placing the patient and others at unnecessary risk for harm. (Refer to B125-III)

IX. Ensure that physicians provided a discharge summary for 1 of 5 discharge records reviewed (D4). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient. (Refer to B133)

I. Based on record review, policy/document review and interview the Director of Nursing (DON) failed to provide consistent documentation of seclusion and restraint events for patient residing on Evergreen (acute treatment) unit for one active sample patient (A5). Nursing progress notes related to the initiation of seclusion was not recorded in the patient medical record and nursing maintained the patient in seclusion and/or performed physical hold without appropriate physician orders. These failures resulted in a lack of communication of the events leading to the use of seclusion and alternative interventions that were utilized in order to prevent the use of more restrictive measures.

A. Policy Review

Facility policy titled "Seclusion and Restraint Policy Section 2.F.-Nonviolent Practices" last reviewed/revised August 19, 2011, section IV. Procedures, E requires "written and/or telephone orders for seclusion and restraint are time limited for up to 4 hours...."; section VI. Documentation, section A states "use of seclusion or restraint is documented in the patient's medical record"; section B states "the initiating RN must document in the patient's record the use of alternative strategies, including de-escalative [sic] and verbal intervention techniques prior to seclusion or restraint."

B. Record Review

1. Patient A5, admitted to Evergreen unit 10/31/11, required locked seclusion on 12/05/11, after being returned to the unit after the patient went AWOL (Absent without leave) and was returned by the police. A review of the patient's medical record revealed that the patient was placed in locked seclusion by physician order at 1:45PM. There was no documentation in the record by the nurse (RN1) who initiated seclusion as required by facility policy.

2. Patient D6, admitted to Evergreen unit on 07/26/11 and transferred to the Criminal Justice Program on 08/16/11 at 1:19PM, required seclusion from 08/14/11 at 5:26PM through 08/16/11 at 1:19PM when transferred. During this time, a total of 14 physician orders were required. A review of the medical record revealed a total of four physician orders that were not completed timely: order dated 08/15/11 at 8:34AM was due at 8:30AM; order dated 08/15/11 at 12:38PM was due at 12:34PM; order dated 8/15/11 at 8:30PM was due at 8:22PM; order dated 08/16/11 at 7:21AM expired at 11:21AM, there was no new order obtained until 08/16/11 at 1:19PM which was a manual hold order to transfer patient to the criminal justice program. The nursing staff maintained the patient in locked seclusion without timely orders.

C. Interview

1. At 11:52 AM on 12/06/11, the DON stated the "nurse should have written a progress note" on patient A5, "when the seclusion was initiated." She reviewed the record with the surveyor and confirmed there was "no nursing documentation."

2. During an interview on 12/06/11 at 12:20PM with RN 1(nurse who initiated locked seclusion on patient A5 on 12/05/11) RN 1 stated that, "I didn't put that note in yet, I think I have 24 hours to do that." The Unit Director, who was present during this interview, clarified the expectation that the progress note is to be written immediately, per facility policy, by the nurse who initiates the restraint and/or seclusion.

3. In a separate interview on 12/07/11 with the DON, she stated "I am not doing specific quality monitoring on the appropriateness of seclusion and/or restraint and whether or not nursing is documenting according to policy or assuring that all orders are obtained as required. We only report on the number of incidents; hours patients spend in seclusion or restraints; the shift and the unit when/where the seclusion or restraint is used."

II. Based on observations, interviews and record review, the Director of Nursing (DON) failed to ensure a consistent policy and procedure for patients who wish to request changes in care. One active sample patient (A5) had been asking for a change in attending physician since admission to the facility on 10/31/11 without response from care providers. Patient A5 attempted to contact the state patient advocate on 12/7/11 but was told that he/she could not contact the advocate; the patient threatened to harm the RN involved and the patient needed to be given a time-out and de-escalation by the nurse manager. The nurse's failure to provide for the patient's right to speak to a patient advocate can lead to increased frustration and acting out by a patient, thus delaying clinical improvement and placing the patient and others ate unnecessary risk for harm .

Findings include:

A. Observations

1. During an observation on 12/7/11 at 10:50am, Patient A5 had been out in the unit hallway. Patient A5 approached the surveyor and wanted to discuss changing attending physicians. Patient A5 stated that they wanted to call the patient advocate and ask for help. Patient A5 then approached the nurse's station and asked RN4 to use the telephone to call the patient advocate. RN4 replied to Patient A5; "No, you can't call the advocate, go to your room." Patient A5 then walked away from the nurse's room looking angry.

2. At 10:55 AM on 12/7/11 the second surveyor walked onto the unit, while walking down the corridor with RN2, Patient A5 opened his bedroom door and came into the corridor and began to speak with the surveyor stating "I am not psychotic, I am only here because I am homeless. My doctor has decreased my medication to three quarters of what I should be taking. I have been telling them since I came in I want a new doctor." The patient was becoming increasingly louder with an angry tone of voice. When RN2 attempted to set limits on Patient A5, the patient began to threaten RN2 "get away from me, I will kill you." Additional staff arrived in the area. The Unit Nurse Manager utilized de-escalation techniques to assist the patient in calming down. The patient agreed to a time out in the seclusion area (unlocked door) to continue to calm down until the lunch trays were brought to the unit.

B. Interview

Both surveyors interviewed RN2 on 12/7/11 at 2:50PM regarding the denied request for use of the phone by Patient A5. RN2 stated "the patient was refusing to go to the group, when the patient asked to use the phone to call the patient advocate, I told [him/her] no. Patients are not allowed to use the phone during group time." This interview was done in the presence of the Unit Nurse Manager. The surveyor asked the Unit Nurse Manager if this was protocol, to which the Nurse Manager replied, "no, that is not how most nurses would do it, they would either allow them to make the call or would tell the patient they would call the patient advocate."

III. Based on record review, policy/document review and interview the Director of Nursing (DON) failed to ensure that nurses' regularly recorded changes in patient condition, accurately recorded patient incidents such as absent without leave and seclusion initiation and/or nursing interventions utilized for 1 of 8 active sample patients (A5). This failure resulted in lack of evidence that nurses were actively involved in the care of patients. (Refer to B127)

Based on document review and interview it was determined that the facility failed to provide adequate numbers of qualified Rehabilitation Therapy staff to ensure services to meet the needs of all patients admitted to the Evergreen unit for the twelve months. This failure resulted in lack of structured therapeutic groups/activities to assist the patients in meeting their treatment goals.

Findings include:

A. Document review

The Therapeutic Group Schedule-Winter Session, October 31, 2011 through January 20, 2012, for the Evergreen unit provided to the surveyors on 12/06/11 consists of the following time slots for therapeutic activities on the unit, 9:30 AM, 10:30 AM, 12:30PM and 1:30PM for Monday through Friday only. There is no scheduled structured on unit programming during the evening hours or on weekends (Saturday or Sunday).

B. Interview

1. During an interview on 12/07/11 at 12:30PM with the Unit Program Manager for the Evergreen unit she stated, "the program is lacking since we have a number of vacant positions. The activities offered in the evening are unstructured and we don't have anything on the weekends." She also stated there is no dedicated RT staff for the Evergreen unit.

2. During an interview on 12/07/11 at 2:00PM with the Discipline Coordinator for Recreational Therapy she stated, "our programming has been reduced somewhat due to our vacancies. Some of our vacancies go back as far as two years ago. We currently have a total of 10 positions approved: 9 recreation therapists and 1 technician, but we only have 5 recreation therapists and 1 technician filled." She further stated "there is no structured or formal therapeutic activity/group offered in the evening hours or weekends on the Evergreen unit for patients who are unable to attend off unit programming."