HospitalInspections.org

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

1) Consistently provide completed Psychosocial Assessments in a timely manner for eight (8) of eight (8) sample patients. This deficiency results in lack of professional social services that may hinder appropriate treatment and discharge services. (Refer to B108)

2) Insure the Psychiatric Assessments assess Intellectual functioning for six (6) of eight (8) sample patients in a sufficiently descriptive manner. This failure makes it impossible to establish baseline functioning for future comparisons. (Refer to B116)

3) Insure the Psychiatric Assessments include an inventory of patient assets in a descriptive, non-interpretive fashion which can be best utilized in formulating treatments for eight (8) of eight (8) active sample patients. This failure to document patient assets/strengths affects the treatment team's ability to utilize best patient attributes in therapy. (Refer to B117)

4) Develop and document comprehensive Multidisciplinary Treatment Plans (MTP) based on multidisciplinary assessments and treatment planning for eight (8) of eight (8) sample patients (Refer to B118). The MTPs also failed to include (A) Patient strengths for eight (8) of eight (8) sample patients (Refer to B119), (B) Substantiated Diagnoses for eight (8) of eight (8) sample patients (Refer to B120), (C) Short Term and Long term Goals in observable, behavioral and measurable terms for 8 of 8 sample patients (Refer to B121), (D) Specific treatment interventions including Physician interventions that address patient's presenting Psychiatric problems for eight (8) of eight (8) sample patients (Refer to B122), and (E) Name and Discipline of staff responsible for listed interventions for eight (8) of eight (8) sample patients (refer to B123). These deficiencies result in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal directed.

5) Insure that the Treatment notes for interventions listed on MTP were documented as being provided for four (4) of eight (8) active sample patients. (Refer to B124)

6) Insure that active treatment measures including alternative treatments are provided to one (1) of four (4) active sample adult patient who was unwilling and/or unable to attend certain therapeutic activities. (Refer to B125)

7) Insure that the Discharge summaries are completed in a timely manner per hospital policy for three (3) of seven (7) sample records. This compromises the effective transfer of care to next care provider. (Refer to B133)

8) Insure that all social work functions are furnished according to standards of practice for one (1) (A8) of eight (8) sample patient. (Refer to B152)

Based on Record Review and Staff interview the facility failed to provide Psychosocial Assessments for eight (8) of eight (8) (A1, A2, A3, A4, A5, A6, A7, and A8) active sample patients in a timely manner. Psychosocial Assessment were either not in the record at the time of record review on 12/19/16 [A8], incomplete [A2, A4, and A6] or they were completed at varying times from 4 to 6 days [ A1, A3, A5 and A7] after the admission. As a result the treatment team does not have available completed professional social work assessments and/or recommendations to be utilized in the design of treatment services at the time of Multidisciplinary Treatment Team [MTP] review for patients.

Findings include:

A. Record review:

1) Patient A1 was hospitalized on 12/14/16 and the Psychosocial Assessment was completed on 12/19/16.

2) Patient A2 was hospitalized on 12/08/16 and as of this review date 12/20/16, has an Assessment "Pending Review and Signature."

3) Patient A3 was hospitalized on 12/15/16 and the Assessment was completed on 12/19/16.

4) Patient A4 was hospitalized on 12/18/16 and as of this review date 12/20/16 has an Assessment "Pending Review and Signature."

5) Patient A5 was hospitalized on 12/13/16 and the Assessment was completed on 12/19/16.

6) Patient A6 was hospitalized on 12/15/16 and as of this review date on 12/20/16 has an Assessment "Unsigned."

7) Patient A7 was hospitalized on 12/15/16 and the Assessment was completed on 12/19/16.

8) Patient A8 was hospitalized on 12/15/16 and no psychosocial Assessment was available as of the review date 12/19/16.

B. Staff Interview:

In a meeting with the Director of Social Services on 12/20/16 at 3pm, the Director agreed with above deficiencies and stated "The expectation is for all Psychosocial assessments to be completed within 48 hours of admission." The Director of Social Services also stated that there was no written hospital or departmental policy establishing a timeframe for completion of Psychosocial Assessments.

Based on record review, staff interview the facility failed to assess and estimate intellectual functioning in a sufficiently descriptive manner to establish baseline parameters for six (6) of eight (8) [A1, A2, A3, A4, A6 and A7] active sample patients. This failure makes it impossible to establish objective baseline functioning for future comparisons and follow changes to adjust treatments as appropriate.

Findings include:

A. Record review:

1. Patient A1 was hospitalized on 12/14/16. Psychiatric Evaluation was completed on12/15/16. The mental status examination in the same document does not show evidence of evaluation and estimation of patient's intellectual functioning.

2. Patient A2 was hospitalized on 12/08/16. Psychiatric Evaluation was completed on12/08/16. The mental status examination in the same document does not show evidence of evaluation and estimation of patient's intellectual functioning.

3. Patient A3 was hospitalized on 12/15/16. Psychiatric Evaluation was completed on12/16/16. The mental status examination in the same document does not show evidence of evaluation and estimation of patient's intellectual functioning.

4. Patient A4 was hospitalized on 12/18/16. Psychiatric Evaluation was completed on12/19/16. The mental status examination in the same document does not show evidence of evaluation and estimation of patient's intellectual functioning.

5. Patient A6 was hospitalized on 12/15/16. Psychiatric Evaluation was completed on12/16/16. The mental status examination in the same document does not show evidence of evaluation and estimation of patient's intellectual functioning.

6. Patient A7 was hospitalized on 12/15/16. Psychiatric Evaluation was completed on12/19/16. The mental status examination in the same document does not show evidence of evaluation and estimation of patient's intellectual functioning.

B. Staff interview:

In a meeting with the Medical Director on 12/21/16 at 9:30 AM, a sample of these medical record deficiencies were reviewed and she concurred with the findings.

This standard is not met as evidenced by: Based on record review and staff interview, the facility failed to provide a psychiatric evaluation that includes the patients personal assets on which to base a meaningful treatment plan in eight (8) of eight (8) [A1, A2, A3, A4, A5, A6, A7 and A8] records reviewed. The failure to identify patient strengths that are descriptive and non-interpretive, impairs the treatment team's ability to choose treatment modalities which best utilize the patient's attributes in therapy. The patient strengths identified are either vague patient traits or external supports.

Findings include:

A. Record review:

1) Patient A1: Psychiatric assessment dated 12/15/16 states patient's strengths as "Has access to care, safe environment, supportive family."

2) Patient A2: Psychiatric assessment dated 12/08/16 states patient's strengths as "Has access to care, educated, supportive family."

3) Patient A3: Psychiatric assessment dated 12/16/16 states patient's strengths as "Access to health care, son is invested, although faraway."

4) Patient A4: Psychiatric assessment dated 12/19/16 states patient's strengths as "Educated, safe environment, access to care."

5) Patient A5: Psychiatric assessment dated 12/15/16 states patient's strengths as "(Patient's name) comes from an intact family and has access to care."

6) Patient A6: Psychiatric assessment dated 12/15/16 states patient's strengths as "(Patient name) has access to care, though how well he/she has been complying with recommendations is unclear."

7) Patient A7: Psychiatric assessment dated 12/19/16 states patient's strengths as "(Patient's name) were he/she to avail him/herself same and be compliant with recommendations."

8) Patient A8: Psychiatric assessment dated 12/19/16 states patient's strengths as "(Patient name) comes from an intact home."

B. Staff interview:

In a meeting with the Medical Director on 12/21/16 at 9:30 AM, a sample of these medical record deficiencies were reviewed and she concurred with the findings.

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

I. Provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary components to provide active treatment. Specifically, the MTPs were missing the following components:

A. An inventory of strengths to be used in active treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). (Refer to B119)

B. Substantiated diagnoses for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). (Refer to B120)

C. Patient oriented goals written in observable, behavioral, and measureable terms for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). (Refer to B121)

D. Specific treatment interventions to address each patient's presenting psychiatric problems for (A1, A2, A3, A4, A5, A6, A7, and A8). (Refer to B122)

E. Both the name and discipline of staff responsible for active treatment interventions for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). (Refer to B123)

Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patients' treatment needs not being met.

II. Ensure that Master Treatment Plans (MTPs) were revised when patients experienced episodes of seclusion or restraint. Specifically, MTPs were not revised to reflect active treatment interventions to assist 2 of 3 non-sample patients (R1 and R2), selected to review episodes of seclusion and restraint, to appropriately manage aggressive behaviors. This failure can prevent the facility from identifying interventions, which would avoid future restraint episodes for patients.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (modification dates of plans in parentheses): R1 (12/13/16 & 12/14/16); R2 (9/16/16 & 11/2/16); and R3 (11/23/16). This review revealed that two experienced two or more episodes of restraint and these patients ' MTPs were not modified.

1. Patient R1 experienced two episodes of restraint on 12/13/16 and 12/14/16 and R2 experienced four episodes of restraint (three episodes on 9/16/16 and one on 9/17/16).

a. The goals for these patients were not stated as patient outcomes reflecting what the patient would be saying or doing to show alternative and healthy replacement behaviors and/or improvement in managing aggressive behaviors. Instead goal statements were staff oriented expectations and were not stated in behavioral or measurable terms. The following identical goal statements were included for each of these patients: "Long Term Goals: Patient will be free of injury related to restraint/seclusion use during hospitalization; Patient safety will be maintained by use of restraint alternatives." "Short Term Goals: Patient will verbalize feeling relate to restraint/seclusion episode by participating in debriefing discussion (Patient R3 only); Patient will identify measures to aid in maintaining safety by completing de-escalation plan."

b. There were no specific active treatment interventions reflecting what clinical staff would do in individual or group sessions to assist patients to use healthy alternatives and approaches to replace or reduce aggressive behavior(s). Instead, MTPs included an identical list of mostly normal nursing tasks noted for each patient. The list include nursing functions or tasks assigned to be performed before patients would be released from restraints including "offering fluid, circulation checks, document every 15 minutes, offer prn [use when necessary] medication as ordered." Nursing tasks routinely performed after episodes of restraint were also included ("15 min safety check, monitor for triggers identified to acting out behavior, offer a snack; Alternatives to restriction, verbal de escalation, offered alternative activities)." The few active treatment interventions were not individualized, non-specific, and failed to identify a frequency of contact or whether the interventions would be provided in individual or group sessions. These included but not limited to the following: "Post Restraint/Seclusion Use." "Complete personal de-escalation plan with patient and engage patient in identifying restraint alternatives." "Assist in recognizing warning signs to impending lost of control and offer therapeutic interventions per de-escalation plan."

B. Document Review

The facility's policy titled "Restraint and Seclusion" revised 10/13, stipulated that, "The use of restraint or seclusion must be in accordance with a written modification in the patient's plan of care. If a patient is restrained repeatedly, the patient's individual plan of service shall be reviewed and modified to facilitate the reduction of the use of restraints."

C. Interview

In an interview on 12/21/16 at 9:30 a.m. with the Director of Nursing, MTPs for Patients RI and R2 were discussed. She agreed that the goals related to restraint use were staff oriented and not written to reflect what the patient would be doing or saying to show replacement behaviors to be used to reduce restraint use. She also agreed that interventions were non-specific and were normal nursing tasks performed during and after any patient after being placed in restraint rather than specific interventions to assist patients to learn and use healthier alternatives when feeling aggressive.

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) were based on an inventory of strengths that reflected each patient's specific assets or personal attributes that could be used to formulate treatment goals and active treatment interventions for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The failure to identify patient strengths can adversely affect clinical decision-making in formulating MTPs and impairs the treatment team's ability to choose treatment modalities that best utilize each patient's attributes in active treatment approaches.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following patients were reviewed (dates of plans in parentheses): A1 (12/16/16); A2 (12/12/16); A3 (12/19/16); A4 (12/19/16); A5 (12/14/16); A6 (12/16/16); A7 (12/16/16); and A8 (12/16/16). This review revealed that none of MTPS contained evidence that interventions were based an inventory of patients' strengths.

B. Interviews

1. During interview on 12/20/16 at 1:00 p.m. with the Director of Nursing (DON), who reportedly provided oversight of treatment plan development, MTPs for the active sample patients were reviewed. The CEO, Director of Social Work, and two administrators from the corporate office were also present at this interview. They did not dispute the findings that patient strengths that could be used to formulate MTPs were absent.

2. In an interview on 12/21/16 at 9:30 a.m. with the Clinical Director, the absence of strength on MTPs was discussed. The clinical director concurred with the above deficiencies.

Based on record review, policy review and staff interview, the facility failed to insure that the MTPs of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) included substantiated diagnoses. Absence of substantiated psychiatric and medical diagnoses that would form the basis for active treatment. Absence of substantiated diagnosis on each patient's MTP compromises the ability of the treatment team to identify specific psychiatric and physical problems and plan effective treatment during the current hospitalization.

Findings include:

A. Record Review

"Eight (8) ( MTPs, A1 dated 2/16/16, A2 dated 12/12/16, A3 dated 12/19/16, A4 dated 12/19/16, A5 dated 12/14/16, A6 dated 12/16/16, A7 dated 12/16/16 and A8 dated12/16/16) of eight (8) active sample patients" Master Treatment Plans failed to include substantiated diagnoses.

B. Facility Policy "Treatment Planning & Documentation Guidelines - Inpatient" Under General Nursing 101, Revised 10/12, under Policy: 2.a. "Multidisciplinary treatment plan" states "The written plan will include, but is not limited to: Substantiated diagnosis", further under 2.c. "Substantiated diagnosis will be determined at the first treatment team meeting."

C. Interview

On12/20/16 at 1:00 PM, the Director of Nursing [DON] acknowledged that diagnoses were not included in patients' Master Treatment Plans.
In a meeting and review with the Medical Director on 12/21/16 at 9:30 am, stated "we will follow our policy".

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that identified individualized treatment goals in observable, measurable behavioral terms for eight (8) of eight (8) active sample patients (A1, A2, A1, A3, A4, A5, A6, A7, and A8). The goals were not specific and some goals described routine hospital functions, which did not define areas of patient improvement. 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

The Master Treatment Plans (MTPs) for the following patients were reviewed (dates of plans in parentheses): A1 (12/16/16); A2 (12/12/16); A3 (12/19/16); A4 (12/19/16); A5 (12/14/16); A6 (12/16/16); A7 (12/16/16); and A8 (12/16/16). This review revealed the goals were not written in behavioral, observable, and measurable terms. Many long-term goals were actually short-term goals. Additionally, several goal statements were identical or similarly worded despite the different presenting symptoms identified for each patient.

1. Patient A1's MTP had the following goals for the problem, "Alteration in Mood: Mania": "Goal: Patient will maintain safety for length of stay." "Goal: Patient will demonstrate/ verbalize a decrease in manic symptoms." These goals were not stated in specific behavioral or measurable terms. Therefore, they failed to provide sufficient information for staff to know what behaviors to observe in order to determine goal attainment or patient improvement. The first goal was a hospital function or staff expectation and not a patient outcome related to what the patient would be doing or saying to show improvement in presenting symptoms.

2. Patient A2's MTP had the following goals for the problem, "Disturbed Thought Process": "Goal: Patient will maintain safety for length of stay." "Goal: Patient will identify coping to manage: [left blank]." "Long-Term Goal: Patient will identify 5 coping skills to mange delusional thinking and hallucinations." "Goal: Patient will take medication willing for: [left blank]." "Long-Term Goal: Patient will take medication willing for length of stay." These goals were not stated in specific behavioral or measurable terms. Therefore, they failed to provide sufficient information for staff to know what behaviors related to delusional thinking and hallucinations to observe in order to determine goal attainment or patient improvement. The goal regarding safety and taking medication were staff expectations and not a patient outcome related to what the patient would be doing or saying to show understanding of his/her psychiatric symptoms, medications, and treatment compliance needs after discharge.

3. Patient A3 ' s MTP had the following goals for the problem, " Alteration in Mood: Anxiety " : " Goal: Patient will maintain safety for length of stay. " " Goal: Patient will demonstrate /verbalize a decrease in anxious symptoms. " " Short Term Goal: Patient will identify 5 coping skills to manage anxiety. " These goals were not stated in specific behavioral, observable, or measurable terms. Therefore, they failed to provide sufficient information for staff to know what behaviors to observe in order to determine goal attainment or patient improvement. The first goal was a hospital function or staff expectation and not a patient outcome related to what the patient would be doing or saying to show improvement in presenting symptoms.

4. Patient A4 ' s MTP had the following goals for the problem, " Risk for Suicide ... " " Goal: Patient will maintain safety for length of stay. " " Goal: Patient will identify coping skills to manage: [left blank]. " " Short Term Goal: 5 coping skills to manage increased suicidal thoughts. " " Short Term Goal: Patient will identify at least 4 triggers to increased suicidal thoughts. " These goals were not stated in specific behavioral, observable, or measurable terms. Therefore, they failed to provide sufficient information for staff to know what behaviors to observe in order to determine goal attainment or patient improvement especially regarding replacement behaviors for suicidal thoughts. The first goal was a hospital function or staff expectation and not a patient outcome related to what the patient would be doing or saying to show improvement in presenting symptoms.

5. Patient A5 ' s MTP had the following goals for the problem, " Risk for Other Directed Violence " : " Goal: Patient will be free of aggressive behavior for: [left blank]. " " Short Term Goal: 3 triggers. " " Goal: Patient will identify coping skills to manage: [left blank]. " " Short Term Goal: 5 coping skills to manage anger. " These goals were not stated in specific behavioral or measurable terms. The goal regarding being " free of aggressive behavior " was not described in behavioral terms regarding positive alternative or replacement behaviors for aggression that would show the patient ' s increased level of functioning. Therefore, they failed to provide sufficient information for staff to know what behaviors to observe in order to determine goal attainment or patient improvement.

6. Patient A6 ' s MTP had the following goals for the problem, " Risk for Other Directed Violence " : " Goal: Patient will be free of aggressive behavior for: [left blank]. " " Long Term Goal: 3 consecutive days. " " Goal: Patient will verbalize freedom desire/intent to harm other for: [left blank]. " These goals regarding being " free of aggressive behavior " was not stated in behavioral terms regarding positive alternative or replacement behaviors for aggression that would show the patient ' s increased level of functioning. Therefore, they failed to provide sufficient information for staff to know what behaviors to observe in order to determine goal attainment or patient improvement.

7. Patient A7's MTP had the following goals for the problem, "Risk for Suicide..." "Goal: Patient will maintain safety for length of stay." "Goal: Patient will identify coping skills to manage: [left blank]" [This goal was noted as " Resolved]. " Long Term Goal: Patient will identify 8 coping skills to manage increased suicidal thoughts." "Goal: Patient will be free of suicidal thoughts for: [left blank]." [This goal was noted as "Resolved]." Short Term Goal: Patient will be free of suicidal thoughts for 3 consecutive days. These goals were not stated in specific behavioral, observable, or measurable terms. Therefore, they failed to provide sufficient information for staff to what behaviors to observe in order to determine goal attainment or patient improvement. The first goal was a hospital function or staff expectation and not a patient outcome related to what the patient would be doing or saying to show improvement in presenting symptoms. The goal regarding the patient being "free of suicidal thoughts" was not stated in behavioral and specific terms with positive alternative or replacement behaviors for suicidal thoughts that would show the patient's increased level of functioning.

8. Patient A8's MTP had the following goals for the problem, "Disturbed Thought Process": "Goal: Patient will maintain safety for length of stay." "Goal: Patient will verbalize/demonstrate a decrease in symptom for: [left blank]." "Long Term Goal - Symptoms: paranoid, non verbal, appears frightened, twitching/grimacing." These goals were not stated in specific behavioral, observable, or measurable terms. Therefore, they failed to provide sufficient information for staff to know the patient's behaviors (such as descriptions of paranoid behaviors) to observe in order to determine goal attainment or patient improvement. The goal regarding safety was a hospital function or staff expectation and not a patient outcome related to what the patient would be doing or saying to show understanding of his/her psychiatric symptoms, medications, and treatment compliance needs after discharge.

B. Interview

2. During interview on 12/20/16 at 1:00 p.m. with the Director of Nursing (DON) who reportedly provided oversight of the treatment plans, along with the CEO, Director of Social Work, and two (2) administrators from corporate office, MTPs were discussed. The DON did not dispute the findings that goals on MTPs were not individualized and were not stated in behavioral, observable, and measurable terms.

Based on record review, document review, and interviews, the facility failed to provide Master Treatment Plans (MTPs) for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) that included individualized active treatment interventions with a specific focus, based on the individual psychiatric needs and presenting symptoms of each patient. Specifically, intervention statements were generic or routine discipline functions. Many intervention statements were identical or similar wording for patients with different problems or needs. In addition, the treatment plans included interventions that failed to identify the frequency of contact and specify how interventions would be delivered (individual or group sessions). There were no attending physician's interventions at all for four (4) of four (4) active sample patients (A5, A6, A7 and A8) on the child and adolescent units. These deficiencies result in treatment plans that do not reflect a comprehensive, integrated, individualized, approach to multidisciplinary treatment. Failure to provide guidance to staff regarding the specific modality needed and the purpose for each modality also potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following patients were reviewed (dates of plans in parentheses): A1 (12/16/16); A2 (12/12/16); A3 (12/19/16); A4 (12/19/16); A5 (12/14/16); A6 (12/16/16); A7 (12/16/16); and A8 (12/16/16). This review revealed following deficient intervention statements that were non-specific and/or generic clinical functions such as assessing, observing, encouraging, setting limits, and monitoring to be delivered by the psychiatrist (MD), registered nurse (RN), therapist/social worker staff (SW), and occupational therapists (OT).

1. Patient A1's MTP included the following non-specific and/or generic or routine clinical functions for the identified problem of: "Alteration in Mood Mania."
MD Intervention: "Medication Management PRN." This statement was identical or similarly worded for Patients A1, A3, and A4. The statement failed to include a focus of treatment reflecting specific medications, information to be provided patients (such as, side effect, benefits, ways to maintain compliance after discharge). The statement also failed to include a frequency of contact and how the intervention would be delivered (individual or group sessions).
RN Interventions: "Therapeutic 1:1 (BID and PRN) to: identify mood baseline, assess for alteration in mood from baseline, provide feedback on observations, assess energy and activity level monitor patient's sleep and encourage sleep hygiene (Daily), reaffirm with patient the need for medication compliance." All of these were normal nursing functions and did not have any specific focus related to meeting with the patient to assist him/her to improve, manage, and understand his/her presenting psychiatric problem(s). The following intervention statement did not state a focus of treatment based on this patient's individual psychiatric needs: "Provide education, groups, learning labs (Daily)."
SW Intervention: "Monitor patient's energy level and reinforce increased control over behavior, pressured speech and expression of ideas." This was a normal function performed by therapy staff and did not have any specific focus related to meeting with the patient to assist him/her to improve, manage, and understand his/her specific psychiatric problems. The following intervention was very broad, not individualized, failed to include specific issues identified in clinical assessments, and had no frequency of contact: "Provide group psychotherapy to provide structure and focus for patient's thoughts and actions by regulating the direction of conversation and establishing plans for behavior."
OT Interventions: "Patient will attend OT programming to explore healthy coping skills to manage symptoms of mania. OT programming to promote pt's [patient's] ability to explore ways to add purpose to daily life & increase self worth." These intervention statements were generic and non-specific, did not identify specific symptoms of mania manifested by the patient to be addressed, and failed to state the frequency of contact with the patient and whether these interventions would be delivered in individual or group sessions.

2. Patient A2's MTP included the following non-specific and/or generic or routine clinical functions for the identified problem of: "Disturbed Thought Process."
MD Intervention: There were no MD interventions for this problem statement.
RN Interventions: "Therapeutic 1:1 (BID and PRN) to: assess for presence of thought disorder symptoms, alleviate patient fears of hallucinations, Encourage medication compliance through education (ongoing). Perform pill/mouth checks (ongoing), Provide low stimuli environment (ongoing)." All of these were normal nursing functions and did not have any specific focus related to meeting with the patient to assist him/her to improve, manage, and understand his/her presenting psychiatric problem(s). The following intervention statement did not state a focus of treatment based on this patient's individual psychiatric needs: "Provide education, groups, learning labs (Daily)."
SW Interventions: There were no therapists' interventions for this problem statement.
OT Interventions: There were no OT interventions for this problem statement.

3. Patient A3's MTP included the following non-specific and/or generic or routine clinical functions for the identified problem of: "Alteration in Mood: Anxiety."
MD Intervention: "Medication Management PRN."
RN Interventions: "Therapeutic 1:1 (BID and PRN) to: assess current level of anxiety. This was a normal nursing function and did not have any specific focus related to meeting with the patient to assist him/her to improve, manage, and understand his/her presenting psychiatric problem(s). The following intervention statement did not state a focus of treatment based on this patient ' s individual psychiatric needs: "Provide education, groups, learning labs (Daily)."
SW Intervention: "Provide psychotherapy to process feelings and stressors, assist patient with developing coping skills to manage symptoms of anxiety and depression..." This intervention failed to include specific stressors to be address as identified in clinical assessments and had no frequency of contact.
OT Interventions: "Patient will attend OT programming to explore healthy coping skills to manage increased depression and anxiety. OT programming to promote pt's [patient's] ability to explore ways to add purpose to daily life & increase self worth." These interventions failed to include specific symptoms of depression that would be addressed as identified in clinical assessments, had no frequency of contact, and failed to identify whether these interventions would be delivered in individual or group sessions.

4. Patient A4's MTP included the following non-specific and/or generic or routine clinical functions for the identified problem of: "Risk for Suicide..."
MD Intervention: "Medication Management."
RN Interventions: "Therapeutic 1:1 (BID and PRN) to: assess for desire/intent to harm self, current level of anxiety. This was a normal nursing function and did not have any specific focus related to meeting with the patient to assist him/her to improve, manage, and understand his/her specific psychiatric problems. The following intervention statement did not state a specific focus of treatment based on this patient ' s individual psychiatric needs: "Provide education, groups, learning labs (Daily)."
SW Interventions: There were no therapists' interventions for this problem statement.
OT Intervention: "Patient will attend OT programming to explore healthy coping skills to manage stressors (feeling alone, anxious, nervous)..." This intervention failed to include a frequency of contact and did not state whether this intervention would be delivered in individual or group sessions.

5. Patient A5's MTP included the following non-specific and/or generic or routine clinical functions for the identified problem of: "Risk for Other Directed Violence."
MD Intervention: There were no MD interventions for this problem statement.
RN Interventions: "Therapeutic 1:1 (BID and PRN) to: assess for desire/intent to harm others, Set clear limits about behavior, Utilize Token Economy to reinforce positive behavior (Ongoing)." These were normal nursing functions and did not have any specific focus related to meeting with the patient to assist him/her to improve, manage, and understand his/her specific psychiatric problem(s). The following intervention statement did not state a focus of treatment based on this patient's individual psychiatric needs: "Provide education, groups, learning labs (Daily)."
SW Intervention: "Provide group psychotherapy to improve positive communication skills and reduce the use of threats to others...Provide information on coping skills to include, taking a break when angry..." These interventions failed to include a frequency of contact. The second intervention also did not include whether it would be delivered in individual or group sessions.
OT Intervention: "Encourage exploration of coping skills via creative media, expressive therapy..." This intervention statement failed to include a frequency of contact and did not identify whether the activities would be delivered in individual or group sessions.
"Provide structured activities to assess frustration tolerance..." This intervention was a routine and normal OT function to obtain information to determine appropriate OT active treatment strategies.

6. Patient A6's MTP included the following non-specific and/or generic or routine clinical functions for the identified problem of: "Risk for Other Directed Violence."
MD Intervention: There were no MD interventions for this problem statement.
RN Interventions: "Therapeutic 1:1 (BID and PRN) to: assess for desire/intent to harm others, Set clear limits about behavior, Utilize Token Economy to reinforce positive behavior (Ongoing)." These were normal nursing functions and did not have any specific focus related to meeting with the patient to assist him/her to improve, manage, and understand his/her presenting psychiatric problem(s). The following intervention statement did not state a focus of treatment based on this patient's individual needs: "Provide education, groups, learning labs (Daily)."
SW Intervention: "Provide group psychotherapy to improve positive communication skills and reduce the use of threats to others...Provide information on coping skills to include, taking a break when angry..." These interventions failed to include a frequency of contact. The second intervention also did not include whether it would be delivered in individual or group sessions.
OT Intervention: "Encourage exploration of coping skills via creative media, expressive therapy..." "Provide various opportunities to express feelings, increase self worth, work on concentration..." These intervention statements failed to include a frequency of contact and did not identify whether the activities would be delivered in individual or group sessions.

7. Patient A7's MTP included the following non-specific and/or generic or routine clinical functions for the identified problem of: "Risk for Suicide."
MD Intervention: There were no MD interventions for this problem statement.
RN Interventions: "Therapeutic 1:1 (BID and PRN) to: assess for desire/intent to harm self, Set clear limits about behavior, Utilize Level System to reinforce positive behavior (Ongoing), Initiate individualized packets to assist patient in focusing on controlling [his/her] anger, Encourage patient to share safety plan with parent/guardian (ongoing)." These were normal nursing functions and did not have any specific focus related to meeting with the patient to assist him/her to improve, manage, and understand his/her specific psychiatric problem(s).
SW Intervention: "Provide group psychotherapy to promote identification of feelings and triggers of suicidal ideation...Identify/process feelings and stressors." These interventions failed to include a frequency of contact. The second intervention also did not include whether it would be delivered in individual or group sessions.
OT Intervention: "Provide various opportunities to express feelings, increase self worth, problem solve & identify stressors...OT programming to promote pt's [patient's] ability to learn positive coping skills to counter suicidal thoughts." These intervention statements failed to include a frequency of contact and did not identify whether the activities would be delivered in individual or group sessions.

8. Patient A8's MTP included the following non-specific and/or generic or routine clinical functions for the identified problem of: "Disturbed Thought Process."
MD Intervention: There were no MD interventions for this problem statement.
RN Interventions: "Therapeutic 1:1 (BID and PRN) to: assess for presence of thought disorder symptoms, alleviate patient fears of hallucinations, Perform pill/mouth checks (ongoing), Ensure adequate hydration and nutrition (ongoing)." All of these were normal nursing functions and did not have any specific focus related to meeting with the patient to assist him/her to improve, manage, and understand his/her specific psychiatric problems. The following intervention statement did not state a specific focus of treatment based on this patient's individual psychiatric needs and problem(s): "Encourage medication compliance through education (ongoing). Provide education, groups, learning labs (Daily)."
SW Interventions: There were no therapist interventions for this problem statement.
OT Interventions: "If appropriate, the patient will attend OT programming to explore... thought disturbance and paranoid thoughts." This treatment intervention failed to include a frequency of contact with the patient, as well failed to include alternative individual or group interventions when the patient was unable to attend OT programming.

B. Interviews

1. During interview on 12/20/16 at 12:15 p.m., OT1 acknowledged that OT interventions were generic and contained non-specific information that was not related to each patient's individual presenting symptoms and/or needs.

2. During interview on 12/20/16 at 1:00 p.m. with the Director of Nursing (DON) who reportedly provided oversight of the treatment plans, along with the CEO, Director of Social Work, and two administrators from corporate office, MTPs were discussed. The DON did not dispute the findings that intervention statements were not active treatment interventions but were actually discipline functions or task that would be performed as a part of normal hospital duties.

Based on record review and interview, the facility failed to identify both the name and discipline of clinical staff responsible for implementing and/or ensuring that treatment interventions on the Master Treatment plans were provided for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This deficient practice results in the facility ' s inability to ensure that the patient received the assigned intervention and to clearly monitor staff accountability for seeing that specific interventions are implemented.

A. Record Review

The Master Treatment Plans (MTPs) for the following patients were reviewed (dates of plans in parentheses): A1 (12/16/16); A2 (12/12/16); A3 (12/19/16); A4 (12/19/16); A5 (12/14/16); A6 (12/16/16); A7 (12/16/16); and A8 (12/16/16). This review revealed that none of the MTPs included both the discipline and name of clinical staff responsible for implementing interventions outlined on MTPs. Since intervention statements only included the discipline, it was not clear what staff was accountable to ensure that interventions identified on MTPs were carried out.

B. Interview

During interview on 12/20/16 at 1:00 p.m. with the Director of Nursing (DON) who reportedly provided oversight of the treatment plans, along with the CEO, Director of Social Work, and two administrators from corporate office, staff responsibility for interventions on MTPs were discussed. The DON admitted that the name of clinical staff responsible for the interventions were not included on treatment plans.

Based on record review and interview, the facility failed to ensure that treatment notes for interventions listed on the Master Treatment Plans (MTPs) were documented as being provided by registered nurses (RNs). Specifically, there was no documentation showing that registered nurses met with patients in individual and/or group sessions to provide active treatment interventions identified on MTPs of four (4) of eight (8) active sample patients (A1, A2, A3, and A4). In addition, there was no evidence to show that RNs documented information regarding the topics discussed and the patient's response (level of participation, level of understand, and behaviors during the intervention). This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following patients were reviewed (dates of plans in parentheses): A1 (12/16/16); A2 (12/12/16); A3 (12/19/16); A4 (12/19/16); A5 (12/14/16); A6 (12/16/16); A7 (12/16/16); and A8 (12/16/16). This review revealed the following interventions identified for registered nurses (RNs) were not documented in the electronic medical record as being implemented.

1. Patient A1 had the following intervention for the problem of "Alteration in Mood: Mania." "Therapeutic 1:1 (BID and PRN) to: ...Identify coping skills to reduce disorganized behavior." The DON was unable to locate any documentation by RNs showing the 1:1 sessions with the patient to provide specific information regarding coping skills and how the patient responded to the intervention.

2. Patient A2 had the following intervention for the problem of "Disturbed Thought Process." "Therapeutic 1:1 (BID and PRN) to:...Encourage medication compliance through education (Ongoing)." The DON was unable to locate any documentation by RNs that showed any 1:1 sessions with the patient to provide specific education regarding medication compliance and how the patient responded to the intervention.

3. Patient A3 had the following intervention for the problem of "Alteration in Mood: Anxiety." - "Therapeutic 1:1 (BID and PRN) to:...Teach coping skills to manage anxiety." The DON was able to locate only one RN note regarding coping skills. There were no other documentation that showed 1:1 sessions with the patient to provide specific information regarding coping skills and how the patient responded to the intervention.

4. Patient A4 had the following interventions for the problem of "Risk for Suicide." - "Therapeutic 1:1 (BID and PRN) to: ... Encourage/assist patient to identify triggers." "Identify and process feelings related to increased suicidal thoughts." The DON was unable to locate any documentation by RNs that showed any 1:1 sessions with the patient to provide specific information regarding these interventions and how the patient responded to the intervention.

5. Patients A1, A2, A3, and A4 all had the following identical intervention for the problem statement related to "Discharge Planning": "Teach and reinforce education of medication and diagnosis with patient. (Ongoing)." This intervention did not include a modality (individual or group sessions) or focus of treatment. The DON was able to find documentation of medication education however; this information was brief and failed to include what specific medication was taught and the level of the patient's participation. The DON was not able to locate any documentation that these patients received education from RNs regarding their diagnosis.

B. Interview

In an interview on 12/21/16 at 9:30 a.m., the DON met with the surveyor to locate RN treatment notes in the electronic medical record for Patient A1, A2, A3, and A4. She acknowledged that active treatment interventions identified on MTPs were not being documented as being implemented by nurses. She admitted that the medication education documentation did not include the specific medications taught and also did not indicate the patient's level of participation and behaviors during medication education.

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

I. Ensure that active treatment measures, such as group treatment, individual treatment, and therapeutic activities, were provided to one (1) of four (4) active sample patients (A2) on the Adult Units who was unwilling to participate and/or attend groups. Specifically, the facility failed to ensure that patient A2 received alternative active treatment measures such as one to one interventions with clinical staff to ensure sufficient hours of active treatment. Failure to provide sufficient active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement.

II. Ensure that a comprehensive face-to-face assessment of the patient's status within one hour of initiation of a restraint procedure was documented for three (3) of three (3) non-sample patients (R1, R2, and R3) whose records were selected to review episodes of restraint. Specifically, the one-hour face-to-face assessments, after an episode of restraint, documented by RNs were very brief and cursory in nature. The evaluations only had brief comments about results of findings and did not contain a review of system, review of laboratory results, review of current medications, and an assessment of whether the patient was injured or not. Failure to conduct a comprehensive one-hour face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's aggressive behavior. In addition, failure to conduct a comprehensive one-hour face-to-face assessment may potentially lead to a failure to detect physical injury if sustained during the application of restrictive procedures.

Findings include:

I. Failure to include individualized active treatment interventions


A. Record and Document Review

1. Patient A2 was admitted to the unit on 12/8/16. The Psychiatric Evaluation dated 12/8/16 noted, "... threatening to kill [his/her] father and brother and sxs [symptoms] of psychosis...Pt [Patient] has a history of alcohol use and drug abuse..." Pt [Patient] does deny any hallucination but was making bizarre noises and looking over his shoulder signaling..."Pt [Patient] is very paranoid that people are after [his/her] money."

2. The patient's Master Treatment Plan dated 12/16/16 identified three problem: "Disturbed Thought Process, Readiness for Enhanced Therapeutic Regimen Management: Discharge Planning, and Risk for Other Directed Violence." The interventions identified to address these problems included: "...medication compliance through education and provide reality orientation" and "Teach and reinforce education of medications and diagnosis by registered nurses;" Provide group psychotherapy..."by therapy staff;" and "...OT programming..." by OT staff.

3. During observation on 12/19/16 at 1:00 p.m., the patient was found sitting in the dayroom with two other patients. An "Education Group" was scheduled to be held from 1:00 p.m. to 2:00 p.m. The patient was found in his room at 1:40 p.m. During observation in the scheduled "Group Therapy" from 2:17 to 3:00 p.m., only active sample patient A1 and one other patient attend. Patient A2 did not attend at all. In an interview after the group at 3:05 p.m. SW1 stated that [PatientA2] declined to attend the session. She stated, "He is going to read in [his/her] room." She admitted that the group was not appropriate given the patient's current level of functioning. She stated that she did not offer alternative individual sessions with the patient.


4. A review of the "Intensive Care Programming Schedule" revealed an array of the therapeutic groups including: Seven "Group Therapy" sessions conducted Saturday and Sunday from 9:30 a.m. to 10:30 a.m. and Monday - Friday from 2:00 p.m. to 3:00 p.m. Ten "OT" sessions conducted Saturday and Sunday from 2:00 p.m. to 3:00 a.m. and Monday from 9:30 a.m. to 10:30 a.m. and from 2:00 p.m. to 3:00 p.m.; Tuesday from 1:00 p.m. to 2:00 p.m. and 6:00 p.m. to 7:00 p.m.; Wednesday from 9:30 a.m. to 10:30 a.m. and from 6:00 p.m. to 7:00 p.m. Friday from 9:30 a.m. to 10:30 a.m. The schedule also included one "Education Class" and four Therapeutic activities sessions offered during the week. The "Close Observations" Sheets revealed that the patient attended less than 50% of these group treatment sessions. There was no mention of alternatives active treatment measures included on MTPs to substitute for the patient not attending groups on this schedule.

5. A further review of the "Close Observations" Sheets from 12/12/16 to 12/20/16 revealed that the patient consistently failed to attend groups scheduled on the unit. The facility reported that all patients were expected to attend scheduled groups. These sheets revealed the following findings regarding nonattendance in active treatment groups for 12/15/16 through 12/18/16:

a. Monday, 12/12/16 - Active treatment sessions:

"Education Class" from 1:00 p.m. to 2:00 p.m. Patient location: "Dayroom." "Bed Reading." "Resting in bed."

"Group Therapy" from 2:15 p.m. to 3:00 p.m. The patient was "Resting in bed."

"Therapeutic Activities" from 3:30 p.m. to 4:00 p.m. The patient was "at the nursing station or watching TV."

"OT" from 6:00 p.m. to 7:00 p.m. The patient was in "Dayroom." Attended the OT session for 15 minutes.

b. Tuesday, 12/13/16 - Active treatment sessions:

"Music Therapy" from 12:00 p.m. to 1:00 p.m. The patient was in the "dayroom." Attended the Music Therapy session for 15 minutes.

"OT" from 1:00 p.m. to 2:00 p.m. The patient was "Resting on couch."

"Group Therapy" from 2:15 p.m. to 3:00 p.m. The patient was "Asleep on couch."

"OT" from 6:00 p.m. to 7:00 p.m. The was in the "dayroom and/or on couch watching TV."

c. Wednesday, 12/14/16 - Active treatment sessions:

"OT" from 1:00 p.m. to 2:00 p.m. Patient's location: "dayroom" and/or "asleep."

"Group Therapy" from 2:15 p.m. to 3:00 p.m. Patient's location: "Asleep." "TV, Dayroom."

"Therapeutic Activities" from 3:30 p.m. to 4:00 p.m. Patient's location: "TV, Dayroom."
"Standing by door."

d. Thursday, 2/15/16 - Active treatment sessions: [Note: Only two group session scheduled on this day.]

"Group Therapy" from 2:15 p.m. to 3:00 p.m. Patient was in court from "12:52 to 2:45 p.m."

"OT" from 6:00 p.m. to 7:00 p.m. Patient's location: "Reading paper in bathroom." "Resting in bed." Attended OT for 15 minutes at the beginning of the session.

e. Friday, 12/16/16 - Active treatment sessions: [Note: Only two group session scheduled on this day.]

"Group Therapy" from 2:15 p.m. to 3:00 p.m. Patient's location: "Dayroom watching TV."

f. Saturday, 12/17/16 - Active treatment sessions:

"OT" from 2:15 p.m. to 3:00 p.m. Patient's location: "Dayroom."

g. Sunday, 12/18/16 - Active treatment sessions:

"Class or Group Therapy" from 9:30 a.m. to 10:30 a.m. Patient location: "Cards with peers."

"Therapeutic Activities" from 1:00 p.m. to 1:30 p.m. Patient location: "Dayroom, TV." Patient was with the MD at the beginning of this scheduled session.

"OT" from 2:00 p.m. to 3:00 p.m. Patient location: "Cards with RN." Attended the first 15 minutes of the OT session.

Despite documentation that the patient was not attending groups, there were no modifications made in the Master Treatment Plan to include appropriate one to one active treatment interventions and alternatives based on this patient's current level of functioning when the patient refused group treatments.

B. Staff Interviews

1. During interview on 12/19/16 at 3:05 p.m., SW1 stated that she did not provide active sample patient A2 alternative one on one active treatment when s/he refused to attend group sessions. She stated that nursing staff had educational packets to give to patients on these occasions but she wasn't sure that Patient A2 had received them.

2. During interview on 12/20/16 at 12:15 p.m., OT1 stated that she does not provide alternative one on one treatment for Patient A2 when he or she refused to attend OT programming.

3. In an interview on 12/21/16 at 10:30 a.m., the DON confirmed that the facility had educational packets reflecting various psychiatric topics. She agreed that alternative active treatment measures should be offered when patients do not attend groups. She stated, "I think we are doing this but it's not being captured so that we can get credit."

II. Failure to document comprehensive face-to-face assessments

A. Record Review

1. Patient R1 was admitted on 12/11/2016. The patient experienced an episode of restraint on 12/14/16 and was placed in five point restraints. The medical record noted: " Antecedent Conditions: Patient wanted a radio and [s/he] was not allowed to have it... given scheduled medication...Patient started to bang on the TV... Patient was punching the plaster wall and plaster fell...started to cut himself with it ... [S/he] was bending [his/her] finger back and trying to break them..." The face-to-face assessment dated 12/14/16 at 10:17 p.m. was brief and cursory for both the patient behavioral and medical condition. There was no evaluation regarding whether the patient was injured or not in the assessment given the information regarding the patient attempting to cut [himself/herself]. In addition, there was no comprehensive evaluation that included a review of systems such as whether the patient's circulation was normal or not and skin (flushed, hot). There was no documentation regarding a review of the patient's laboratory results or current medications.

2. Patient R2 was admitted 9/14/16 and experienced four episodes of restraint 9/16/16 (three episodes) and on 9/17/16 at 6:38 p.m. For the restraint episode on 9/17/16, the medical record noted: "Patient...got a hold of a pillow case that [s/he] was not going to give to staff. Code green was called and patient was able to be talked into giving it to staff ... was in the corner and was scratching at [his/her] neck until [s/he] bled." A second code was called and patient tried to physically get away from to harm self and was placed in restraints for [his/her] safety. The face-to-face assessment for the restraint dated 9/17/16 at 7:02 p.m. was brief and cursory for both the evaluation of the patient's behavioral and medical condition. There was no evaluation regarding whether the patient was injured or not in the assessment. In addition, there was no comprehensive evaluation that included a review of systems such as comprehensive check of the patient's circulation, respiratory (color change, diaphoretic, increate rate, wheezing, etc., and skin (flushed, hot). There was no documentation regarding a review of the patient's laboratory results or current medications.

3. Patient R3 was admitted 11/16/16 and experienced an episode of restraint on 11/23/16 at 10:20 a.m. The medical record noted: "Antecedent Conditions: Pt [Patient] tried to choke a RN and slammed her into the door. Yelling, hitting, kicking staff. Had to be manually restrained for a while we waited for reinforcement..." For the restraint episode on 11/23/16, the face-to-face assessment dated 11/23/16 at 10:42 a.m. was brief and cursory for both the evaluation of the patient's behavioral and medical condition. There was no evaluation regarding whether the patient was injured or not in the assessment. In addition, there was no comprehensive evaluation that included a review of systems such as comprehensive check of the patient's circulation, respiratory (color change, diaphoretic, increate rate, wheezing, etc., and skin (flushed, hot). There was no documentation regarding a review of the patient ' s laboratory results or current medications.

B. Document Review

The facilities policy titled "Restraint and Seclusion" revised 10/13, stipulated for, "One Hour Face-to-Face Evaluation: Restraint or seclusion used for the management of violent or self-destructive behavior requires that the patient be seen by a Psychiatrist, APRN or RN...This assessment includes: The patient's immediate situation; The patient's reaction to the intervention; The patient's medical and behavioral condition; and The need to continue or terminate the restraint or seclusion."

C. Interviews

1. During interview on 12/21/16 at 9:00 a.m., the DON this not dispute the findings that the face-to-face assessments for Patient R1, R2, and R3 did not contain comprehensive findings regarding the each patient's evaluation after use of a restraint procedure.

2. In an interview on 12/21/16 at 10:45 a.m. RN1 agreed the face-to-face assessment for Patient R1 was not comprehensive and did include all pertinent information.

Based on record review, policy review and interview, the facility failed to ensure that the Discharge summaries were completed in a timely fashion as defined by the hospital policy for three (3) of seven (7) patients discharged patients [D4, D5 and D7]. This compromises the effective transfer of care to the next provider.

Findings include:

A. Record Review:

As of this review date on 12/21/16;

1) Patient D4 was discharged on 11/9/16 and the discharge summary states "Pending Review and Signature".

2) Patient D5 was discharged on 11/11/16 and the discharge summary states "Pending Review and Signature".

3) Patient D7 was discharged on 11/21/16 and the discharge summary states "Pending Review and Signature".

Additionally staff was asked to provide from the list of discharges for the dates between 10/21/16 and 11/21/16, a summary list of Discharge Summaries that are "pending review and signature." They provided a list and that indicates 51 discharge summaries (of 169 discharges) were not completed per hospital policy.

B. Policy Review:

Medical staff policy 16.C.1. ( j ) states "All discharge summaries will include the following and must be completed within 30 days of discharge".

C. Staff Interview:

1. In a meeting with the DON on 12/20/16 at 1pm, the DON concurred with the above findings.

2. In a meeting and review with Medical Director on 12/21/16 at 9:30 am, the Medical Director also concurred with the above deficiencies and stated "we will follow our policy".

The Clinical Director failed to adequately monitor and evaluate the quality of care provided to patients at the facility. Specifically, the Clinical Director failed to ensure that:

(A) The Psychosocial Assessments are completed consistently in a timely manner. (Refer to B108)

(B) Psychiatric Assessments contained an estimation of intellectual functioning documented in a sufficiently descriptive manner to allow for future comparisons. (Refer to B116)

(C) The patient assets are consistently documented in a descriptive, non-interpretive fashion in the Psychiatric Assessments. (Refer to B117)

(C) The MTPs (Refer to B118) included patient strengths (Refer to B119), substantiated diagnoses (Refer to B120), short term and long term goals (Refer to B121), patient specific treatment intervention (Refer to B122), and identify by discipline and name of staff responsible for providing specific interventions (Refer to B123)

(D) Active including alternative treatments are provided to patients who are unwilling and/or unable to participate in offered therapeutic activities (Refer to B125).

(E) The Discharge summaries are completed in a timely manner per hospital policy. (Refer to B133)

(F) Psychosocial Assessments are completed per accepted standards of practice. (Refer to B152)

In an interview and review of the above deficiencies with the Clinical Director on 12/21/16 at 9:30 am, the Clinical Director concurred with the above deficiencies and stated "We will follow our policies", "No MD interventions in the treatment plan, need to provide individualized Interventions."

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

I. Ensure that Master Treatment Plans (MTPs) were revised when patients experienced episodes of seclusion or restraint. Specifically, MTPs were not revised to reflect active treatment interventions to assist 2 of 3 non-sample patients (R1 and R2), selected to review episodes of seclusion and restraint, to appropriately manage aggressive behaviors of. This failure can prevent the facility from identifying interventions, which would avoid future restraint episodes for patients. (Refer to B118).

II. Provide Master Treatment Plans (MTPs) for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) that included individualized active treatment interventions with a specific focus, based on the individual needs and abilities of each patient. Specifically, registered nurse (RN) intervention statements were generic or routine nursing functions. Many intervention statements were identical or similar wording for patients with problems or different needs. These deficiencies result in treatment plans that do not reflect a comprehensive, integrated, individualized, approach to multidisciplinary treatment. Failure to provide guidance to nursing staff regarding the specific modality needed and the purpose for each modality also potentially results in inconsistent and/or ineffective treatment. (Refer to B122).

III. Identify the name of registered nurse(s) responsible for implementing and/or ensuring that treatment interventions on the Master Treatment plans were provided for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This deficient practice results in the facility ' s inability to ensure that the patient received the assigned intervention and to clearly monitor nursing staff accountability for seeing that specific interventions are implemented. (Refer to B123).

IV. Ensure that treatment notes for interventions listed on the Master Treatment Plans (MTPs) were documented as being provided by registered nurses (RNs). Specifically, there was no documentation showing that registered nurses met with patients in individual and/or group sessions to provide active treatment interventions identified on MTPs of 4 of 8 active sample patients (A1, A2, A3, and A4). In addition, there was no evidence to show that RNs documented information regarding the topics discussed and the patient's response (level of participation, level of understand, and behaviors during the intervention). This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed. (Refer to B124)

V. Ensure that a comprehensive face-to-face assessment of the patient's status within one hour of initiation of a restraint procedure was documented for two (2) of three (3) non-sample patients (R1, R2, and R3) whose records were selected to review episodes of restraint. Specifically, the one-hour face-to-face assessments, after an episode of restraint, documented by RNs were very brief and cursory in nature. The evaluation only had a brief comment about findings and did not contain a review of system, laboratory results, or current medications, or an assessment of whether the patient was injured or not, and did not include how the patient responded to the restrictive intervention. Failure to conduct a comprehensive one-hour face-to-face assessment potentially results in inadequate information to determine whether other factors such as medication side effects and/or medical problems may have led to the patient ' s aggressive behavior. In addition, failure to conduct a comprehensive one-hour face-to-face assessment may potentially lead to a failure to detect physical injury if sustained during the application of restrictive procedures. (Refer to B125-II)

Based on record review and staff interview, the facility failed to provide professionally designed and directed social work services for one (1)of eight (8) (A8) active sample patient records reviewed. This failed practice can result in a lack of professional social work services potentially delaying patients improvement and timely discharge.

Findings include:

Record review:

1) Patient A8 hospitalized on 21/15/16, had psychosocial assessment in the record dated 12/20/16 "pending review and signature", completed by a "Licensed Professional Counselor" [LPC] who functions as a "Therapist" (SW1) on Child and Adolescent unit. This staff has no Social Work education (MSW or LCSW) nor her work is overseen by a staff with professional social work education.

Staff interview:

1) In a meeting and review with SW1 on 12/20/16 at 10 am, the staff acknowledged her role as a "therapist" and that she does not have social work (MSW,LCSW) education and that she is supervised by a supervisor that does not have Masters level Social Work (MSW) education or an LCSW.

2) In a meeting with the Director of Social Services on 12/20/16, the Director acknowledged that the SW1's supervisor does not have a MSW/LCSW education, rather her education is Masters of Science degree in public administration.