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Based on record review and interview, the facility failed to formulate treatment goals that were relevant to the patients' psychiatric condition for five (5) of eight (8) active sample patients (1, 4, 6, 7, and 8). The goals as stated were difficult to measure. Without a set of defined goals against which to measure progress, it is impossible to judge the effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress.

Findings include:

A. Record Review

1. In patient 1's Master Treatment Plan (MTP), dated 3/19/19, the difficult to measure short-term goal for the problem "Substance [sic] use disorder (methamphetamine AEB [As Evidenced By]: Chronic use 'I was using meth [methamphetamines] daily until a week ago,"' was: "[Name of patient] will be able to demonstrate a written understanding of the cognitive behavioral and spiritual aspects of addiction recovery." This statement failed to include descriptive behaviors to be measured.

2. In patient 4's MTP, dated 3/21/19, the difficult to measure short-term goal for the problem "Alteration in thought process - psychosis AEB: Disorganized and delusional thoughts FOI [flight of ideas], auditory hallucinations, loose associations," was: "[Name of patient] will think clearly as demonstrated by logical and coherent speech two days prior to discharge."

3. In patient 6's MTP, dated 4/4/19, the difficult to measure short-term goal for the problem "Hx [history] of mania, impulsive control, verbal/physical aggression, 'I'll beat the hell out of you,'" was: "[Name of patient] will identify two symptoms of mood disorder and two signs of true self."

4. In patient 7's MTP, dated 4/11/19, the difficult to measure short-term goal for the problem "Altered thought process - psychosis AEB: walking naked outside in frigid weather, beating people unprovoked, paranoia," was: "[Name of patient] will think more clearly as demonstrated by logical and coherent speech two days prior to discharge."

5. In patient 8's MTP, dated 4/4/19, the difficult to measure short-term goal for the problem "Altered thought process - psychosis, 'I'm [sic] bleeding to death,' not compliant with medications," was: [Name of patient] will think more clearly as demonstrated by logical and coherent speech two days prior to discharge."

B. Interview

On 4/16/19 at 1:10 p.m., the problem of difficult to measure goals was discussed with the Director of Nursing. He stated, "I have some education to do."

Based on record review and staff interview, it was determined that for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 5, 6, 7, and 8) the Master Treatment Plans failed to describe the patient-specific interventions by the psychiatrist, the APRN (Advanced Practice Nurse Practioner), and nursing staff. This failure results in similar non-informative, generic discipline function statements.

Findings include:

A Record Review

1. Patient1: The Master Treatment Plan (MTP), dated, 3/19/19, had the following interventions for the problem "Depression with Suicidality": psychiatrist - "Assess need for medications and evaluate effectiveness" and for nursing "Administer medication as prescribed and provide medication education."

2. Patient 2: The Master Treatment Plan, dated 4/6/19, had the following interventions for the problem "Depression with Suicidality": psychiatrist - "Assess need for medications and evaluate effectiveness" and for nursing: "Administer medication as prescribed and provide medication education."

3. Patient 3: The Master Treatment Plan, dated 3/6/19, had the following nursing intervention for the problem: "Alteration in thought process-Psychosis": "Administer medication as prescribed and provide medication education for nursing intervention."

4. Patient 4: The Master Treatment Plan, dated 3/21/19, for the problem "Alteration in thought process-Psychosis" had the following nursing intervention: "Administer medication as prescribed and provide medication education for nursing."

5. Patient 5: The master Treatment Plan, dated 12/18/19, for the problem "Alteration in thought process" had the following intervention for the psychiatrist: "Assess need for medication and measure effectiveness."

6. Patient 6: The Master Treatment Plan, dated 4/4/19, for the problem "Mood Instability," the psychiatrist intervention was "Evaluate need for medication" and the nursing interventions were "Monitor for safety," "Evaluate for medication efficacy," and administer medication."

7. Patient 7: The Master Treatment Plan dated 4/11/19, for the problem "Alteration in thought process" had the following intervention for the psychiatrist: "Assess need for medication and measure effectiveness and the nursing intervention was: "Administer medications as prescribed and provide medication education."

8. Patient 8: The Master Treatment Plan dated 4/4/19 had the following interventions for the problem "Altered thought Process-Psychosis": psychiatrist - "Assess need of med of medication and measure effectiveness" and nursing - "Administer medication as prescribe and provide education."

B. Staff Interviews:

1. On 4/16/19 at 1:10 p.m., the Director of Nursing was interviewed. A partial focus was the issue of generic discipline functions as interventions by nursing staff as described in Section A above. He concurred with the findings and stated, "We have some education to do."

2. On 4/16/19 at 1:30 p.m., the Clinical Director was interviewed. The findings described in Section A above were a partial focus in the interview. He agreed with the findings and noted they were not individualized.

Based on medical record review and staff interview, it was determined that for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 5, 6, 7, and 8) the clinical director failed to:

I. Ensure that Master Treatment Plans contained observable goals that were measurable patient behaviors and not staff goals. Refer to B121.

II. Ensure that treatment interventions noted in the Master Treatment Plans were more than generic discipline functions and were patient specific. Refer to B122