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Based on a review of sample patient records and on interviews and observations, the facility failed to maintain records with adequate information to document that appropriate assessments, treatment planning, treatment and discharge planning were occurring for the active patients in the facility. Specifically:

I. Based on record review and interview; the facility failed to provide social work assessments that met professional social work standards, including: 1) a description of patient strengths and deficits; and 2) conclusions and recommendations that described anticipated social work roles in treatment and discharge planning. This resulted in a lack of adequate clinical information and guidance for the master treatment planning process for 5 of 8 active sample patients (A4, A14, B1, B16 and F9). In the case of patient F9, no psychosocial evaluation was found in the record. (Refer to B108)

II. Based on record review and interview, the facility failed to document neurological examinations in such a way as to verify the specific cranial nerve testing performed for 8 of 8 active sample patients (A4, A14, B1, B16, C5, F9, T4 and T8). Additionally, the facility failed to ensure that history and physical examinations were updated on an annual basis for 1 of 8 active sample patients (F9). These failures to document examinations compromise the identification of pathology which may be pertinent to the current mental illness and compromise future comparative re-examination to assess patient's response to treatment interventions. (Refer to B109)

III. Based on record review and interview, the hospital failed to provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for 5 of 8 active sample patients (A4, A14, B1, B16 and C5). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

IV. Based on record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of assets to be utilized in treatment for 6 of 8 active sample patients (A14, B1, B16, C5, F9, and T4). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (Refer to B117)

V. Based on record review and interview, the facility failed to develop comprehensive multidisciplinary Master Treatment Plans (MTPs) for 4 of 4 active sample patients residing on the Adult Acute Units (A4, A14, B1, B16), 1 of 1 active sample patient on the Children's Unit (C5), and 2 of 2 active sample patients on the Adolescent Unit (T4 and T8). The MTPs for the patients A4, A14, B1, C5, T4 and T8 were generated by the admitting RN before the multidisciplinary assessments had been completed. The plans to address the problems identified by the admission RN on these MTPs were poorly developed and lacked a multidisciplinary focus. The only team members routinely attending treatment planning meetings on the Adult Acute Units were the MD and RN, and there was insufficient documentation of other disciplines' involvement in treatment planning. The absence of integrated, comprehensive Master Treatment Plans hampers the staff's ability to provide coordinated treatment, based on data from multidisciplinary assessments, potentially resulting patients' treatment needs not being met. (Refer to B118)

VI. Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for 7 of 8 active sample patients (A4, A14, B1, B16, C5, T4 and T8) that were based on patient strengths and disabilities. The MTPs for these patients did not sufficiently address active problems identified in the assessments and/or failed to specify how patient strengths would be utilized in treatment. This deficient practice diminishes the effectiveness of treatment interventions by not engaging patients through use of their strengths, with an awareness of their disabilities. (Refer to B119)

VII. Based on record review and interview, the facility failed to develop written Master Treatment Plans (MTPs) that included substantiated diagnoses for 4 of 4 active sample patients (A4, A14, B1 and B16) on the Adult Acute Units and 1 of 2 active sample patients (T8) on the Adolescent Unit. The "Axis I-IV" admission diagnoses for these patients were written on the "Acute Initial Treatment Plan" by the admitting RN before the multidisciplinary assessments had been completed. The only team members attending treatment team meetings on the Adult Acute Units were the attending physician (psychiatrist) and the RN in charge of the unit when the treatment planning meeting was held; there was no evidence that other team members were involved in discussions to substantiate the diagnoses. Failure to base treatment plans on substantiated diagnoses can potentially result in ineffective treatment and prolonged hospitalizations for patient. (Refer to B120)

VIII. Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that included appropriate short-term and long-term goals for 8 of 8 active sample patients (A4, A14, B1, B16, F9, C5, T4 and T8). The MTP goals for these patients did not relate to the identified problem(s), were non-measurable, lacked dates for goal achievement, and/or were stated as staff goals for patient participation in program activities rather than patient outcomes. Failure to specify patient goals on MTPs hampers staffs' ability to provide goal-directed care and measure patients' responses to treatment, potentially resulting in prolonged hospitalizations. (Refer to B121)

XI. Based on record review and interview, the facility failed to provide individualized and focused interventions for 7 of 8 active sample patients (A4, A14, B1, B16, C5, T4 and T8). The staff interventions for these patients were generic tasks for specific disciplines instead of individualized interventions based on assessed patient needs, and they failed to specify the treatment modalities that were to be used for the interventions. In addition, the MTPs for patients A4 and A14 lacked physician interventions, and those for patients A4, A14, C5 and T8 had no social work or activity therapy interventions. These deficiencies result in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed. (Refer to B122)

X. Based on record review and interview, the facility failed to identify by name staff responsible for interventions on the Master Treatment Plans (MTPs) for 7 of 8 active sample patients (A4, A14, B1, B16, C5, T4 and T8). None of the interventions for patients A4, A14, B1, B16, C5 and T8 had assigned staff; those interventions were only listed as discipline functions. The MTP for patient T4 had no assigned staff for interventions on the "Acute Treatment Plan" the "Plan for Continuing Treatment" had missing staff names for one of the listed problems. Failure to specify the names of responsible staff for interventions diffuses responsibility and can result in patient's treatment needs not being addressed in a timely fashion. (Refer to B123)

XI. Based on observation, record review and interview, the facility failed to provide alternative interventions for 2 of 2 active sample patients (A4 and A14) on the Adult Acute Unit B and 1 of 1 active sample patient (F9) on the Forensics Unit when they did not participate in regularly scheduled treatment programming. These patients spent large blocks of time in their rooms or in the hallways in isolated activities. Failure to provide active treatment results in patients being hospitalized without all possible interventions for recovery being provided, potentially delaying the patients' improvement and discharge from the hospital. (Refer to B125 Part I)

XII. Based on record review, interview and policy review, the facility failed to ensure for 1 of 1 active non- sample patients (B10) that physician orders gave nursing staff proper guidance on the administration of sedative antianxiety medications. For this patient, physician orders were written on a PRN (as necessary) basis for the non-described condition "anxiety" by a choice of delivery methods; nurses could choose to administer the medications by intramuscular injection ("IM") or by mouth ("po"). This failure resulted in nursing staff being required to function outside the scope of nursing practice. (Refer to B125 Part II)

XIII. Based on record review, policy review and interview, the facility failed to ensure that physician's orders for combination sedative medications administered simultaneously (chemical restraint) included specific parameters for their use with each patient, and that the orders were written specifically for each episode where chemical restraint was required for 2 of 8 active sample patients (active sample Patients (B1 and B16) and additionally 11 non-sample Patients (from a total census of 31) in the Mokihana unit (A&B). Additionally, for two of the active sample patients (B1 and B16) and the 11 non-sample patients noted, these orders were written on admission on an "as needed" ("prn") basis prior to the patient being evaluated by a psychiatrist. This resulted in physicians, via inappropriately written orders, giving nurses prescriptive authority for combination sedative medications that were being used as a means of chemical restraint on a prn basis as a matter of convenience for the medical and nursing staff, thus placing patients at risk of receiving restrictive measures without adequate medical supervision. (Refer to B125 Part III)

XIV. Based on record review and interview, the facility failed to ensure that the medical problems identified at the time of admission for 1 of 8 active sample patients (B1) were adequately monitored during the patient's hospitalization at the facility. Failure to address these problems compromised the patient's medical status; the patient required emergency transfer and care at a medical hospital, where the patient was admitted for cardiac observation. (Refer to B125 Part IV)

Based on record review and interview; the facility failed to provide social work assessments that met professional social work standards, including: 1) a description of patient strengths and deficits; and 2) conclusions and recommendations that described anticipated social work roles in treatment and discharge planning. This resulted in a lack of adequate clinical information and guidance for the master treatment planning process for 5 of 8 active sample patients (A4, A14, B1, B16 and F9). In the case of sample patient F9, admitted 9/19/08, there was no psychosocial evaluation in the record.

Findings are:

A. Record Review

Patient A4: A psychosocial evaluation dated 4/2/10, under the section for "Patient's Strengths," noted "cooperative." There were no deficits noted and there were no specific social work interventions described.

Patient A14: A psychosocial evaluation dated 3/23/10 did not document any specific social work interventions.

Patient B1: A psychosocial evaluation dated 4/5/10, under the section for "Patient's Strengths," noted "cooperative." There were no deficits noted and there were no specific social work interventions described.

Patient B16: A psychosocial evaluation, dated 10/9/09 from a prior admission (there was no update for this admission of 4/4/10), did not document any specific social work interventions.

Patient F9, admitted 9/19/08, did not have a psychosocial evaluation in the record. There was no updated note located in the record.

B. Interview

In an interview on 4/13/10 at 11:45 a.m., the Director of Clinical Services agreed with the findings.

Based on record review and interview, the facility failed to document neurological examinations in such a way as to verify the specific cranial nerve testing performed for 8 of 8 active sample patients (A4, A14, B1, B16, C5, F9, T4 and T8). Additionally, the facility failed to ensure that history and physical examinations were updated on an annual basis for 1 of 8 active sample patients (F9). These failures to document complete examinations compromise the identification of pathology which may be pertinent to the current mental illness and compromise future comparative re-examination to assess patient's response to treatment interventions.

Findings are:

A. Record Review

Patient A4: In a history and physical examination dated 4/1/10 under the section for physical examination it noted, "Other Cranial Nerves: nl (normal)."

Patient A14: In a history and physical examination dated 3/23/10 under the section for physical examination it noted, "Other Cranial Nerves: intact and symmetric."

Patient B1: In a history and physical examination dated 4/4/10 under the section for physical examination it noted, "Other Cranial Nerves: 2-12 intact."

Patient B16: In a history and physical examination dated 4/5/10 under the section for physical examination it noted, "Other Cranial Nerves: intact and symmetric."

Patient C5: In a history and physical examination dated 3/26/10 under the section for physical examination: Other Cranial Nerves: "intact and symmetric."

Patient F9: In a history and physical examination dated 9/20/08 under the section for physical examination it noted, "Other Cranial Nerves: intact and symmetric." No updated physical examinations were present in the record.

Patient T4: In a history and physical examination dated 3/19/10, under the section for physical examination, it noted, "Other Cranial Nerves: intact and symmetric."

Patient T8: In a history and physical examination dated 4/1/10, under the section for physical examination, it noted, "Other Cranial Nerves: cn (cranial nerves) 2-12 intact".

B. Interview

In an interview on 4/13/10 at 2:15 p.m., the Medical Director agreed with the information noted above and commented that "we need to do a better job."

Based on record review and interview, the hospital failed to provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for 5 of 8 active sample patients (A4, A14, B1, B16 and C5). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings are:

A. Record Review

Patient A4: In a Psychiatric Evaluation dated 4/1/10 it noted under the section Mental Status Examination: "Cognitively, he appeared to be intact. His memory for immediate, recent and remote events was intact." There was no mention of specific tests used; testing of orientation or estimation of intellectual function were not noted.

Patient A14: In a Psychiatric Evaluation dated 3/23/10 it noted under the section Mental Status Examination: "Fair memory. Good level of intelligence. Fair fund of knowledge. Poor attention. Poor concentration." There was no mention of testing used in the assessments.

Patient B1: In a Psychiatric Evaluation dated 4/4/10, it noted under the section Mental Status Examination: "I was unable to evaluate her orientation." There was no mention of memory testing or estimation of intellectual function.

Patient B16: In a Psychiatric Evaluation dated 4/5/10, it noted under the section Mental Status Examination: "Cognition is significant for decreased attention and poor retrieval." There was no mention of memory testing, orientation or estimation of intellectual function.

Patient C5: In a Psychiatric Evaluation dated 3/28/10 under the section Mental Status Examination there was no mention of memory testing or estimation of intellectual function.

B. Interview

In an interview on 4/13/10 at 2:15 p.m., the Medical Director agreed with the information noted above and commented that "we need to do a better job."

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of assets to be used in treatment for 6 of 8 active sample patients (A14, B1, B16, C5, F9, and T4). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy.

Findings are:

A. Record Review

Patient A14: A Psychiatric Evaluation dated 3/25/10 under the section for Strengths and Assets noted, "Pleasant and cooperative and agreeable with medication management."

Patient B1: A Psychiatric Evaluation dated 4/4/10 did not note any strengths or assets in the body of the report.

Patient B16: A Psychiatric Evaluation dated 4/5/10 did not note any strengths or assets in the body of the report.

Patient C5: A Psychiatric Evaluation dated 3/28/10 did not note any strengths or assets in the body of the report.

Patient F9: A Psychiatric Evaluation dated 9/19/08 did not note any strengths or assets in the body of the report. There was no evidence of any more recent evaluations being performed.

Patient T4: A Psychiatric Evaluation dated 3/19/10 noted within the mental status examination the following: "The patient's strengths are that mother is supportive."

B. Interview

In an interview on 4/13/10 at 2:15 p.m., the Medical Director agreed with the information noted above and commented that "we need to do a better job."

Based on record review and interview, the facility failed to develop comprehensive multidisciplinary Master Treatment Plans (MTPs) for 4 of 4 active sample patients residing on the Adult Acute Units (A4, A14, B1, B16), 1 of 1 active sample patient on the Children's Unit (C5), and 2 of 2 active sample patients on the Adolescent Unit (T4 and T8). The MTPs for the patients A4, A14, B1, C5, T4 and T8 were generated by the admitting RN before the multidisciplinary assessments had been completed. The plans to address the identified problems on these MTPs were poorly developed and lacked a multidisciplinary focus. The only team members routinely attending treatment planning meetings on the Adult Acute Units were the MD and RN, and there was insufficient documentation of other disciplines' involvement in treatment planning. The absence of integrated, comprehensive Master Treatment Plans hampers the staff's ability to provide coordinated treatment, based on data from multidisciplinary assessments, potentially resulting patients' treatment needs not being met.

Findings are:

A. Policy Review:

Kahi Mohala Policy and Procedure, "Treatment Planning/Delivery," policy #0800.0053, last revised 7/09 noted the following:

Section I: Purpose: "To provide an individualized patient and family centered interdisciplinary integrated plan of patient care."

Section II: Policy: "Each patient will have an individualized master treatment plan emphasizing patient strengths and directed at resolution of patient issues."

Section III: Procedure:

A. "Multidisciplinary Planning and Delivery of Care" 1. "While each patient's treatment shall be based on the written orders of a physician, treatment planning and delivery shall be interdisciplinary in nature."

B. Written Treatment Plan: 4. "On the acute units, a treatment plan is initiated within 24 hours and established with the patient within 72 hours. The Treatment Team will meet weekly (as scheduled) updating the plan as appropriate until patient is discharged from acute services. A Treatment Plan review must include at least 3 of the following: patient, physician, therapist, RN, teacher, MHS."

B. Record Review: (MTP dates in parentheses)

The Master Treatment Plan (MTP) for patients receiving care for "acute" problems was a preprinted form that included: 1) a face page titled "Your Kahi Mohala Treatment Team," with spaces for signatures of the "Admitting Physician," "Attending Physician(s)," the "Program Nurse Manager," and the "Clinical Therapist" (no listing for OT, or RT, or other disciplines); 2) an "Acute Master Problem List" for documenting active, inactive, or deferred problems, 3) an "Acute Initial Treatment Plan" page which listed the Axis Diagnoses and a synthesis of assessment findings and criteria for discharge, and 4) a page(or pages) titled "Acute Treatment Plan" that included spaces to enter the identified problems and related goals and interventions. An "Acute Treatment Plan Update" page, to be completed in treatment team planning meetings, was attached to some of the MTPs. Patients receiving care for less acute problems had similar forms titled "Plan for Continuing Treatment." Review of the sample patients MTPs revealed the following deficiencies:

1. Patient A4 was a 46 year old male admitted to the Adult Acute Unit B on 3/31/10. The MTP (3/31/10; update 4/9/10) "Treatment Team" page only listed the names of the Admitting Physician and the Program Nurse Manager; spaces for other staff names were left blank. Problems on the "Acute Master Problem List" were "Schizoeffective [sic] D/O [disorder]", "Risk for Harm to Self/Others," and "HTN [hypertension] + Hep C [hepatitis C]." There was no "Acute Treatment Plan" for any of these listed problems. Instead, the MTP included a one page plan for a problem "Coping Skill (as evidenced by) inappropriate racial comment," which was not on the problem list. There were no physician interventions on the plan. The "MTP update" (4/9/10) did not address specific problems or goals but merely stated "Pt [patient] has had a couple of moments of agitation but has mainly controlled [sic]. Pt sits on unit and does self activities for hours..." There were no suggested changes in the MTP except for medication: "Pt started on Invega 3 mg po Q am [by mouth every morning]."

2. Patient A14 was an 81 year old male admitted to the Adult Acute Unit B on 3/22/10. The MTP (3/22/10) "Treatment Team" page only listed the names of the Admitting Physician and the Program Nurse Manager; spaces for other staff names were left blank. The only problem listed on the "Acute Master Problem List" was "Risk for Self Harm...as evidenced by...Pt states has 'no will to live.' "The plan failed to include specific interventions to address the patient's risk for self harm, including observational status by nursing staff or safety precautions by other staff. There were no physician, OT or RT interventions. Although plans were to be updated weekly, the plan was not updated as of 4/12/10 (21 days after admission and after the MTP was generated).

3. Patient B1 was a 33 year old female admitted to the Adult Acute Unit A on 3/30/10. The MTP (4/4/10) "Treatment Team" page only named the Admitting Physician, the Program Nurse Manager, and the Social Worker/Case Manager. Spaces for the attending psychiatrist and other staff were blank. The "Acute Master Problem List" listed the following "active problems": "Meth induced psychosis," "Risk for harm to self with plan to jump of building," "Increased cholesterol" and "Meth abuse." The MTP only addressed the problem "Risk for self harm." As of 4/12/10 (13 days after admission), there was no MTP update found.

4. Patient B16 was a 69 year old male admitted to the Adult Acute Unit A on 4/4/10. The "Treatment Team" face page on the MTP (4/4/10) only named the Admitting Physician and the Program Nurse Manager. Spaces for other staff names were blank. The "Acute Master Problem List," dated 4/5/10, listed the following active problems: "Bipolar Mixed," "Risk or harm to self/others," and "HTN [hypertension]." However, the MTP only included a treatment plan for "Risk of harm to self/others."

5. Patient C5 was a 7 year old male admitted to the Children's Unit on 3/26/10. On the initial MTP (3/26/10), the "Acute Master Problem List" listed "Risk for harm to self and others" as the only active problem, even though the assessments listed on the "Acute Initial Treatment Plan " stated that the patient's oppositional behaviors and the parents' marital discord needed to be addressed. The "Acute Treatment Plan" included no social work/case management interventions. The patient was transferred to the residential treatment program on 4/6/10 but continued to be housed and treated on the Children's Inpatient Unit. Thus, the record continued to be reviewed as an extension of acute care. The "MTP for Continued Treatment" in the residential program listed "Ineffective Coping"...as evidenced by... "Impulsive/Aggressive behaviors" as the only active problem. As of 4/12/10, there were no identified interventions to address this problem.

6. Patient T4 was a 15 year old female admitted to the Adolescent Unit on 3/19/10. The MTP (3/19/10) "Treatment Team" page named only the Physician(s) and the Program Nurse Manager as members of the treatment team. The "Acute Master Problem List" included only "Risk for harm to self/others" as an active problem, even though Axis I diagnoses included "Depressive DO [disorder)," R/O [rule out] "Anorexia/Bulemia," "Psychotic DO NOS [not otherwise specified]," and "Polysubstance Abuse-Cannabis/amphetamines." The patient was transferred to the residential treatment program on 3/28/10 but continued to be housed and treated on the Adolescent Inpatient Unit. Thus the record continued to be reviewed as an extension of acute care. The MTP for "Continued Treatment" in the residential program included 3 active problems: "family issues," "emotion dysregulation," and "ineffective coping." There were no physician, nurse, or social work/case management interventions for these problems. The only modalities specified on the MTP were OT group (for ineffective coping) and RT "Ropes" program to address the patient's "emotion dysregulation."

7. Patient T8 was a 15 year old male admitted to the Adolescent Unit on 3/30/10. The MTP (3/30/10) "Treatment Team" page named only the Admitting Physician and the Program Nurse Manager as members of the treatment team. The "Acute Problem List" only included "Risk for Self Harm" as an active problem. The plan for this problem failed to identify specific interventions to protect the patient from self harm behaviors (e.g., specific observational status by nurses), and it had no social work/case management, OT or RT interventions. As of 4/12/10, there were no MTP updates found in the record.

B. Observation

A Treatment Planning Meeting held on the Adult Unit A was observed on 4/14/10 from 10:00 to 10:20 a.m. Team members present in the meeting included Physician Y1 and RN Y2 (the charge nurse for the unit). During the observation, the physician conducted a patient interview while the RN completed the treatment update form. The physician/patient discussion primarily focused on medication management and the patients' participation in unit activities. There was no discussion of the MTP goals or interventions by the multidisciplinary staff.

C. Interview

1. A joint interview was held on 4/13/10 at 11:00 a.m. with the Program Nurse Manager for the Adult Acute and Forensic Units, the Program Nurse Manager for the Child/Adolescent Units, and the Clinical RN Coordinator. The program managers and RN coordinator stated that all patients should have a scheduled initial treatment team meeting within 72 hours of admission, and that the MTP should be completed (with multidisciplinary input) at that time. They stated that attendance of staff beyond the RN and psychiatrist for patients on the Adult Acute Units was "dropped last month." They acknowledged the treatment plans were not comprehensive and did not reflect a multidisciplinary approach to treatment.

2. In an interview on 10/13/10 at approximately 10:30 a.m., Physician Y1 acknowledged that treatment team meetings that only included the attending physician and an RN, and that they did not offer sufficient opportunity for multidisciplinary treatment planning for patients.

3. In an interview on 10/13/10 at 1:30 p.m., the Director of Social (Therapeutic) Services stated that the MTPs should include input from the Social Work Case Managers, Masters-prepared Clinical Therapists, and Activities staff (OT/RT), but that was often not occurring. He agreed that MTPs did not incorporate social services information from the assessments and that the MTPs were not well developed.

4. In an interview on 4/13/10 at 2:15 p.m., the Medical Director acknowledged that the sample patients' MTPs were not comprehensive and did not provide sufficient guidance for staff.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for 7 of 8 active sample patients (A4, A14, B1, B16, C5, T4 and T8) that were based on patient strengths and disabilities. The MTPs for these patients did not sufficiently address active problems identified in the assessments and/or failed to specify how patient strengths would be utilized in treatment. This deficient practice diminishes the effectiveness of treatment interventions by not relating to patients through use of their strengths, with an awareness of their disabilities.

Findings are:

A. Record Review

1. Patient A4 was a 46 year old male admitted to the Adult Acute Unit B on 3/31/10. Active problems listed on MTP (3/31/10; update 4/9/10) "Acute Master Problem List" were "Schizoeffective [sic] D/O [disorder]", "Risk for Harm to Self/Others," and "HTN [hypertension] + Hep C [hepatitis C]." The review of 4/12/10 found no treatment plan for any of these listed problems. Instead, the MTP included a one page plan for a problem "Coping Skill [sic]...as evidenced by...inappropriate racial comment," which was not on the problem list.

The only patient strengths listed on the MTP were "cooperative, redirectable." There was no mention of how these strengths could be used in treatment.

2. Patient A14 was an 81 year old male admitted to the Adult Acute Unit B on 3/22/10. As of 4/12/10, the only problem listed on the MTP (3/22/10) "Acute Master Problem List" was "Risk for Self Harm"...as evidenced by...Pt states has 'no will to live.'

Strengths listed on the MTP were "honest/cooperative, seeking help." There was no mention of how these strengths could be used in treatment.

3. Patient B1 was a 33 year old female admitted to the Adult Acute Unit A on 3/30/10. Active problems listed on the MTP (4/4/10) "Acute Master Problem List" were "Meth induced psychosis," "Risk for harm to self with plan to jump of building," "Increased cholesterol" and "Meth abuse." As of 4/12/10, there was no specific treatment plan to address the psychosis or the drug abuse problems.

The only patient strengths identified on the MTP were "Pt. cooperative, seeking help, willing to ask questions and participate in groups." There was no mention of how these strengths could be used to help the patient achieve the treatment goals.

4. Patient B16 was a 69 year old male admitted to the Adult Acute Unit A on 4/4/10. Active problems listed on the MTP "Acute Master Problem List" (4/5/10) were "Bipolar Mixed," "Risk o harm to self/others," and "HTN [hypertension]." As of 4/12/10, the MTP only included a one page plan to address the problem "Risk of harm to self/others." There was no plan to address the "Bipolar Mixed" diagnosis or the hypertension.

The only patient strengths identified on the MTP were "voluntary, seeking help" and "cooperative." There was no mention of how these strengths could be used in treatment.

5. Patient C5 was a 7 year old male admitted to the Children's Unit on 3/26/10. The "Acute Treatment Plan" (3/26/10) listed only "Risk for harm to self and others" as an active problem. There were no documentations on the Acute Treatment Plan (3/6/10) or the "MTP for Continued Treatment" (4/6/10) to address family issues ("marital discord") identified in the assessments.

Patient strengths listed on Patient C5's "Acute Initial Treatment Plan" were "Pt. cooperative, seeking help, willing to ask questions and participate in groups." These strengths were not consistent with staff reports of the patient's aggressive behavior on the unit. Strengths noted on the "MTP for Continued Treatment" were "sociable, active." The plan did not specify how these strengths were to be used to support the treatment goals.

6. Patient T4 was a 15 year old female admitted to the Adolescent Unit on 3/19/10 with Axis I diagnoses of "Depressive DO [disorder] NOS [not otherwise specified] R/O [rule out] "Anorexia/Bulemia; Psychotic DO NOS [not otherwise specified]," and "Polysubstance Abuse-Cannabis/amphetamines." The only active problem addressed by the MTP (3/19/10) was "Risk for harm to self/others." The "MTP for Continued Treatment" (3/28/10) listed 3 active problems: "family issues," "emotion dysregulation [sic]," and "ineffective coping" but did not address the eating disorder or substance abuse issues.

The only statement regarding patient strengths on the MTP was "Willing and Seeking Help while admitted." There was no other evidence of staff efforts to identify patient strengths that could be used in treatment.

7. Patient T8 was a 15 year old male admitted to the Adolescent Unit on 3/30/10 for "Major Depression with S/I [Suicidal Ideation]". As of 4/12/10, the only active problem on the MTP (3/30/10) was "Risk for Self Harm." The only listed patient strengths were "Cooperative and eager to engage in treatment." The plan did not specify how these strengths would be used to help the patient achieve his treatment goals.

B. Interview

1. In an interview on 4/13/10 at 11:00 a.m., the Program Nurse Managers for the Adult Acute Units and the Children/Adolescent Units acknowledged that the MTPs were incomplete.

2. In an interview on 4/13/10 at 2:15 p.m., the Medical Director noted that the MTPs were not based on all available multidisciplinary assessments, and agreed that the treatment planning process needed improvement.

3. In an interview on 4/13/10 at 3:50 p.m., the Director of Social Services acknowledged the above cited deficiencies in the MTPs.

Based on record review and interview, the facility failed to develop written Master Treatment Plans (MTPs) that included substantiated diagnoses for 4 of 4 active sample patients (A4, A14, B1 and B16) on the Adult Acute Units and 1 of 2 active sample patients (T8) on the Adolescent Unit. The "Axis I-IV" admission diagnoses for these patients were written on the "Acute Initial Treatment Plan" by the admitting RN before the multidisciplinary assessments had been completed. The only team members attending treatment team meetings on the Adult Acute Units were the attending physician (psychiatrist) and the RN in charge of the unit when the treatment planning meeting was held; there was no evidence that other team members were involved in discussions to substantiate the diagnoses. Failure to base treatment plans on substantiated diagnoses can potentially result in ineffective treatment and prolonged hospitalizations for patients.

Findings are:

A. Record Review (MTP dates in parentheses)

Review of the MTPs for active sample patients A4 (3/31/10; update 4/9/10), A14 (3/22/10), B1 (4/4/10), B16 (4/4/10) and T8 (3/30/10) revealed no updates of the Axis I-IV diagnoses after the admission RN documentations on the "Acute Initial Treatment Plans." One of the Axis I diagnoses for Patient A14 was "R/O alcohol abuse," which was not a substantiated diagnosis.

B. Interview

1. In a joint interview on 4/13/10 at 11:00 a.m., the Program Nurse Managers for the Adult Acute Units and the Children/Adolescent Units verified that the only diagnoses on the above MTPs were those entered by the admission RN. The Program Nurse Managers were unaware that the diagnoses needed to be substantiated by members of the multidisciplinary team.

2. In an interview on 4/13/10 at 10:30 a.m., Physician Y1 acknowledged that the current treatment team meetings did not include multidisciplinary discussions to substantiate the admission diagnoses.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that included appropriate short-term and long-term goals for 8 of 8 active sample patients (A4, A14, B1, B16, F9, C5, T4 and T8). The MTP goals for these patients did not relate to the identified problem(s), were non-measurable, lacked dates for goal achievement, and/ or were stated as staff goals for patient participation in program activities rather than patient outcomes. Failure to specify patient goals on MTPs hampers staffs' ability to provide goal-directed care and measure patients' responses to treatment, potentially resulting in prolonged hospitalizations.

Findings are:

A. Record Review (dates of MTPs in parentheses)

1. Patient A4 (3/31/10). For the stated problem "Coping Skill [sic]...as evidenced by...inappropriate racial comment," the long-term goal was "Discharge in 5-7 days, able to contract for safety." This goal did not relate to the stated problem. The short-term goals were "calm, redirected, attending groups on coping strategies" and "compliance c [with] meds." It was unclear how the stated goals related to the patient's need to develop better coping skills or refrain from inappropriate racial comments. The short-term goals were non-measurable as stated and failed to include target dates for expected achievement. The patient's attendance at groups also was a staff goal, not a patient outcome to be achieved.

2. Patient A14 (3/22/10). For the stated problem "Risk for self harm," the long-term goal was "Display safe behavior." This goal was not measurable as stated; the plan did not specify what specific behaviors would be considered "safe." Non-measurable short-term goals were "...compliant in taking meds as order [sic]" and "identify 3+ coping skills that he can use during hard times." It was unclear how often the patient would need to take the prescribed medications to be considered "compliant" or what behaviors would be considered positive coping skills. None of the short-term goals had listed target dates.

3. Patient B1 (4/4/10). For the stated problem "Risk for self harm," the long-term goal was "Pt. will demonstrate a stable mood, and safe behaviors to self and others, by the discharge date determined by the Treatment Team." This goal is not measurable since it is unclear what behaviors the staff would consider "stable mood" or "safe behaviors." The short-term goal "...Pt. will verbalize to staff when feeling unsafe" also is not measurable; there is no way to determine whether the patient is sharing unsafe thoughts and feelings. None of the short-term goals on the MTP had target dates for achievement.

4. Patient B16 (4/4/10). For the stated problem "Risk of harm to self/others," the long-term goal was "Pt. will demonstrate a stable mood and safe behavior to self and others (not measurable as stated). The short-term goal "Identify 3 triggers and 3 positive coping skills...Pt. will utilize coping skills identified 100% of the time" also is not measurable as stated.

5. Patient F9 (last MTP update 3/23/10). One of the long-term goals on this patient's current MTP was "will have all services in place prior to discharge." This goal is not a measurable patient behavior to be achieved but is a goal for staff. For the problem " Altered Thought Process," a patient goal was "process sxs [symptoms] and + coping in groups." It was unclear how this goal would be measured. The other short-term patient goals for this problem were stated as staff interventions instead of patient outcome behaviors.

6. Patient C5 (3/26/10; update 4/8/10). For the problem "Risk of self harm and others," the long-term goal was "Pt. will demonstrate a stable mood and safe behaviors to self and others..." The plan did not specify what specific behaviors would indicate "stable mood" or "safe behaviors." The short-term goal "...Pt will verbalize to staff when feeling unsafe" is also not measurable. For the problem "Ineffective Coping," a short-term goal was "Pt. will identify at least 2 coping strategies/options when needed. This goal is not measurable as stated. There also was no target date for the patient's achievement of this goal.

7. Patient T4 (3/19/10; update 4/1/10). For the problem "Risk for harm to self/others," the long-term goal was "Pt. will demonstrate a stable mood and safe behaviors to self and others." This goal is not measurable as stated. The short-term goals were "...Pt will verbalize to staff when feeling unsafe" and "Identify 3 triggers and 3 positive coping skills." There would be no way for staff to know whether the patient verbalized his feelings. It also was unclear how staff would agree on what behaviors were "positive coping skills." There were no target dates for any of the problems on the plans to address the problems of "Family Issues," Emotional [sic] Dysregulation," or "Ineffective Coping."

8. Patient T8 (3/30/10). For the problem "Risk for harm to self harm [sic]," the long-term goal was "Pt will demonstrate a stable mood and safe behaviors to self..." This goal is not measurable unless the staff has a consistent way of determining "stable mood" and "safe behaviors." The short-term goals were "...Pt will verbalize to staff when feeling unsafe" and "Identify 3 new positive coping skills to use." These goals also were not measurable (see comment at Patient T4 citation).

Based on record review and interview, the facility failed to provide individualized and focused interventions for 7 of 8 active sample patients (A4, A14, B1, B16, C5, T4 and T8). The staff interventions for these patients were generic tasks for specific disciplines instead of individualized interventions based on assessed patient needs, and they failed to specify the treatment modalities that were to be used for the interventions. In addition, the MTPs for patients A4 and A14 lacked physician interventions, and those for patients A4, A14, C5 and T8 had no social work or activity therapy interventions. These deficiencies result in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed.

Findings are:

A. Record Review (MTP dates in parentheses)

1. Patient A4 (3/31/10; update 4/9/10). The Case Management/Clinical Therapist intervention listed for the identified problem "Coping Skill [sic]...as evidenced by...inappropriate racial comment" was "Meet c [with] pt. Review community supports. Colleral [sic] contact, assist c [with] aftercare." These were generic tasks for a social worker, and they did not specifically address the stated problem. The MTP did not specify which scheduled unit activities the patient was to attend, and there were no physician, OT or RT interventions on the plan.

2. Patient A14 (3/22/10). For the stated problem "Risk for self harm," the Nursing intervention was "Monitor mood/behavior and assist in giving meds as ordered." The Case Management/Clinical Therapist intervention was "Meet c pt, review comm. [community] supports, explore housing option and arrange for aftercare." These interventions were generic tasks for nursing and social work, not specific interventions to address the stated problem. There were no physician or activity therapy (OT/RT) interventions on the plan. The MTP did not specify what modalities were to be used or what unit activities the patient was to attend.

3. Patient B1 (4/4/10). The MTP only included the following generic discipline tasks for the problem "Risk for self harm:" Physician: "Assess for psychosis and dangerousness, Rx meds"; Nursing: "Monitor patient's mood and behaviors, intervene as needed. Assist Patient in identifying and meeting treatment goals. Assist Pt. to verbalize her thoughts and feelings. Teach and manage medications as needed"; Case Management/Clinical Therapist: "Meet c patient, assist c aftercare, collateral contacts, & review community supports." The MTP did not specify what modalities were to be used or what unit activities the patient was to attend.

4. Patient B16 (4/4/10). The MTP only included generic tasks for the problem "Risk of harm to self/others." These were: Physician - "Monitor mental status, adjust meds as tolerated." Nursing - "Monitor pt. mood and behavior, intervene prn [as needed], keep pt. safe and teach + coping skills. Teach and manage medication as needed." Case Management/Clinical Therapist: (Same as for Patient B1 above). The treatment plan did not specify what modalities were to be used or which unit activities the patient was to attend.

5. Patient C5 (3/26/10; update 4/8/10). For the problem "Risk for self harm and others," the MTP only listed generic tasks for the physician and nurse (monitoring for safety; medications; encouraging attendance in structured activities). There was a patient goal to participate in all structured unit activities. However, there were no social work, OT, or RT interventions to support this goal. The MTP listed no staff interventions for the problem "Ineffective Coping." Review of incident reports for March/April 2010 revealed that this patient had multiple episodes of Seclusion/Restraint for aggressive behaviors from 3/26/10 (admission) thru 4/12/10 (beginning of survey). However, the MTP did not include a behavioral plan or other multidisciplinary efforts being used to de-escalate the patient's aggressive behaviors.

6. Patient T4 (3/19/10). For the problem "Risk for harm to self/others," the MTP only listed generic tasks for the physician, nursing, and Case Manager/Clinical Therapist (same as those for patient B16). There were no OT or RT interventions for this problem. For the problem "Ineffective Coping," the plan only included interventions for the OT staff; for the problem "Emotion [sic] Dysregulation," the plan only listed an intervention for the "Ropes Department (Recreational Therapy)." There were no staff interventions for the problem "Family Issues." The MTP did not specify what scheduled unit activities the patient was to attend.

7. Patient T8 (3/30/10). For the problem "Risk for harm to self harm [sic]," the MTP only listed generic tasks for the physician and nurse (monitoring for safety; medications; encouraging verbalization of thoughts and feelings). There were no listed interventions for the Social Work Case Manager, the Clinical Therapist, or for OT or RT staff. The MTP did not specify what scheduled unit activities the patient was to attend.

B. Interview

1. In an interview on 4/12/10 at 11:15 a.m., Patient A14 was asked about his treatment plan and activities on the unit. He could not identify any specific activities that he attended, and could not name any staff members who worked with him.

2. In an interview on 4/12/10 at approximately 10:00 a.m., RN Y2 was asked which group activities (of those listed on the daily schedule of unit activities) that Patients A4 and A14 were assigned to attend. RN Y2 replied, "Patients are expected to attend all the unit activities."

3. In an interview on 4/12/10 at 11:30 a.m., Patient A4 was asked what things the staff was doing to help him. Other than medications, he could not name any specific interventions and/or treatment modalities. According to nursing staff reports and record notes, this patient spent the majority of his day, sitting in the hallway, writing in his journal. However, there were no staff interventions on the MTP related to this issue.

Based on record review and interview, the facility failed to specify the names of staff responsible for interventions on the Master Treatment Plans (MTPs) for 7 of 8 active sample patients (A4, A14, B1, B16, C5, T4 and T8). None of the interventions for patients A4, A14, B1, B16, C5 and T8 had assigned staff; those interventions were only listed as discipline functions. The MTP for patient T4 had no assigned staff for interventions on the "Acute Treatment Plan." The "Plan for Continuing Treatment" had missing staff names for one of the listed problems. Failure to specify the names of responsible staff for interventions diffuses responsibility and can result in patient's treatment needs not being addressed in a timely fashion.

Findings are:

A. Record Review (MTP dates in parentheses)

Review of the Master Treatment Plans (MTPs) for sample patients A4 (3/31/10; update 4/9/10), A14 (3/22/10), B1 (4/4/10), B16 (4/4/10; update 4/9/10), C5 (3/26/10; update 4/8/10) and T8 (3/30/10) revealed no staff names on the intervention lists. The only staff names on Patient T4's MTP (3/19/10; update 4/1/10) were those for an OT intervention (for the patient's problem "ineffective coping") and for the Ropes Department (RT intervention for the problem "Emotion Dysregulation").

B. Interview

1. In an interview on 4/12/10 at 3:50 p.m., the Director of Nursing agreed that the MTPs needed to include the names of staff responsible for the treatment interventions.

2. In an interview on 4/13/10 at 11:00 a.m., the Program Nurse Managers acknowledged that the MTPs did not identify the specific staff responsible for the listed interventions.

3. In an interview on 4/13/10 at 1:30 p.m., the Director of Social Work (Therapeutic Services) acknowledged the lack of social work signatures on the MTP interventions and said "Case Managers should put more notes in the treatment plans."

4. Each of the 2 Program Nurse Managers had put her name on the Face sheets of the Treatment plans (titled "Your Kahi Mohala Treatment Team"), but neither attended the Rx team meetings on the Adult Acute Units. In interviews, the floor nursing staff were not aware of the goals or interventions listed on the patients' Treatment plans, nor were any staff who would be responsible for the interventions. When asked about responsible staff on the plans, the staff referred the surveyors to the charge RN.

I. Based on observation, record review and interview, the facility failed to provide alternative interventions for 2 of 2 active sample patients (A4 and A14) on the Adult Acute Unit B and 1 of 1 active sample patient (F9) on the Forensics Unit when they did not participate in regularly scheduled treatment programming. These patients spent large blocks of time in their rooms or in the hallways in isolated activities. Failure to provide active treatment results in patients being hospitalized without all possible interventions for recovery being provided, potentially delaying the patients' improvement and discharge from the hospital.

II. Based on record review, interview and policy review, the facility failed to ensure for 1 of 1 active non-sample patients (B10) that physician orders gave nursing staff proper guidance on the administration of sedative antianxiety medications. For this patient, physician orders were written on a PRN (as necessary) basis for the generic conditions "anxiety" by a choice of delivery methods; nurses could choose to administer the medications by intramuscular injection ("IM") or by mouth ("po"). This failure resulted in nursing staff being required to function outside the scope of nursing practice.

III. Based on record review, policy review and interview, it was determined that the facility failed to ensure that physician's orders for combination sedative medications administered simultaneously (as chemical restraint) included specific parameters for their use with each patient, and that the orders were written specifically for each episode where chemical restraint was required for 2 of 8 active sample patients (active sample Patients B1 and B16) and additionally 11 non-sample Patients (from a total census of 31) in the Mokihana units (A&B). Additionally, these orders were written on admission on an "as needed" basis prior to being evaluated by a psychiatrist for two of the active sample patients (B1 and B16) and the 11 non-sample patients noted above. This resulted in physicians, via inappropriately written orders, giving nurses prescriptive authority for combination sedative medications that were being used as a means of chemical restraint as a matter of convenience for the medical and nursing staff and thus placing patients at risk of receiving restrictive measures without adequate medical supervision.

IV. Based on record review and interview, the facility failed to ensure that the medical problems identified at the time of admission for 1 of 8 active sample patients (B1) medical care were adequately monitored during the patients' hospitalization at the facility. Failure to address these problems compromised the patients' medical status; the patient required emergency transfer and care at a medical hospital, where he/she was admitted for cardiac observation.

Findings are:

I. Lack of Active Treatment

A. Adult Acute Unit

Observations on the Adult Acute Unit B on 4/12/10 (10:00 a.m. - 12:00 p.m.), 4/13/10 (11:30 a.m. -12:00 p.m.) and 4/14/10 (11:30 a.m. - 12:00 p.m.) revealed Patients A4 and A14 not participating in the scheduled treatment activities. During these times, Patient A14 was in his room; patient A4 was in his room or sitting alone in the hallway, writing in his journal. No alternative activities were offered to the patients during the observations.
1. Patient A14

a) While on the Adult Acute Unit B on 4/12/10 at approximately 10:40 a.m., the surveyor asked the staff if Patient A14 was participating in the MHS-led "Humor Group" in progress. RN Y2 responded, "No; he is in his room."

b) On 4/12/10 at 11:15 a.m., the surveyor met with Patient A14 who had declined to attend the OT group being held on the unit at that time. The patient stated that he did not usually attend groups offered on the unit. He could not name any other activities that he did with staff when he did not attend the treatment groups.

c) In an interview on 4/13/10 at 10:40 a.m., Patient A14's attending psychiatrist, Physician Y1 stated that the patient refused to participate in treatment activities on the unit. He could not name any specific alternative activities being provided (and none were on the treatment plan). He stated that he had recommended ECT for Patient A14, but the patient was not willing to receive this treatment.

d) Review of the medical record revealed this patient had been hospitalized since 3/22/10. A review of his medical record revealed no update of his MTP since admission. Progress notes for patient A14 revealed that this patient regularly refused to attend scheduled treatment activities on the unit. There were no documented efforts to provide alternative interventions.

2. Patient A4

a). On 4/12/10 at 11:30 a.m., the surveyor met with Patient A4 who had declined to attend the OT group being held on the unit at that time. The patient had slurred speech and was difficult to understand. When asked about his treatment, he could not explain anything about his treatment plan (other than name one medication) and could not say what unit activities he was supposed to attend. He was carrying a Bible and his journal and he pointed to them.

b) Review of the medical record for this patient revealed that the patient had been hospitalized since 3/31/10. The progress notes showed that the patient regularly refused to attend treatment activities on the unit. The MTP update of 4/9/10 stated "Pt. has had a couple of moments of agitation but has mainly controlled. Pt sits on unit and does self activities for hours." The MTP update sheet had no comments in the section "Progess on goals." There were no recommended changes in treatment other medication: "Pt started on Invega 3 mg po Q. AM."

B. Forensics Unit

1. While on the Forensic Unit on 4/12/10 (11:45 a.m.-12:00 p.m. and 3:00 p.m.-3:30 p.m.), the surveyor noted that sample Patient F9, admitted 9/19/08, was not participating in the scheduled activities being led by Mental Health Specialists. Staff stated that the patient had declined to participate in the unit activities and was in his room.

2. Review of Patient F9's medical record revealed that he was a 38 year old single male who had been hospitalized since 9/19/08 on involuntary status (court order) after being arrested for "threatening behavior on a bus." At the time of the survey (4/12/10), the patient continued to be on an "Extended 72 hour court hold." According to the record, the patient had a long history of mental illness: Axis I Diagnosis "Schizophrenia, Paranoid Type." He also had sustained a "traumatic brain injury" in a motor vehicle accident at age 16.
3. Review of the OT progress notes (initial 9/23/08; update 6/5/09; weekly notes for February/March 2010) noted that when first hospitalized, Patient F9 had participated in treatment. However, his functional status declined over time before he could be discharged. At time of the survey (4/12/10), he had not been regularly attending the unit group activities for several months. However, the MTP (last update 3/23/10) listed the patient's goal as "process - [negative] symptoms and + [positive] coping skills in psychoeducational groups." There was no evidence that alternative modalities had been recommended or were being used to address the patient's treatment needs.

4. Review of the Activity Therapy progress notes in Patient F9's medical record for the month of March, 2010 revealed that the patient had only participated in 2 of the 24 offered OT skills building groups and 3 of the 12 available RT groups. An OT progress note for the week of 3/21/10 read: "Pt. attended 1 (of 6) groups c [with] extra VC's [sic] from staff. Pt was finding difficult [sic] to stay in group-even c [with] 0 [no] interaction required." An RT note written on 3/24/10 read: "Pt came to his first AT [Art Therapy] group in many months. During check-in, he curiously spoke about how exciting the different groups were though he hasn't been to any groups for months. Pt. proceeded to engage in drawing of a different style than he used to, but then threw the paper away & returned to his room before group processing."

5. While on the Forensics Unit on 4/14/10 at 11:45 a.m., the surveyor queried the nursing staff about what alternative activities were offered to patients who did not attend regularly scheduled unit activities. Staff person Y3 replied that all patients are expected to attend regular programming, and that no alternative activities are offered on the Forensics Unit. She added that patients not attending unit activities stay in their rooms or do activities by themselves.

6. In an interview on 4/14/10 at 12:30 p.m, Patient F9 could not explain anything about his treatment except for the name of one medication. He said the he usually doesn't go to groups on the unit, even when reminded of them. When asked if staff did anything else with him when he did not go to the group activities, he said "No, I stay in my room".

II. Ambiguous Medical Orders

A. Record Review

Patient B10, was an active patient added to the survey sample after reviewing the medical record, as part of a review of the use of "prn" chemical restraint. The Physician's Orders stated the following: "4-8-10 1230 [time], Ativan 2 mg. po (orally) or IM (intramuscular) q4hrs (every 4 hours) NTE (not to exceed) 4 doses in 24 hours for agitation." [Note: There was no clarification that this was a PRN (as needed) order or a standard order.] The Medical Administration Record noted the following: "Lorazepam (Ativan) 2 mg tabs every 4 hours as needed PRN AGITATION [sic]by mouth NTE 4 doses in 24 hours OR Lorazepam 2 mg every 4 hours as needed intramuscular PRN AGITATION [sic]NTE 4 doses in 24 hours." There was no indication in the Physician Orders or Progress Notes that nursing staff obtained clarification of the original order to see if the dosing was meant as standard routine or "as needed" prior to transcribing the order as an "as needed" dosing. There was also no indication that nursing staff clarified the ambiguity of oral or intramuscular dosing or the ambiguity of the total dosing for a twenty four hour period. As written, it would be possible that the patient could receive 8 total doses instead of 4 total doses.

The patient received one dose of medication orally on 4/11/10 at 4:00 a.m., one oral dose on 4/12/10 at 5:20 a.m., and one oral dose on 04/13/10 at 7:30 a.m. Nursing notes for the 4/11/10 dose indicated the following: "Patient very needy- asking repeatedly for various items, going into patient's rooms. Tearful and saying [the patient is] afraid of everything." The nurse checked the box on a preprinted stamp for "anxiety" and wrote in the word "agitation". There were no similar preprinted stamped notes for the 4/12/10 dosing or for the 4/13/10 dosing in the record.

B. Interviews

In an interview on 4/13/10 at 2:45 p.m., RN Y4, who transcribed the original order, agreed that the order was ambiguous and stated that it was transcribed as a prn medication. Y4 said that neither the nurse nor the pharmacist called the physician to clarify the order. When asked how nursing staff would determine the route of administration, the nurse noted, "I would let the patient decide."

In an interview on 4/13/10 at 3:00 p.m., the unit nurse manager agreed that the order was ambiguous and that nursing staff should have called the physician for clarification before administering the medication to the patient.

In an interview on 4/13/10 at 2:15 p.m. the Medical Director agreed that the order was ambiguous and should have been written differently by the physician.

In an interview on 4/14/10 at 11:30 a.m., the patient confirmed that nursing asked if the patient wanted the medication "as a pill or a shot?" Each time the patient stated he/she chose the oral route.

III. Use of PRN Chemical Restraint

During routine review of active sample patient B1's medical record, the surveyor noticed that the Physician's Order sheet upon admission included the following order: 4/4/10 at 2200 [time]: "Risperidone (antipsychotic) 3 mg PO (oral) at bedtime; Haldol(antipsychotic) 5mg po or IM (intramuscular) prn agitation linked [to be given with other drugs labeled "linked"] q2hours (every 2 hours) NTE (not to exceed) 2 doses in 24 hours. Ativan (sedating benzodiazepine) 2 mg po or IM prn agitation linked q2hours NTE 2 doses in 24 hours. Cogentin (anticholinergic) 1mg po or IM prn agitation linked q2hours NTE 2 doses in 24 hours.

Further review found that active sample Patient B1 also had similar orders written on admission on 4/4/10 at 1:55 a.m. Patient B1 did receive all three medications (Haldol, Ativan and Cogentin) on 4/5/10 at 4:15 a.m.; the Medication Administration Record did not identify if the medication was given orally or intramuscular. On 4/5/10 at 1:30 p.m., the order was clarified by nursing staff to give the three medications at the same time, preferably by the oral route, and to give the three medications IM if the patient refused the oral route. B1 did receive all three medications again on 4/6/10 at 2:45 a.m.

This regimen of three medications was outside of Patient B1's usual regimen of antipsychotic medication, which was: Geodon 20 mg twice a day and Seroquel 400 mg each night. The combination was given to the patient in order to sedate him and therefore was a chemical restraint.

In an interview on 4/12/10 at 11:15 a.m. regarding the orders noted above, the unit medication nurse reported that the orders were written because "the attending physician didn't want to be called at night if the patient was out of control, and (the on-call physician) was trying to make things easier for the nurses."

In an interview on 4/12/10 at 1:20 p.m., the Director of Nursing agreed that the combination of medication was intended as chemical restraint and "should not have been written as a prn." She also noted that nursing staff should have clarified the orders before transcribing them.

A review of all the current active patient records revealed that 11active non-sample patients (out of a census of 31 acute adult patients on the Mokihana Unit) had similar orders written upon admission. Six of the 11 active non-sample patients received this combination of medications.

Hospital Policy #0500.0034, effective date 2/19/09, noted on page 3 under "13. Informed Consent for Psychotropic Drugs: a) Physician must complete [the consent form] with patient prior to starting psychotropic medications the patient is not already taking." Only one of the 13 patients noted above signed a medication consent form for Haldol.

The facility's Seclusion and Restraint [S/R] Policy #0800.0043, last revised 7/09, noted on page 1 under the section "Philosophy": "S/R shall never be used as coercion, discipline, and retaliation or for the convenience of staff...Any form of PRN or standing order for S/R is prohibited."

In an interview on 4/13/10 at 2:30 p.m., the Medical Director agreed that the physician should not have written the orders as prn and stated, "He (the on call physician) was probably just trying to make things easier for the nurses on a busy weekend."

IV. Insufficient Medical Care

A. Record Review

Patient B16, a 69 year-old, per the Admission History and Physical dated 4/5/10 and the Psychiatric Admission History dated 4/5/10, had a medical history of hypertension, coronary artery disease and myocardial infarction. The patient was admitted to the acute adult psychiatric unit on 4/4/10 for depressive symptoms.

On 4/6/10, Patient B16 developed hypotension and decreased mental status necessitating emergency transfer to an emergency department for evaluation and treatment. The patient was diagnosed with dehydration, hyperkalemia (high potassium) and evidence of an old CVA (cerebral vascular accident) and responded to fluids and was transferred back to the facility per Consultation Report by the facility's internal medicine physician dated 4/7/10 at 1730. The facility physician recommended: "encourage fluids and mixed diet without salt and hold Lisinopril (antihypertensive) 10mg until assessment on 4/9/10 and continue tid (three times a day) VS (vital signs)."

Physician Orders dated 4/7/10 at 1700 noted "1) continue to hold Lisinopril 10mgm po daily, 2) BP (blood pressure) and Pulse tid and ask MD to assess status on 4/9/10 re medication needs. (I have noted this and will follow up on 4/9 [MD's name]), 3) encourage mixed diet and fluids but no added salt or shoyu (soy sauce)."

There were no further physician orders within the medical record related to the orders noted above.

There were no physician progress notes or consultations by the internal medicine physician for the rest of the patient's hospital stay (discharged 4/14/10).

There was no evidence that the patient's medical condition was included as a problem for treatment in the patient's master treatment plan dated 4/7/10.

Vital Signs Log for Patient B16 noted three times a day vital signs for 4/8/10 but only once a day through 4/13/10.

On 4/13/10 at 1600, Patient B16 developed chest pain rated 10 out of 10 by the patient and a blood pressure of 193/92 (substantially elevated); Patient B16 was then transferred to an emergency department and subsequently admitted for cardiac observation.

B. Interview

In an interview on 4/14/10 at 10:15 a.m., RN Y2 noted that "we failed to follow through with the doctor's orders."

In an interview on 4/14/10 at 10:30 a.m., the unit nurse manager agreed that nursing "failed to follow through with doctor's orders and...the internal medicine physician failed to reevaluate the patient" between 4/7/10 and discharge.

In an interview on 4/14/10 at 10:50 a.m., the internal medicine physician initially could not recollect seeing Patient A14 for the original consultation on 4/7/10 and then stated, "I must have seen (Patient B16) on April 9th but I guess I didn't write a note or write any orders. I didn't know that (B16) went to the ER yesterday."

In an interview on 4/14/10 at 11:30 a.m., the Medical Director agreed that internal medicine failed to follow-up and that nursing staff failed to monitor the patient's vital signs as ordered.

The facility's Medical Director failed to supervise and monitor the following areas:

I. Based on record review and interview, the facility failed to document neurological examinations in such a way as for to verify the specific cranial nerve testing performed for 8 of 8 active sample patients (A4, A14, B1, B16, C5, F9, T4 and T8). This failure to document specific testing compromises the identification of pathology which may be pertinent to the current mental illness and compromises future comparative re-examination to assess patient's response to treatment interventions. Additionally, the facility failed to ensure that history and physical examinations were updated on an annual basis for 1 of 8 active sample patients (F9). (Refer to B109)

II. Based on record review and interview, the hospital failed to provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for 5 of 8 active sample patients (A4, A14, B1, B16 and C5). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

III. Based on record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion for 6 of 8 active sample patients (A14, B1, B16, C5, F9, and T4). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (Refer to B117)

IV. Based on record review and interview, the facility failed to develop comprehensive multidisciplinary Master Treatment Plans (MTPs) for 4 of 4 active sample patients residing on the Adult Acute Units (A4, A14, B1, B16), 1 of 1 active sample patient on the Children's Unit (C1), and 2 of 2 active sample patients on the Adolescent Unit (T4 and T8). The MTPs for the patients A4, A14, B1, C5, T4 and T8 were generated by the admitting RN before the multidisciplinary assessments had been completed. The plans to address the identified problems on these MTPs were poorly developed and lacked a multidisciplinary focus. The only team members routinely attending treatment planning meetings on the Adult Acute Units were the MD and RN, and there was insufficient documentation of other disciplines' involvement in treatment planning. The absence of integrated, comprehensive Master Treatment Plans hampers the staff's ability to provide coordinated treatment, based on data from multidisciplinary assessments, potentially resulting patients' treatment needs not being met. (Refer to B118)


V. Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for 7 of 8 active sample patients (A4, A14, B1, B16, C5, T4 and T8) that were based on patient strengths and disabilities. The MTPs for these patients did not sufficiently address active problems identified in the assessments and/or failed to specify how patient strengths would be utilized in treatment. This deficient practice diminishes the effectiveness of treatment interventions by not engaging patients through use of their strengths, with an awareness of their disabilities. (Refer to B119)

VI. Based on record review and interview, the facility failed to develop written Master Treatment Plans (MTPs) that included substantiated diagnoses for 4 of 4 active sample patients (A4, A14, B1 and B16) on the Adult Acute Units and 1 of 2 active sample patients (T8) on the Adolescent Unit. The "Axis I-IV" admission diagnoses for these patients were written on the "Acute Initial Treatment Plan" by the admitting RN before the multidisciplinary assessments had been completed. The only team members attending treatment team meetings on the Adult Acute Units were the attending physician (psychiatrist) and the RN in charge of the unit when the treatment planning meeting was held; there was no evidence that other team members were involved in discussions to substantiate the diagnoses. Failure to base treatment plans on substantiated diagnoses can potentially result in ineffective treatment and prolonged hospitalizations for patient (Refer to B120.)

VII. Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that included appropriate short-term and long-term goals for 8 of 8 active sample patients (A4, A14, B1, B16, F9, C5, T4 and T8). The MTP goals for these patients did not relate to the identified problem(s), were non-measurable, lacked dates for goal achievement, and/or were stated as staff goals for patient participation in program activities rather than patient outcomes. Failure to specify patient goals on MTPs hampers staffs' ability to provide goal-directed care and measure patients' responses to treatment, potentially resulting in prolonged hospitalizations. (Refer to B121.)

VIII. Based on record review and interview, the facility failed to provide individualized and focused interventions for 7 of 8 active sample patients (A4, A14, B1, B16, C5, T4 and T8). The staff interventions for these patients were generic tasks for specific disciplines instead of individualized interventions based on assessed patient needs, and they failed to specify the treatment modalities that were to be used for the interventions. In addition, the MTPs for patients A4 and A14 lacked physician interventions, and those for patients A4, A14, C5 and T8 had no social work or activity therapy interventions. These deficiencies result in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed. (Refer to B122.)

IX. Based on record review and interview, the facility failed to specify the names of staff responsible for interventions on the Master Treatment Plans (MTPs) for 7 of 8 active sample patients (A4, A14, B1, B16, C5, T4 and T8). None of the interventions for patients A4, A14, B1, B16, C5 and T8 had assigned staff; those interventions were only listed as discipline functions. The MTP for patient T4 had no assigned staff for interventions on the "Acute Treatment Plan." The "Plan for Continuing Treatment" had missing staff names for one of the listed problems. Failure to specify the names of responsible staff for interventions diffuses responsibility and can result in patient's treatment needs not being addressed in a timely fashion. (Refer to B123)

X. Based on observation, record review and interview, the facility failed to provide alternative interventions for 2 of 2 active sample patients (A4 and A14) on the Adult Acute Unit B and 1 of 1 active sample patient (F9) on the Forensics Unit when they did not participate in regularly scheduled treatment programming. These patients spent large blocks of time in their rooms or in the hallways in isolated activities. Failure to provide active treatment results in patients being hospitalized without all possible interventions for recovery being provided, potentially delaying the patients' improvement and discharge from the hospital. (Refer to B125 Part I)

XI. Based on record review, interview and policy review, the facility failed to ensure for 1 of 1 non-active sample patients (B10) that physician orders gave nursing staff proper guidance on the administration of sedative antianxiety medications. For this patient, physician orders were written on a PRN (as necessary) basis for the non-described conditions "anxiety" by a choice of delivery methods; nurses could choose to administer the medications by intramuscular injection ("IM") or by mouth ("po"). This failure resulted in nursing staff being required to function outside the scope of nursing practice. (Refer to B125 Part II)

XII. Based on record review, policy review and interview, it was determined that the facility failed to ensure that physician's orders for combination sedative medications administered simultaneously (and therefore as chemical restraints) included specific parameters for their use with each patient, and that the orders were written specifically for each episode where chemical restraint was required for 2 of 8 active sample patients (active sample Patients B1 and B16) and additionally 11 non-sample Patients (from a total census of 31) on the Mokihana unit (A&B). Additionally, these orders were written on admission on an "as needed" basis prior to patients being evaluated by a psychiatrist for two of the active sample patients (B1 and B16) and the 11 non-sample patients. This resulted in physicians, via inappropriately written orders, giving nurses prescriptive authority for combination sedative medications that were being used as a means of chemical restraint as a matter of convenience for the medical and nursing staff and thus placing patients at risk of receiving restrictive measures without adequate medical supervision. (Refer to B125 Part III)

XIII. Based on record review and interview, the facility failed to ensure that the medical problems identified at the time of admission for 1 of 8 active sample patient's (B16) medical care were adequately monitored during the patient's hospitalization at the facility. Failure to address these problems compromised the patient's medical status; the patient required emergency transfer and care at a medical hospital, where he/she was admitted for cardiac observation.. Additionally, The Medical Director was aware of this type of problem for at least the prior thirty days as evidenced by the following excerpt from Medical Executive Committee minutes dated 3/18/10, under "New Business": "Several of the medical staff expressed concern regarding patients needing consults and continued management for such medical conditions as diabetes." (Refer to B125 Part IV)

Based on observation, record review and interview, it was determined that the Director of Nursing failed to:

I. Ensure that all patients have immediate availability of an RN at all times. Observations on the Adult Acute Unit A and the Forensic Treatment Unit revealed the absence of the charge RN for 10-20 minute periods without the presence of another RN on the unit. This deficient practice poses a risk for patients and staff on the unit, and violates patient's rights to a safe treatment environment.

II. Ensure adequate RN supervision of Mental Health Specialists (MHS) conducting treatment groups for patients. Observations on the Adult Acute Units, the Forensic Unit, and the Adolescent Unit revealed MHSs using CDs and television programs for their scheduled patient groups without therapeutic discussions with patients. This practice results in patients not receiving the benefit of therapeutic programming.

III. Ensure that Master Treatment Plans (MTPs) for 7 of 8 active sample patients (A4, A14, B1, B16, C5, T4 and T8) included individualized and focused nursing interventions. The nursing interventions for these patients were generic tasks for nurses on psychiatric units instead of individualized interventions based on the patients' assessed needs. These deficiencies result in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed.

IV. Ensure that the Master Treatment Plans (MTPs) for 7 of 8 active sample patients (A4, A14, B1, B16, C5, T4 and T8) specified the names of nursing staff responsible for the assigned nursing interventions. None of the nursing interventions on these patients' MTPs had assigned staff members. Failure to specify the names of responsible staff for interventions diffuses responsibility and can result in patient's treatment needs not being addressed.

V. Ensure that alternative interventions were provided for 2 of 2 active sample patients (A4 and A14) on the Adult Acute Unit B and 1 of 1 active sample patient (F9) on the Forensics Unit when they did not participate in regularly scheduled treatment programming. These patients spent large blocks of time in their rooms or in the hallways in isolated activities. Failure to provide active treatment results in patients being hospitalized without all possible interventions for recovery being provided, potentially delaying the patients' improvement and discharge from the hospital.

VI. Ensure that the medical problems identified at the time of admission for 1 of 8 active sample patient's (B16) medical care were adequately monitored during the patient's hospitalization at the facility. Failure to address these problems compromised the patient's medical status; the patient required emergency transfer and care at a medical hospital, where he/she was admitted for cardiac observation.

Findings are:

I. Failure to ensure immediately availability of an RN

A. While on the Adult Acute Unit B on 4/12/10 at 11:45 a.m., the surveyor observed that the charge RN was absent from the unit. LPN X3 stated, "The RN is off of the unit right now, so I am the only license, so I'm in charge...."

B. While arriving on the Forensics Unit on 4/14/10 at 11:40 a.m., the RN surveyor requested to speak with the charge nurse. Staff person Y3 replied that the charge RN (Y1) had stepped off of the unit but would be back soon. RN Y1 did not return to the unit until 11:50 a.m. When arriving on the unit, RN Y1 stated that it is OK for the charge RN to leave the unit "for a few minutes" without obtaining other RN coverage, but that RN coverage is needed for extended leaves such as lunch breaks.

C. In a joint interview on 4/14/10 at 12:30 p.m., the Program Nurse Managers for the Adult Acute and Forensics Unit and the Child/Adolescent Units were asked about the RN charge nurses leaving their assigned treatments units when another RN is not on the unit. The Program Nurse Managers replied that brief RN absence from the unit is acceptable. They also noted that the RN charge nurses may leave their assigned units to respond to a Code Blue (emergency situations) on another unit, even if there is not another RN on the unit. The Program Nurse Managers also stated that there is sufficient RN staffing during the day shift to ensure continuous RN coverage on all treatment units, but that it is a challenge to maintain such coverage on the evening and night shifts.

II. Failure to ensure adequate RN supervision of MHS-led groups

A. While on the Adult Acute Unit B on 4/12/10 at 10:00 a.m., the RN surveyor observed a MHS group in progress. The focus of the group was "Humor Activity." The group activity was a DVD on the group topic, with eight patients attending. The MHS leader did not lead any group discussion during the observation. The MHS also could not tell the surveyor explain the goals for any of the patients attending the group.

B. While on the Forensics Unit on 4/12/10 at 3:00 p.m. the RN surveyor observed a scheduled MHS Activity Group in progress. The MHS group leader was sitting with 6 patients who were watching Dr. Phil on TV. When asked if this was the scheduled activity, the MHS replied "Yes." When queried about the goal of the activity or what specific patients were to learn from the group, the MHS leader had no answers.

C. While on the Mokihana units (A & B) at 11:00 am on 4/12/10, the surveyor observed a scheduled MHS Activity group in progress. The MHS leading the group placed a DVD into a player and told the patients to follow the instructions for Tai Chi (exercise). The MHS then left the group area in both parts of the unit to carry out other duties. The group was attended by 3 of 16 patients on the "B" unit and 5 of 15 patients on the "A" unit. The surveyor queried the group leader about the group attendance. The leader stated, "All patients are supposed to be in groups but it's hard to motivate these people to come to groups." He went on explain that this was "a substitute group time because the occupational therapist couldn't be here on time."

D. In a joint interview on 4/13/10, the Program Manager for the Adult Acute and Forensic Units stated that they were aware of the problem. They acknowledged that it has been a major challenge to orient and train the MHSs to do active treatment in their assigned groups.

III. Failure to ensure individualized nursing interventions on MTPs

A. Record Review (MTP dates in parentheses)

1. Patient A14 (3/22/10). For the stated problem "Risk for self harm," the nursing intervention was "Monitor mood/behavior and assist in giving meds as ordered." This intervention was a generic task for nursing, not a specific intervention based on patient assessments.

2. Patients B1 (4/4/10), C5 (3/26/10; update 4/8/10,) T4 (3/19/10) and T8 (3/30/10). The MTPs for these patients included the same generic nursing interventions to address the problem "Risk for self harm." The interventions were "Monitor patient's mood and behaviors, intervene as needed. Assist Patient in identifying and meeting treatment goals. Assist Pt. to verbalize her thoughts and feelings. Teach and manage medications as needed." These interventions were generic tasks for nursing, not specific interventions based on patient assessments.

3. Patient B16 (4/4/10). The MTP included the following generic nursing tasks to address the problem "Risk of harm to self/others:" "Monitor pt. mood and behavior, intervene prn [as needed], keep pt. safe and teach + coping skills. Teach and manage medication as needed." This intervention was a generic task for nursing, not a specific intervention based on patient assessments.

B. Interview

1. In an interview on 4/12/10 at 11:15 a.m., Patient A14 was asked about his treatment plan and activities on the unit. He could not identify any specific activities that he attended, and could not name any nursing staff members who worked with him.

2. In an interview on 4/12/10 at approximately 10:00 a.m., RN Y2 was asked which group activities (of those listed on the daily schedule of unit activities) that Patients A4 and A14 were assigned to attend. RN Y2 replied "All patients are expected to attend all the unit activities."

3. In an interview on 4/12/10 at 11:30 a.m., Patient A4 was asked what things the staff was doing to help him. Other than medications, he could not name any specific interventions and/or treatment modalities. This patient spent the majority of his day, sitting in the hallway, writing in his journal.

IV. Failure to ensure that MTPs included the names of nursing staff

A. Review of the Master Treatment Plans (MTPs) for sample patients A4 (3/31/10; update 4/9/10), A14 (3/22/10), B1 (4/4/10), B16 (4/4/10; update 4/9/10), C5 (3/26/10; update 4/8/10), T4 and and T8 (3/30/10) revealed no nursing staff names on the intervention lists.

B. In an interview on 4/12/10 at 3:50 p.m., the Director of Nursing agreed that the MTPs needed to include the names of staff responsible for the treatment interventions.

C. In an interview on 4/13/10 at 11:00 a.m., the Program Nurse Managers acknowledged that the MTPs did not identify the specific staff responsible for the listed interventions.

V. Failure to ensure alternative interventions for patients not participating in programming.

A. Observations on the Adult Acute Unit B on 4/12/10 (10:00 a.m. - 12:00 p.m.), 4/13/10 (11:30 a.m. -12:00 p.m.) and 4/14/10 (11:30 a.m. - 12:00 p.m.) revealed Patients A4 and A14 not participating in the scheduled treatment activities. During these times, Patient A14 was in his room; patient A4 was in his room or sitting alone in the hallway, writing in his journal. No alternative activities were offered to the patients during the observations.

B. On 4/12/10 at 11:15 a.m., the surveyor met with Patient A14 who had declined to attend the OT group that was currently being held on the unit. The patient stated that he did not usually attend groups offered on the unit. He could not name any activities that he did with nursing staff when he did not attend the treatment groups.

C. While on the Forensic Unit on 4/12/10 (11:45 a.m.-12:00 p.m. and 3:00 p.m.-3:30 p.m.), the surveyor noted that sample patient F9 was not participating in the scheduled activities being led by Mental Health Specialists. Nursing staff stated that the patient had declined to participate in the unit activities and was in his room. No alternative activities were offered by nursing staff.

D. While on the Forensics Unit on 4/14/10 at 11:45 a.m., the surveyor queried the nursing staff about what alternative activities were offered to patients who did not attend regularly scheduled unit activities. Staff person Y3 replied that all patients are expected to attend regular programming, and that no alternative activities are offered. She added that patients not attending unit activities stay in their rooms or do activities by themselves.

VI. Failure to assure that the identifed medical were adequately monitored:

A. Record Review:

Patient B16: Physician Orders dated 4/7/10 at 1700 noted "1) continue to hold Lisinopril 10mgm po daily, 2) BP (blood pressure) and Pulse tid and ask MD to assess status on 4/9/10 re medication needs. (I have noted this and will follow up on 4/9 [MD's name]), 3) encourage mixed diet and fluids but no added salt or shoyu (soy sauce)."

There were no physician progress notes or consultations by the internal medicine physician for the rest of the patient's hospital stay (discharged 4/14/10).

There was no evidence that the patient's medical condition was included as a problem for treatment in the patient's master treatment plan dated 4/7/10.

Vital Signs Log for Patient B16 noted three times a day vital signs for 4/8/10 but only once a day through 4/13/10.

On 4/13/10 at 1600, Patient B16 developed chest pain rated 10 out of 10 by the patient and a blood pressure of 193/92 (substantially elevated); Patient B16 was then transferred to an emergency department and subsequently admitted for cardiac observation.

B. Interview

In an interview on 4/14/10 at 10:15 a.m., RN Y2 noted that "we failed to follow through with the doctor's orders."

In an interview on 4/14/10 at 10:30 a.m., the unit nurse manager agreed that nursing "failed to follow through with doctor's orders and...the internal medicine physician failed to reevaluate the patient" between 4/7/10 and discharge.

In an interview on 4/14/10 at 11:30 a.m., the Medical Director agreed that nursing staff failed to monitor the patient's vital signs as ordered.