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Based on observation, interview, and record review, the hospital failed to ensure the GB effectively carried out its responsibilities for the conduct of the hospital as evidenced by:

1. Failure to review the contracted nutrition service on a regular basis for the provision of safe food handling and to ensure the hospital had a full time director of nutrition services. Cross reference to A83.

2. Failure to ensure the QAPI program's quality processes were designed and implemented to ensure the quality and safety of patient care. The contracted department of nutrition services failed to report quality studies or activities to the hospital committee and the grievance process quality indicator data was not analyzed to identify areas of improvement and an action plan developed. Cross reference to A273.

3. Failure to ensure the nutrition services were organized and directed by adequate staff to ensure safe food handling practices. Cross reference to A618.

4. Failure to ensure an active IC program to prevent the spread of infections in accordance with the hospital's P&Ps and nationally recognized infection control practices and guidelines. Cross reference to A747.

5. Failure to ensure the hospital's P&Ps for Violent Restraint/Seclusion and Management of Patient/Family/Visitor Complaints and Grievances were developed to meet the regulatory requirements. Cross references to A170, example #1 and A123, example #1.

The cumulative effect of these systemic failures resulted in the hospital's inability to provide quality healthcare to the patients in a safe environment.

Based on observation, interview, and record review, the hospital failed to ensure the GB reviewed the contracted nutrition service on a regular basis for the provision of safe food handling and ensure the hospital had a full time director of nutrition services. This failure resulted in unsafe food handling of patient food and had the potential to result in food borne illnesses in a patient population of 54.

Findings:

A review of the hospital's document titled Memorandum of Agreement dated June 2011 showed, "Although independently licensed by [the Department], the [acute care hospital] and the [neuropsychiatric hospital] have a unique relationship. The two facilities are part of the [main health system] and share the same governing body....In light of this unique relationship and proximity of the [two hospitals], the parties wish to enter into a formal agreement by which the [acute care hospital] agrees to provide certain necessary specialty and ancillary medical services to the [neuropsychiatric hospital] and its patients...Contracted Services: The [acute care hospital] shall provide the specialty and ancillary services....identified on Appendix 1 to patients of the [neuropsychiatric hospital] in the same manner as it provides such services to its own patients." A review of Appendix 1 of the document showed Nutritional Services as one of the contracted services provided by the acute care hospital.

During an interview with the DNS on 6/19/17 at 1100 hours, she stated she was the Director of Nutrition Services for the health system, which included three hospitals. The Director stated the health system provided food and nutrition services for this hospital and the hospital did not have its own kitchen or nutrition services. The Director further stated the hospital did not have a full time Director of Nutrition Services since all food and nutrition services were provided by the health system that covered the three hospitals.

During the course of the survey, unsafe food handling practices were observed that had the potential to result in food borne illnesses for the patients. Cross reference to A749, examples #1, 2, 3, and 4.

a. Potentially Hazardous Foods (PHF) were not cooled safely or monitored for safe cooling to prevent food borne illnesses;

b. Warewashing staff failed to perform hand hygiene between handling dirty and clean utensils;

c. Dietary and management staff were not knowledgeable on the safe washing of fresh produce; and

d. Bulk, dry panko breadcrumbs were not stored safely to prevent cross contamination and pest harborage.

During a follow-up interview with the DNS on 6/21/17 at 0800 hours, she stated the health system nutrition services department did not report any QAPI activities to the hospital's quality committee.

During an interview with the hospital's quality committee on 6/22/17 at 0935 hours, the Director of Quality stated the health system nutrition services department did not participate in the quality activities for the hospital.

During an interview with the hospital's GB on 6/22/17 at 1300 hours, the President-UCLA Health stated the GB conducts a comprehensive review quarterly of all aspects, top to bottom, of the hospital's operations. Upon further questioning, the President stated the contracted nutrition service was not reviewed. The President stated the GB considered nutrition services to be a "shared service" and did not consider it as a contracted service that required review.

Based on interview and record review, the hospital failed to ensure the legal representative of one of 30 sampled patients (Patient 25) was informed of the patient's rights in a language or manner that the patient's representative could understand. This posed the potential for the patient and/or the patient's representative to not be fully aware of or allowed to exercise the patient's rights.

Findings:

An interview and concurrent review of Patient 25's medical record was conducted with the Assistant Nursing Manager on 6/20/17 at 1000 hours. The patient was admitted to the hospital on 2/19/17.

Review of the Consults dated 2/19/17 at 0212 hours, showed Patient 25's representative was non-English speaking.

Review of the Declaration of Patients' Rights and Responsibilities and the Patients' Right Notification forms showed Patient 25's representative signed the forms on 2/19/17; however, the forms were written in English. There was no documented evidence showing the forms were interpreted in the language the patient's representative could understand.

The Assistant Nurse Manager confirmed the finding.

Based on interview and record review, the hospital failed to ensure a grievance was reviewed and completed timely for one of three nonsampled patients (Patient A). This created the increased risk of a failed grievance process.

Findings:

Review of the hospital's P&P titled Management of Patient/Family/Visitor Complaints and Grievances Policy revised 6/30/16, showed patient complaints and grievances shall be responded to and resolved in a timely manner. The appropriate Health Systems Office Grievance Committee Office will investigate and respond directly to the patient within 30 days of the time the grievance was filed.
An interview and concurrent review of the hospital's grievance process was conducted with Clinical Specialist 1 on 6/20/17 at 1500 hours. Patient A's grievance was randomly selected from the list of grievances provided by the Clinical Specialist for review on 6/20/17.

Review of the Confidential Grievance Form (Form #1-064) for Patient A showed a complaint was filed for the patient on 3/14/17. The allegations were harassment, quality/outcome of clinical care, staff behavior, and unprofessionalism.

Documentation showed Clinical Specialist 1 received this grievance on 3/15/17, and the grievance was forwarded by email to the Assistant Nurse Manager on 3/15/17 at 1549 hours. On 3/16/17, Nurse Manager 1 and the Assistant Nurse Manager responded they would follow up with the staff. However, documentation showed the investigation was not completed until 5/9/17. On 5/10/17, a letter was sent to the patient, almost 60 days after the grievance was filed.

During an interview and concurrent review of Patient A's grievance with Clinical Specialist 1 on 6/21/17 at 0800 hours, the Clinical Specialist confirmed Patient A's grievance was not resolved and a response sent to the patient within 30 days as per the hospital's P&P.

Based on interview and record review, the hospital failed to ensure the hospital's P&P for the grievance process was developed to include providing the patient with a written notice of its decisions. In addition, the hospital failed to ensure the written grievance resolution provided to two of three nonsampled patients reviewed for grievances (Patients A and B) were complete. For Patient B, no written response was provided to the patient for their verbal allegation of staff abuse. For Patient A, the written response provided did not include the results of the investigation.
These failures resulted in the increased risk of a failed grievance process.

Findings:

Review of the hospital's P&P titled Management of Patient/Family/Visitor Complaints and Grievances Policy revised 6/30/16, showed the following:

* A written complaint is considered a grievance. All verbal and written complaints regarding abuse, neglect, patient harm or privacy violation are considered grievances.

* If the grievance cannot not be resolved immediately, the Grievance Committee shall acknowledge receipt of the Grievance, in writing. The appropriate Health System Office Grievance Committee Office will investigate and respond directly to the patient within 30 days of the time the grievance was filed. The grievance response shall include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, results of the grievance process, and the date of completion.

1. During an interview and documentation review with Clinical Specialist 1 on 6/20/17 at 1500 hours, the Clinical Specialist stated she was designated to oversee the grievance process for the hospital. The Clinical Specialist stated she would talk to the patient and send a notice letter to the patient when the investigation was completed when the patient filed his/her complaints on the Confidential Grievance Form (Form #1-064). If the patient verbalized any concerns or complaints, she would not send a notice letter to the patient, but she verbally notified the patient of the investigation.

During an interview and concurrent review of the hospital's P&P for Management of Patient/Family/Visitor Complaints and Grievances Policy with Clinical Specialist 1 on 6/21/17 at 0800 hours, the Clinical Specialist confirmed the hospital's P&P did not address the requirement to provide the patient with a written notice of its decision as per the regulatory requirements.

2. From a list provided by the hospital on 6/20/17, the grievances for Patients A and B were randomly selected for review. The following was identified:

a. Review of the hospital documentation showed on 3/27/17 at 1009 hours, Patient B alleged CNA 1 assaulted and pushed the patient hard.

Further review failed to show a written notice letter was provided to the patient to address the above concern.

During an interview and concurrent document review with Clinical Specialist 1 on 6/20/17 at 1500 hours, the Clinical Specialist stated Patient B's complaint was about a staff assault on the patient. It was considered an abuse allegation and a grievance.

When asked, the Clinical Specialist confirmed no written notice of findings of an investigation was provided to the patient since this allegation was resolved within 24 hours and was not written on the Confidential Grievance Form (Form #1-064) to be considered as a grievance.

During an interview and concurrent review of Patient B's grievance with the Chief Clinical Social Worker on 6/21/17 at 1020 hours, the Social Worker stated Patient B's above allegation should be considered as an abuse allegation. The Social Worker stated the grievance process should have been implemented for this allegation.

b. Review of Patient A's Confidential Grievance Form (Form #1-064) dated 3/14/17, showed the patient alleged harassment, quality/outcome of clinical care, staff behavior, and unprofessionalism.

Further review showed the investigation was completed on 5/9/17. A notice letter was sent to Patient A on 5/11/17.

Review of the hospital's letter dated 5/11/17, signed by the Clinical Specialist, showed the staff member named in the grievance met with Nurse Manager 1 to discuss/review the alleged incidents. However, there was no documentation to show the written letter provided to the patient contained the results of the grievance process.

During an interview and document review with Clinical Specialist 1 on 6/21/17 at 0800 hours, the Clinical Specialist stated she received Patient A's grievance on 3/14/17, and the patient's grievance was sent to the Unit Manager on 3/15/17. The Unit Manager responded to the patient's grievance on 4/28, 5/2, and 5/9/17. The patient's grievance was closed on 5/10/17, and a final letter was sent to the patient on 5/11/17. When asked, she stated the results of the grievance process would not be included in the written letter provided to the patient due to safety issues. The Clinical Specialist confirmed the written response did not contain the results of the grievance process as per the regulatory requirements or the hospital's P&P.

Based on interview and record review, the hospital failed to ensure the admission and nursing staff completely assessed and documented the AD status for one of 30 sampled patients (Patient 23). This failure posed the potential for the healthcare provider to not being aware of or to not honor the patient's wishes.

Findings:

Review of the hospital's P&P titled Advance Directives (AD) revised 11/16 showed the purpose was to provide information regarding the requirements of the Federal Patient Self-Determination Act and the California Health Care Decisions Law regarding Advance Directives. The Act requires all institutional providers to provide information to all adult hospital patients regarding their right to create AD concerning health care decisions. The P&P showed the following:

* Written information regarding an individual's right to formulate an AD shall be provided to each adult patient (or emancipated minor) at the time of his or her admission and whenever requested by a patient.

* As part of the admission process for inpatients, the admissions representative shall provide each adult inpatient with information regarding AD and his/her rights to make health care decisions.

* The admissions clerk will indicate in the COA (Conditions of Admission), the receipt of an AD or completion of a Temporary AD form. The presence of an AD will also be recorded on the patient face sheet of demographic information.

Patient 23's medical record review was initiated on 6/20/17. The medical record showed Patient 23 was admitted to the hospital on 1/17/17, and was discharged on 2/27/17. The medical record also showed Patient 23 was previously admitted to the hospital on 11/28/11.

Review of the AD tab in the CareConnect (hospital electronic health care program) showed on 11/28/11, the nursing staff assessed and received the Advance Health Care Directive completed on 3/27/08.

Further medical record review failed to show Patient 23's AD was assessed for the admission of 1/17/17.

Review of the Terms and Conditions of Service Confidentiality of Information for the admission of 1/17/17, showed the following areas were left blank:

* I have an AD for health care.
* I have provided the hospital with a current copy of my AD.

During an interview and concurrent medical record review with Nurse Manager 1 on 6/20/17 at 1441 hours, the Manager stated Patient 23's AD was enduring from 11/28/11. When asked how to ensure if there was no change from the previous admission (six years ago) without assessing the status of Patient 23's AD, Nurse Manager 1 was not able to answer it. Nurse Manager 1 verified the status of Patient 23's AD was not assessed upon the admission.

Based on observation, interview, and record review, the hospital failed to ensure patient care was provided in a safe setting when the infection control surveillance program did not identify unsafe food handling practices. This could result in food borne illnesses when unsafe food was provided to the patients.

Findings:

1. Potentially Hazardous Foods were not safely cooled to prevent food borne illness. Cross reference to A749, example #1.

2. Warewashing staff failed to perform hand hygiene between handling the dirty and clean utensils. Cross reference to A749, example #2.

3. Dietary and management staff were not knowledgeable on the safe washing of fresh produce. Cross reference to A749, example #3.

4. Bulk, dry panko breadcrumbs were not stored safely to prevent cross contamination and pest harborage. Cross reference to A749, example #4.

Based on interview and record review, the hospital failed to ensure an allegation about one staff (CNA 1) assaulting and pushing one nonsampled patient (Patient B) was reported to the hospital's reporting systems (Descriptive Behavior and SOFI). This failure could result in the increased potential of unsafe environment for the patient.

Findings:

On 6/20/17, the grievance for Patient B was randomly selected for review. Review of Patient B's grievance showed Patient B alleged CNA 1 assaulted and pushed the patient hard.

An interview and concurrent review of the hospital's document was conducted with Clinical Specialist 1 on 6/20/17 at 1500 hours. The Clinical Specialist stated on 3/27/17 at 1009 hours, Patient B verbally complained CNA 1 assaulted and pushed the patient hard. She stated this complaint was considered as an abuse allegation. The patient's complaint was referred to the Assistant Nurse Manager for investigation. On 3/28/17, the investigation was completed; the allegation was unable to be substantiated; and the case was closed. The Clinical Specialist did not verbalize she reported this complaint as an abuse allegation to the hospital's reporting systems.

During an interview and concurrent review of the hospital's document with the Chief Clinical Social Worker on 10/21/17 at 1020 hours, she stated she was the designated staff to oversee abuse allegation or reporting of abuse allegation. She stated the above allegation should be considered as an abuse allegation. When asked, she was unable to find documented evidence showing this allegation was reported as an abuse allegation to the hospital's reporting system.

An interview and concurrent review of the hospital's document was conducted with the Director Human Resource, Clinical Specialist 1, Chief Clinical Social Worker, CNO, Director of Quality, and Clinical Specialist 2 on 6/22/17 at 0835 hours. When asked regarding the reporting of abuse, Clinical Specialist 2 stated the hospital had two reporting systems, the Descriptive Behavior (used to report the employee's behavior) and the SOFI (Safety Opportunities for Improvement). The Director Human Resource stated staff would report an abuse allegation to either system when a patient reported to the staff any abuse allegation. The hospital's staff was asked to provide documented evidence of the reporting for the above abuse allegation.

On 6/22/17 at 1200 hours, Nurse Manager 1 stated the above abuse allegation was investigated and was not substantiated. However, the requested documentation of the reporting for the above abuse allegation was not provided.

On 6/22/17 at 1430 hours, there was no further documentation provided as requested.

Based on interview and record review, the hospital failed to ensure the plan of care was reviewed and updated for one of two sampled patients (Patient 25) reviewed for the use of restraint or seclusion. This created the increased risk of the health care provider's lack of knowledge in providing care to the patient.

Findings:

Review of the hospital's P&P titled Violent Restraint/Seclusion dated 6/19/17, showed the use of restraint and seclusion shall be reviewed by the treatment team involved in the patient's care and reflected in the Master Treatment Plan.

Review of the hospital's P&P titled Treatment Planning Policy dated 5/1/14, showed Master Treatment Plan updates shall be updated whenever there is a significant change in the patient's condition or diagnosis.

An interview and concurrent review of Patient 25's medical record was conducted with the Assistant Nurse Manager and Clinical Specialist 1 on 6/20/17 at 1000 hours.

The patient was admitted to the hospital on 2/19/17. The patient was placed in the seclusion room for 90 minutes (from 1345 to 1515 hours) on 2/20/17, and for another 120 minutes (from 1915 to 2115 hours) on 2/21/17.

Review of the RN Seclusion/Restraint Assessment Note dated 2/20 at 1405 hours and 2/21/17 at 1017 hours, showed the nursing staff documented the use of less restrictive measures and rationale for the use of seclusion for Patient A on 2/20 and 2/21/17.

Review of the Master Treatment Plan signed by the physician on 2/21/17 at 2030 hours, showed Patient 25 required multiple PRN medications and seclusion for agitation.

However, there was no documentation to show the use of seclusion was reviewed by the treatment team and was reflected in the Master Treatment Plan when the patient was placed on seclusion on 2/20/17.

The Assistant Nurse Manager confirmed the finding.

Based on observation, interview, and record review, the hospital failed to ensure a P&P was developed to address the notification of the attending physician as soon as possible if the attending physician did not order the restraint or seclusion as required by this regulation and failed to define "as soon as possible."

In addition, the hospital failed to ensure the attending physician was consulted regarding the restraint order in a timely manner for two of two sampled patients (Patients 1 and 25) reviewed for the use of restraint and seclusion.

These failures posed the potential for the attending physician not knowing the patient's condition and being aware of the restraint intervention.

Findings:

Review of the hospital's P&P titled Violent Restraint/Seclusion revised 6/17 showed the following:

* In an emergency situation in which a patient is assessed to be at serious risk for self-harm or for harming others, a patient may be placed in physical or mechanical restraint or seclusion at the discretion of a RN. The treating physician must be consulted as soon as possible if the restraint or seclusion is not ordered by him or her.

* The attending physician/designee shall be informed of instances in which patients experience extended or multiple episodes of restraint or seclusion. The attending physician/designee shall be notified immediately of any instance in which a patient a) remains in restraint or seclusion for more than 12 hours; or b) experiences two or more separate episodes of restraint or seclusion, of any duration, within 12 hours. The attending physician/designee must conduct an in-person patient evaluation if the restraint or seclusion continues beyond 24 hours.

Review of the Inpatient Attending Physician's Role revised 7/10 showed the attending physician shall be contacted and apprised of an emergency situation as soon as possible by the resident, fellow or case coordinator. An emergency is defined as a situation where immediate care is necessary to preserve the life or prevent serious impairment of the health or well-being of a patient or others who might be directly affected by the patient.

1. The hospital's P&P for Violent Restraint/Seclusion did not specify the attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion as required by the regulation.

An interview and concurrent review of the hospital's P&P was conducted with Clinical Specialist 1 on 6/20/17 at 1000 hours. The Clinical Specialist was asked when the attending physician would be notified if a resident ordered the use of a restraint or seclusion. The Clinical Specialist stated the attending physician would be notified about the use of a restraint or seclusion if the patient remains in restraint or seclusion for more than 12 hours or experienced two or more separate episodes of restraint or seclusion within 12 hours. The Clinical Specialist did not verbalize the attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion.

During an interview and concurrent record review with Clinical Specialist 1 on 6/22/17 at 0909 hours, the Clinical Specialist verified the hospital's P&P did not address the definition of "as soon as possible" based on the needs of their particular patient population.

During a meeting with the hospital's administrative staff on 6/22/17 at 1315 hours, the hospital administrative staff was informed and acknowledged the hospital's P&P for Violent Restraint/Seclusion did not address the definition of "as soon as possible" and the attending physician must be consulted as soon as possible as required by the regulation.

2. Patient 1's medical record review was initiated on 6/19/17. The medical record showed Patient 1 was admitted to the hospital on 5/24/17.

Review of the physician's order dated on 6/2/17, showed a resident ordered to start physical hold at 2215 hours for Patient 1.

Review of the Inpatient Progress Note dated 6/5/17 (three days later), showed the attending physician acknowledged the physical hold applied to Patient 1 on 6/2/17. The Inpatient Progress Note also showed the assessment and plan for Patient 1 on 6/5/17. However, there was no documented evidence the attending physician was notified or consulted when the resident ordered the physical hold for Patient 1 on 6/2/17.

During an interview and concurrent medical record review with the Clinical Specialist 1 on 6/22/17 at 0909 hours, the Clinical Specialist stated the attending physician should be notified of the restraint on the next day during the daily rounding. When asked for documented evidence the attending physician was notified the following day of the restraint used for Patient 1 on 6/2/17, the Clinical Specialist was not able to provide it.


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3. An interview and concurrent review of Patient 25's medical record was conducted with the Assistant Nurse Manager and Clinical Specialist 1 on 6/20/17 at 1000 hours.

Review of Patient 25's medical record showed the patient was admitted to the hospital on 2/19/17. The patient was placed in the seclusion room for 90 minutes (from 1345 to 1515 hours) on 2/20/17.

Review of the Default Flowsheet Data for the use of a behavioral restraint for Patient 25 showed the patient was placed in the seclusion room on 2/20/17 at 1345 hours, due to kicking, hitting, biting, and threatening to harm self or others. However, there was no documented evidence to show the attending physician was notified when Patient 25 was placed on seclusion on 2/20/17 at 1345 hours.

Review of the physician's order dated 2/20/17 at 1408 hours, showed Resident 1 ordered the use of seclusion for Patient 25.

Review of the MD Seclusion/Restraint Assessments signed by Resident 1 on 2/20/17 at 1452 hours, failed to show the attending physician was consulted for the use of seclusion for Patient 25 on 2/20/17.

When asked, the Assistant Nurse Manager was unable to find documented evidence to show the attending physician was notified or consulted when Patient 25 was placed on seclusion on 2/20/17.

Based on interview and record review, the hospital failed to ensure one resident physician (Resident 1) was trained or had a working knowledge of the hospital's policy for the use of restraint or seclusion when Resident 1 ordered seclusion for one of two patients reviewed for restraints or seclusion (Patient 25). This failure created the increased risk of inappropriate care provided to the patient.

Findings:

Review of the resident appointment agreement form e-signed by Resident 1 on 10/7/16, showed to comply with all University, School, and Hospital rules, regulations, practices, procedures and policies, professional standards, and codes of ethics.

Review of Patient 25's medical record was initiated on 6/20/17. The patient was admitted to the hospital on 2/19/17. Resident 1 ordered the use of seclusion for the patient. The patient was placed in the seclusion room for 90 minutes (from 1345 to 1515 hours) on 2/20/17.

On 6/21/17, review of Resident 1's personal file failed to show documented evidence the resident was trained or had knowledge of the hospital's P&P for the use of Violent Restraint/Seclusion.

During an interview and concurrent review of Resident 1's personal file with Administrative Analyst 1 and Clinical Specialist 2 on 6/21/17 at 1515 hours, the Administrative Analyst stated it was a mandated requirement for residents to complete the Prevention and Management of Aggressive Behavior Training. This module included the use of restraint and seclusion. When asked, the Analyst was unable to find documented evidence to show Resident 1 completed the mandated training.

On 6/22/17 at 1430 hours, there was no further information provided by the hospital to show Resident 1 completed the training for the use of restraint and seclusion.

Based on observation, interview, and record review, the hospital failed to ensure their QAPI program's quality processes were designed and implemented to ensure the quality and safety of patient care provided as evidenced by:

1. Failure to ensure the QAPI program measured, analyzed, and tracked quality indicators for the nutrition service when the contracted Department of Nutrition Services did not report any quality studies or activities to the hospital's quality committee. Cross reference to A273, example #1.

2. Failure to ensure the quality indicator data for the hospital's grievance process was analyzed and action plans were developed for improvements in the grievance process. Cross reference to A273, example #2.

The cumulative effect of these systemic failures resulted in the hospital's inability to provide an efficient QAPI program and quality healthcare to the patients in the hospital.

Based on observation, interview, and record review, the hospital failed to ensure quality indicators for nutrition service were measured, analyzed, and tracked when the contracted department of nutrition services did not report any quality studies or activities to the hospital's quality committee. Deficient practices in nutritional services identified during the course of the survey were not identified by the hospital as potential high risk, high volume practices that required quality committee oversight. These failures had the potential to allow these unsafe food handling practices to continue without remediation.

In addition, the hospital failed to ensure grievance process quality indicator data was analyzed and action plans were developed for improvements in the grievance process. These failures could result in the patient's grievances not completely addressed.

Findings:

1. A review of the hospital document titled Memorandum of Agreement dated June 2011, showed, "Although independently licensed by [the Department], the [acute care hospital] and the [neuropsychiatric hospital] have a unique relationship. The two facilities are part of the [main health system] and share the same governing body....In light of this unique relationship and proximity of the [two hospitals], the parties wish to enter into a formal agreement by which the [acute care hospital] agrees to provide certain necessary specialty and ancillary medical services to the [neuropsychiatric hospital] and its patient ...Contracted Services: The [acute care hospital] shall provide the specialty and ancillary services ....identified on Appendix 1 to patients of the [neuropsychiatric hospital] in the same manner as it provides such services to its own patient." A review of Appendix 1 of the document showed Nutritional Services as one of the contracted services provided by the acute care hospital.

During the course of the survey, unsafe food handling practices were observed that had the potential to result in food borne illnesses for the patients. Cross reference to A749.

a. PHF were not cooled safely or monitored for safe cooling to prevent food borne illnesses;

b. Warewashing staff failed to perform hand hygiene between handling dirty and clean utensils;

c. Dietary and management staff were not knowledgeable on the safe washing of fresh produce; and

d. Bulk, dry panko breadcrumbs were not stored safely to prevent cross contamination and pest harborage.

During a follow-up interview with the DNS on 6/21/17 at 0800 hours, she stated the health system nutrition services department did not report any QAPI activities to the hospital quality committee.

During an interview with the hospital's quality committee on 6/22/17 at 0935 hours, the Director of Quality stated the health system nutrition services did not participate in the quality activities for the hospital. The Director stated an unusual event regarding nutrition services would be captured by the committee if there was a complaint, but no quality assurance or performance improvement activities were reported to the committee. The committee was not aware of the unsafe food handling practices that were noted during the survey process that had the potential to result in food borne illnesses in the patients.


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2. Review of the hospital's P&P titled Management of Patient/Family/Visitor Complaints and Grievances Policy dated 6/30/16, showed patient complaint data is reported to the leadership team of the hospital and directors of patient care areas at least on a quarterly basis, and is shared with the executive team and incorporated in the hospital's quality assessment and performance improvement plan. A summary of investigations and resolutions of all grievances will be presented at least annually to the GB or designee. The data and information regarding complaints and/or grievances will be used for performance improvement.

During the survey from 6/19 to 6/22/17, the following was identified:

* The hospital failed to ensure Patient A's grievance was reviewed and completed timely. Cross reference to A122.

* The hospital failed to ensure the P&P for the grievance process was developed to meet the requirement to provide the grieving patient with a written notice of its decisions. Cross reference to A123, example #1.

* The hospital failed to provide a written response to Patient B's grievance and failed to provide a written response describing the results of the grievance process for Patient A. Cross reference to A123, example #2.

On 6/22/17, review of hospital's document showed the summary of investigations and resolution of grievances were reported on a quarterly basis to the hospital's quality assessment and performance improvement program. The summary showed the reported information included the date of initial contact, the patient's name, location, description of the complaint, resolution of the complaint, and the level of severity.

However, further review failed to show documented evidence the collected data for investigation and resolution of the grievances were analyzed or any recommendations or action plans were developed to ensure the hospital's P&P for Management of Patient/Family/Visitor Complaints and Grievances Policy was implemented or met the regulatory requirements.

On 6/22/17 at 0940 hours, a meeting with the hospital staff was conducted to discuss the hospital's quality assessment and performance improvement program. The Director of Quality stated the quality assessment and performance improvement program also reviewed the summary of investigations and resolutions of grievances. This summary usually went to the MEC and GB and could go to other committees for review.

Clinical Specialist 1 stated patients' grievances were categorized into five levels. Level zero indicated there was no quality issue or no harm. Level four indicated significant quality issues or harm. Clinical Specialist 1 stated she summarized and reported the patients' grievance quarterly; she investigated case by case, tracked, trended and reported to the performance improvement program.

The Director was asked whether the summary of investigation and resolution of grievances were reviewed to ensure the hospital's P&P was implemented or whether recommendations were made to ensure the implementation of the hospital's P&P. The Director stated, no. Clinical Specialist 1 stated the hospital's P&P must be followed in order to close grievances.

The Director of Quality was informed and acknowledged the hospital's P&P for Management of Patient/Family/Visitor Complaints and Grievances Policy was not implemented as there was no recommended action to ensure the grievance process met the regulatory requirements.

Based on interview and record review, the hospital failed to ensure the nursing staff evaluated the care of two of 30 sampled patients (Patients 23 and 25) as evidenced by:

1. For Patient 23, the post fall intervention was not completely and timely implemented as per the hospital's P&P.

2. For Patient 25, the nursing staff failed to reassess the patient for suicidal risk at least once per shift as per the hospital's P&P and failed to show documented evidence 1:1 (one patient to one staff) care was provided to the patient on 2/19/17 from 0613 hours to 2335 hours, as per the nursing plan.

These failures had the potential for unsafe care to the patients.

Findings:

1. Review of the hospital's P&P titled Safety of the Patient (Post Fall/Post Fall Head Injury) revised 4/15 showed to obtain vital signs and perform neurocheck assessments every 30 minutes for two hours, then every two hours for 24 hours, then every four to eight hours or routinely as appropriate to the patient's condition for fall patients with a head injury or suspicion of a head injury. Neurochecks include GCS score, level of consciousness, and behavior changes.

The P&P also showed to perform hourly rounds by the RN/LVN/CCP to assess the following (the six Ps):
* Pain - check the patient's pain level and provide medicine if needed.
* Personal needs - offer help using the toilet; offer hydration, offer nutrition, empty commodes/urinals.
* Position - help the patient get in a comfortable position or turn immobile patients to maintain skin integrity.
* Placement - make sure patient's essential needs are within easy reach.
* Prevent Fall - ask the patient to put on the call light if the patient needs to get out of bed or needs to use the toilet or urinal.
* Pumps - ask the patient to put on call light if the patient needs to get out of bed and the pump is plugged in.

Review of the Fall Prevention Protocol revised 3/14 showed the GCS score estimates coma severity based on Eye (4 being the best eye response and 1 being the worst), Verbal (5 being the best response and 1 being the worst) and Motor (6 being the best motor response and 1 being the worst) criteria.

Patient 23's medical record review was initiated on 6/20/17. Patient 23 was admitted to the hospital on 1/17/17, and was discharged on 2/27/17. On 2/3/17 at 0350 hours, the patient fell to the ground after standing up from the toilet and reportedly hit her head.

Review of the Physician's Order dated 2/3/17 at 0433 hours, showed to perform neurochecks every two hours for Patient 23.

Review of the medical record showed the following:

* Vital signs were taken on 2/3 at 0400, 0430, and 0800 hours, and on 2/4/17 at 0858 hours. The vital signs were not taken as frequently as directed by the hospital's P&P.

* Neurochecks were performed on 2/3/17 at 0600 hours. However, further review of the medical record failed to show the neurochecks included the GCS score.

* The nursing note dated 2/3/17 at 1040 hours, showed the neurochecks were performed every two hours; However, there was no documentation to show the results of the neurocheck assessments including the GCS score, level of consciousness, and behavior changes.

During an interview and concurrent medical record review with Nurse Manager 1 on 6/21/17 at 1033 hours, the Manager stated the forms for documenting the GCS and the 6 Ps assessments and interventions were not available in the electronic medical record system. Nurse Manager 1 verified the post-fall protocol was not completely implemented for Patient 23.


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2. Review of the hospital's P&P titled Assessment/Reassessment of Inpatient revised 4/1/15, showed the following:

* Reassessment including suicidal risk, is performed by the health care team according to discipline-specific standards of care. The Assessment/Reassessment Matrix showed nursing reassessment occurs routinely at least once per shift or as necessary as patient condition warrants or as the change in clinical condition is manifested by subjective or objective criteria.

* Patients on "1:1" status are assigned a staff member who is to be with the patient at all times.

Review of Patient 25's medical record was initiated on 6/20/17. The patient was admitted to the hospital on 2/19/17.

Review of the Consults dated 2/19/17 at 0212 hours, showed Patient 25 was at moderate risk for self-directed violence with suicidal intent.

a. Review of the Default Flowsheet Data for suicidal risk assessment failed to show the nursing staff reassessed Patient 25's suicidal risk at least once per shift for 24 hours (from 2/19 at 1000 hours to 2/20/17 at 1000 hours), for 56 hours (from 2/20 at 1300 hours to 2/22/17 at 2100 hours), and for 58 hours (from 2/26 at 1000 hours to 2/28/17 at 2000 hours).

During an interview and concurrent review of Patient 25's medical record with the Assistant Nurse Manager on 6/20/17 at 1000 hours, the Assistant Nurse Manager confirmed the nursing staff should conduct the suicidal risk assessment every shift or every 12 hours. When asked, the Assistant Nurse Manager was unable to find documented evidence to show the nursing staff reassessed Patient 25's suicidal risk for the above dates.

b. Review of the End of Shift Summary dated 2/19/17 at 0613 hours, showed Patient 25 was unpredictable. The plan was "1:1."

Review of the End of Shift Summary dated 2/19/17 at 1803 and 1815 hours, showed to "continue current plan." However, the form failed to show a "1:1" was provided to Patient 25.

Review of the End of Shift Summary dated 2/19/17 at 2220 hours, showed to continue with the nursing care plan and monitor for safety. However, the form failed to show a "1:1" was provided to Patient 25.

Review of the End of Shift Summary dated 2/19/17 at 2335 hours, showed Patient 25 was asleep. The plan was "15 minute rounds."

An interview and concurrent review of Patient 25's medical record and the hospital's document was conducted with the Assistant Nurse Manager and CNO on 6/22/17 at 0900 hours. When asked, the Assistant Nurse Manager was unable to find documented evidence to show a staff member was assigned to Patient 25 at all times (1:1) on 2/19/17, from 0613 to 2335 hours as planned.

Based on interview and record review, the hospital failed to ensure the master treatment plan for three of 30 sampled patients (Patients 1, 5, and 23) was developed and individualized for each patient's needs. The lack of comprehensive treatment plan development may result to the interventions not being developed which could further compromise the patients' medical status.

Findings:

Review of the hospital's P&P titled Treatment Planning revised 5/14 showed the following:

* Master treatment plan updates shall be updated at least on a weekly basis for inpatients, or whenever there is a significant change in the patient's condition or diagnosis. An update shall consider the patient's response to care.

* The master treatment plan shall include:
- Specific goals, both short-term and long-term.
- Specific treatment modalities/interventions utilized, including a description of planned services, activities and programs, and initials of responsible service provider.
- Documentation of patient/family participation in the formulation of the plan.

* The case coordinator shall enter a summary progress note addressing assessment of the patient's progress in achieving the goals established in the current treatment plan weekly for inpatients.

1. Patient 1's medical record review was initiated on 6/19/17. Patient 1 was admitted to the hospital on 5/24/17.

Patient 1's Master Treatment Plan dated 5/26/17, showed the short term goals included six to eight hours sleep at night without daytime naps, attend and participate in at least three therapeutic activities daily, and to comply with the medication regime daily.

The Master Treatment Plan also showed the following multidisciplinary interventions:
* Physician interventions.
* Physician/Case Coordinator interventions.
* Nursing interventions.
* Social worker interventions.
* Occupation therapy interventions.

Review of the Treatment Plan Update dated 6/2, 6/9 and 6/16/17, showed the same multidisciplinary interventions as initiated on 5/26/17. In addition, there was no documented evidence the elements were addressed in short term goals and Patient 1's progress in the current treatment plan were evaluated.

On 6/20/17 at 0849 hours, the Assistant Nurse Manager verified the above findings.

2. Patient 5's closed medical record review was initiated on 6/19/17. Patient 5 was admitted to the hospital on 6/6/17, and discharged on 6/19/17.

Review of the Master Treatment Plan, under the social work interventions dated 6/9/17 at 1129 hours, showed to encourage expression of feelings in group situations in milieu.

Review of the social worker's note dated 6/9/17 at 1436 hours, showed Patient 5 attended group activity and excused herself after the explanation of what would be discussed. The note also showed Patient 5 verbalized the group activity would not be a good fit for her.

Review of the Master Treatment Plan dated 6/16/17, showed the multidisciplinary interventions including the social work interventions were not updated and were the same as the initial treatment plan. There was no documented evidence to show the social worker communicated with the other disciplinary team members and the treatment plan was updated in accordance with the patient's response to care.

On 06/21/17 at 0921 hours, the Chief Clinical Social Worker verified the above findings.

3. Patient 23's closed medical record review was initiated on 6/20/17. Patient 23 was admitted to the hospital on 1/17/17, and was discharged on 2/27/17.

Patient 23's Master Treatment Plan dated 1/19/17, showed long-term and short-term goals. The short term goal included to initiate interaction with staff and peers at least two times daily, report a decrease in at least two or more symptoms for two consecutive days, and to have six to eight hours of sleep at night without daytime naps. The Master Treatment Plan also showed the following multidisciplinary interventions:

* Physician interventions.
* Physician/Case Coordinator interventions.
* Nursing interventions.
* Social worker interventions.
* Occupation therapy interventions.

The Master Treatment Plan showed the bio-psycho-social formulation was included under the review and approval of the multidisciplinary treatment plan.

Review of the Treatment Plan Update dated 1/26/17, showed only comments. The form did not include long term or short term goals, or multidisciplinary interventions. In addition, the Treatment Plan Update contained the same documentation as addressed in the bio-psycho-social formulation initiated on 1/19/17.

Review of the Treatment Plan Update dated 2/2/17, showed the same format and the documentation as the previous treatment plan update.

Review of the nursing note dated 2/3/17 at 0350 hours, showed Patient 23 had a fall.

Review of the Treatment Plan Update dated 2/10/17, showed no update from 2/2/17, and the Update failed to show a post-fall assessment and any interventions developed.

Review of the Treatment Plan Update dated 2/17/17, showed to plan on adjunctive treatment due to the poor response to multiple medication trials under the same format as the previous treatment plan update.

Review of the Treatment Plan Update dated 2/24/17, showed to add augmentation of Patient 23's support system for discharge plans.

During an interview and concurrent medical record review with Nurse Manager 1 on 6/21/17 at 0839 hours, the Manager verified the treatment plan did not include the evaluation of short/long-term goals and the progress in the treatment plan.

Based on observation, interview, and record review, the hospital failed to ensure their P&P on medication administration was implemented when RN 6 removed four patients' medications from the ADS and left them unattended. In addition, the hospital failed to ensure the nursing staff assessed or documented the reason why the medication was administered to one of 30 sampled patients (Patient 7). These failures had the potential to expose the patients to avoidable medication errors.

Findings:

1. Review of the hospital's P&P titled Administration of Medications by Authorized Nursing Staff, 400 dated 6/17 showed "... Medications shall not be left unattended..."

On 6/20/17 at 0830 hours, during an observation on 4 North, RN 6 informed RN 4 that she pulled the morning medications for the RN's patients. Further investigation revealed RN 6 left the patients' medications in the medication room unattended.

During an interview on 6/21/17 at 1030 hours, RN 6 acknowledged she removed four patient's medications from the ADS and left them unattended while attending to other patient care activities. RN 6 also stated only a single patient's medications should be pulled at a time for administration.


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2. An interview and concurrent review of Patient 7's medical record was conducted with the Interim Manager on 6/19/17 at 1400 hours. The patient was admitted to the hospital on 6/18/17 at 0700 hours.

Review of the physician's order dated 6/18/17 at 0758 hours, showed an order for hydroxyzine (a medication used for anxiety) 25 mg every six hours as needed for anxiety.

Review of the Medication Administration Report showed the nursing staff administered hydroxyzine to Patient 7 on 6/18/17 at 2140 hours.

When asked, the Interim Manager was unable to find documented evidence to show the reason why the hydroxyzine was administered to Patient 7 on 6/18/17 at 2140 hours. The Interim Manager stated the nursing staff should document the reason why the hydroxyzine was administered.

Based on observation, interview, and record review, the hospital failed to ensure the medication discharge instructions for two of the three discharged patients reviewed (Patients 10 and 23) were clearly and completely documented. This failure increased the risk for the patients to not be fully informed on the medications they were taking, and how to take the medications safely.

Findings:

Review of the hospital's P&P titled Medication Reconciliation, NPH 1414 revised 6/19/17, showed at discharge, the responsible MD documents a complete list of medications at discharge (including non-psychotropics drugs) and including medications that may be prescribed by another physician in the electronic health record.

1. Patient 23's closed medical record review was initiated on 6/20/17. The medical record showed Patient 23 was admitted to the hospital on 1/17/17 and was discharged on 2/27/17.

a. Review of the physician's Discharge Summary dated 2/27/17, showed the following discharge medications:

* duloxetine DR (antidepressant medication) 60 mg; take two capsules (120 mg total) by mouth daily.

* fluticasone (a steroid) 50 mcg/spray nasal spray; spray two sprays in each nare at bedtime.

* tramadol (pain medication) 50 mg; take two tablets (100 mg total) by mouth three times daily as needed.

* trazodone (an antidepressant)100 mg; take one tablet by mouth at bedtimes for three days.

However, review of the Discharge Instructions provided to the patient dated 2/27/17, showed the following medications were listed:

* duloxetine DR 60 mg; take two capsules (120 mg total) by mouth daily for major depressive disorder and musculoskeletal pain.

* duloxetine DR 60 mg; take one capsule by mouth daily.

* fluticasone 50 mcg/spray nasal spray; spray two sprays in each nare at bedtime for signs and symptoms of nose diseases.

* fluticasone 50 mcg/spray nasal spray; spray two sprays in each nare at bedtime for three days as directed.

* trazodone 100 mg; take two tablets (200 mg total) by mouth at bedtime for three days.

* trazodone 100 mg; take one tablet by mouth at bedtime for three days.

* modafinil (a CNS stimulant) 200 mg; take one tablet by mouth daily- this medication was listed two times on the instruction.

* pregabalin (for complex regional pain syndrome) 100 mg; take one capsule by mouth three times daily- this medication was listed two times on the instruction.

* quetiapine (antipsychotic medication) 25 mg; take one tablet by mouth three times daily as needed for anxiety- this medication was listed two times on the instruction.

* quetiapine 300 mg; take one tablet by mouth at bedtime for depression - this medication was listed two times on the instruction.

There was no documentation found in the medical record to show Patient 23 received clarification regarding the duplicate medications and different dosages for the same medications prior to discharge.

b. Further review of the Discharge Instructions dated 2/27/17, showed to take tramadol 50 mg tablet. However, there were no instructions to the patient for the route, frequency to take the medication, or an indication for use listed for the medication.

On 6/21/17 at 0839 hours, Nurse Manager 1 verified the above findings.


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2. On 6/19/17 at 1309 hours, Patient 10's closed medical record was reviewed. Patient 10 was in the outpatient clinic for the Adult Partial Program. Review of Patient 10's discharge instructions dated 6/15/17, showed Patient 10's current medications were the following:

* Drospirenone-Ethinyl Estradiol (oral contraceptive); take by mouth. However, there was no documentation of the dose, frequency of how often to take the medication, or indication for use listed for the medication.

* Trazodone (sedative and antidepressant medication) 50 mg tablet; take one tablet (50 mg) by mouth at bedtime as needed for sleep. However, there was also a duplicate listing for trazodone 50 mg tablet with instructions for the patient to take two tablets (100 mg) by mouth at bedtime with no indication for use listed.

Review of the medical record failed to show documentation the above medications were clarified with Patient 10 prior to his discharge.

On 6/19/17 at 1440 hours, an interview was conducted with MD 1 and the Chief Administrative Officer. MD 1 explained the medication ordering was done on the EHR. MD 1 stated this same functionality was used on the discharge template for the patient's discharge instructions. MD 1 demonstrated the ordering function for medications on the EHR; how to order the specific medication, the dose, route, frequency, and duration for the medication. However, when MD 1 demonstrated how to order a medication's indication for use, he was unable to do so until the surveyor pointed out a drop-down link where the indications for use and a free text option was available to complete the order. MD 1 stated it was his first time seeing this menu on the ordering function. The Chief stated the medication ordering functionality was updated and only recently went "live" a few months prior. The Chief stated all the medical staff was trained on the new function; however, further teaching should be done to ensure complete ordering of medications including the dose, route, frequency, indication for use, and clarification of medication duplicates so a patient is fully informed and educated on the discharge instructions.

On 6/19/17 at 1510 hours, the above findings were verified with the Chief Administrative Officer and Manager of the Adult Partial Program.

Based on observation, interview, and record review, the hospital failed to ensure the concentration of sodium bicarbonate syringes (used to treat metabolic acidosis) stored inside the emergency crash cart (used for storing medications and medical supplies needed during a medical emergency) on 4 West matched the concentration listed outside of the crash cart. This failure had the potential to result in delayed medication administration in an emergency.

Findings:

Review of the hospital's P&P titled Emergency Resuscitation Carts, HS 1324 dated 4/16 showed the Adult/Pediatric standard emergency cart medications Tray # 1 was last revised on 3/15, with the sodium bicarbonate 8.4% 50 ml.

On 6/19/17 at 1405 hours, the emergency crash cart on 4 West was inspected. Sodium bicarbonate syringe 7.5% 50 ml was listed outside the crash cart. However, the concentration of the sodium bicarbonate syringe 50 ml stored in the cart was 8.4%.

The PIC and Clinical Nurse Specialist acknowledged the finding.

Based on interview and record review, the hospital failed to ensure sterile pharmaceuticals were compounded in an area free from pathogens as evidenced by:

* Failure to identify at least the genus level, the microorganisms identified in the sterile compounding area environmental test as required by the USP.

* Failure of the hospital's P&P to address identification of microbial growth to the genus level when the viable air and surface environmental test report was positive for any microorganisms.

These failures had the potential to expose patients to contaminated compounded sterile products.

Findings:

Review of the hospital's P&P titled Pharmaceutical Services: Viable Air Sampling dated 12/16, showed "...Technical Safety Services (TSS) must perform viable air sampling at least semi-annually in conjunction with the recertification of primary and secondary engineering controls ...Viable air sampling shall be performed for each area where compounding is performed (example, all segregated compounding areas and the Reagan I.V. Additive Service)..."

The USP is a scientific, non-profit organization that sets the standards for the quality, purity, identity, and strength for medications manufactured and consumed worldwide. The USP is federally recognized as an authoritative source regarding minimum standards of safe practice applicable to both sterile and non-sterile compounding. The USP <797> (USP chapter 797) establishes the minimum standards of practice applicable when preparing, storing, and transporting CSPs to be followed by all health care personnel in any setting.

According to the USP <797>, regardless of the number of CFU of microorganisms identified, further corrective actions will be dictated by the identification of microorganisms recovered (at least the genus level - family or subfamily in the classification of organisms) by an appropriate credentialed laboratory of any microbial bioburden captured as a cfu. Highly pathogenic microorganisms (e.g. Gram-negative rods, coagulase positive staphylococcus, molds, and yeasts) can be potentially fatal to patients receiving compounded sterile products and must be immediately remedied, regardless of the cfu count, with the assistance of a competent microbiologist, infection control professional or industrial hygienist.

According to the CMS, USP <797> is the minimum applicable standards of practice for safe sterile compounding. Hospitals must ensure that they meet all currently accepted standards for the safe preparation and administration of compounded sterile products.

1. On 6/19/17 at 1330 hours, the IV compounding area environmental viable air testing reports were reviewed. The following was identified:

The report for March 2017 showed the following:

- Viable air sample had bacterial and fungal growth inside the laminar flow hood and bacteria growth in segregated area outside the hood.

The above test was repeated in April after cleaning. The April 2017 report showed no fungal or bacterial growth inside the hood; however, the segregated area outside the hood still had 26 colonies of bacterial growth (down from 85 colonies in 3/17).

The segregated area outside the laminar flow hood was cleaned and retested.

During the concurrent interview, the PIC acknowledged the above fungal and bacterial growths were not identified, contrary to the USP <797>.

2. On 6/20/17 at 1330 hours, the hospital's P&P titled Pharmaceutical Services: Viable Air Sampling dated 12/16 was reviewed. The P&P failed to address the identification of microbial growth to the genus level when the environmental viable air and/or surface sample tests showed any microorganism growth as required by the USP <797>.

On 6/20/17 at 1410 hours, the CPO and PIC acknowledged the above finding.

Based on observation, interview, and record review, the hospital failed to ensure outdated medications were not available for patient use when several outdated medications were found stored with in-date medications in the pharmacy. In addition, the hospital failed to ensure one single use vial and one single use bottle were discarded after one use. These failures had the potential for the patients to receive medications which might no longer provide their desired benefits.

Findings:

1. Review of the hospital's P&P titled Distribution and Security of Medications and Controlled Substances dated 6/14, showed "...Medicines shall not be kept in stock beyond the expiration date on the label ..."

On 6/19/17 at 1100 hours, during an observation in the pharmacy, the following outdated medications were observed stored with the in-date medications:

* 105 tablets of bethanechol chloride (medication used to treat urinary and bladder problems) 25 mg had expired on 12/16.

* 75 tablets of bethanechol chloride 10 mg had expired on 4/17.

* 52 tablets of amiodarone 200 mg (medication used to treat heart rhythm problems) had expired on 5/17.

* 100 tablets of captopril 12.5 mg (medication used to treat high blood pressure and heart failure) had expired on 1/17.

* One tablet of desmopressin acetate 0.1 mg (medication used to treat diabetes insipidus, bedwetting problems, and certain bleeding disorders) had expired on 3/17.

* One tablet of diltiazem 30 mg (medication used to treat high blood pressure and chest pain) had expired on 2/17.

The PIC acknowledged the above findings.

2. Review of the hospital's P&P titled Medication Administration, HS 1450 dated 3/15 showed "...Single dose vials and tubes are discarded after one use..."

a. On 6/19/17 at 1100 hours, during an observation in the pharmacy, a single use bottle of sterile water for irrigation 250 ml labeled with an opened date of 6/17/17, was found on the counter next to the laminar flow hood. The PIC acknowledged the bottle should be discarded after the initial use.

b. On 6/19/17 at 1355 hours, during an observation on 4 West, a needle punctured single use vial of sterile water for injection 10 ml was observed in a patient's cassette. The PIC and RN 5 acknowledged the finding.

The hospital failed to ensure the Condition of Participation, CFR 482.28 Food and Dietetic Services, was met by failing to:

1. Employ a full time Director of Nutrition Services to ensure safe food handling practices were followed and QAPI activities of the department were reported to the hospital committee. This failure had the potential for patients to be exposed to food borne illnesses and to allow unsafe food handling practices to continue without remediation. Cross reference to A619.

2. Ensure safe food handling systems were effective when unsafe food handling practices were not identified and remedied, including: a) potentially hazardous foods were not safely cooled to prevent food borne illnesses; b) warewashing staff failed to perform hand hygiene between handling dirty and clean utensils; c) dietary and management staff were not knowledgeable on the safe washing of fresh produce; and d) bulk, dry panko breadcrumbs were not stored safely to prevent cross contamination and pest harborage. These failures had the potential to result in food borne illnesses in a highly susceptible patient population. Cross reference to A749.

The cumulative effects of these systemic problems resulted in a failure of the hospital to deliver food and dietetic services in a safe and effective manner in compliance with the Condition of Participation for Food and Dietetic Services.

Based on observation, interview, and record review, the hospital failed to employ a full time Director of Nutrition Services to ensure safe food handling practices were followed and the QAPI activities of the department were reported to the hospital's quality committee. This failure had the potential for patients to be exposed to food borne illnesses and to allow unsafe food handling practices to continue without remediation in a hospital with a population of 54 patients.

Findings:

A review of the hospital document titled Memorandum of Agreement dated June 2011 showed, "Although independently licensed by [the Department], the [acute care hospital] and the [neuropsychiatric hospital] have a unique relationship. The two facilities are part of the [main health system] and share the same governing body....In light of this unique relationship and proximity of the [two hospitals], the parties wish to enter into a formal agreement by which the [acute care hospital] agrees to provide certain necessary specialty and ancillary medical services to the [neuropsychiatric hospital] and its patient...Contracted Services: The [acute care hospital] shall provide the specialty and ancillary services ....identified on Appendix 1 to patients of the [neuropsychiatric hospital] in the same manner as it provides such services to its own patient." A review of Appendix 1 of the document showed the Nutritional Services as one of the contracted services provided by the acute care hospital.

During an interview with the DNS on 6/19/17 at 1100 hours, she stated she was the Director of Nutrition Service for the health system, which included three hospitals. The DNS stated the health system provided food and nutrition services for this hospital. The hospital did not have its own kitchen or nutrition services. The DNS further stated the hospital did not have a full time Director of Nutrition Service since all food and nutrition services were provided by the health system that covered the three hospitals.

During the course of the survey, unsafe food handling practices were observed that had the potential to result in food borne illnesses for the patients. Cross reference to A 749.

a. Potentially Hazardous Foods were not cooled safely or monitored for safe cooling to prevent food borne illnesses;

b. Warewashing staff failed to perform hand hygiene between handling dirty and clean utensils;

c. Dietary and management staff were not knowledgeable on the safe washing of fresh produce; and

d. Bulk, dry panko breadcrumbs were not stored safely to prevent cross contamination and pest harborage.

During a follow-up interview with the DNS on 6/21/17 at 0800 hours, she stated the health system nutrition services department did not report any QAPI activities to the hospital's quality committee.

During an interview with the hospital's quality committee on 6/22/17 at 0935 hours, the Director of Quality stated the health system nutrition services did not participate in the quality activities for the hospital. The Director stated an unusual event regarding nutrition services would be captured by the committee if there was a complaint; however, no quality assurance or performance improvement activities were reported to the committee. The committee was not aware of the unsafe food handling practices that were noted during the survey process that had the potential to result in food borne illnesses in the patients.

Based on observation, interview and record review, the hospital failed to ensure an active IC program was developed and implemented to prevent the spread of infections in accordance with the hospital's P&Ps and nationally recognized infection control practices and guidelines as evidenced by:

* The hospital failed to ensure an effective system was in place to implement and evaluate measures governing the identification, reporting, prevention, and control of infections and communicable diseases. Cross reference to A749.

The cumulative effect of these systemic failures resulted in the hospital's inability to provide quality healthcare to the patients in a safe environment.

Based on observation, interview, and record review, the hospital failed to ensure the IC program had developed an effective system to implement and evaluate measures for identification, investigation, reporting, and preventing infections within the hospital as evidenced by:

1. Potentially Hazardous Foods were not safely cooled to prevent food borne illnesses.

2. Warewashing staff failed to perform hand hygiene between handling dirty and clean utensils.

3. Dietary and management staff were not knowledgeable on the safe washing of fresh produce.

4. Bulk, dry panko breadcrumbs were not stored safely to prevent cross contamination and pest harborage.

5. Two staff in the ECT treatment room did not perform hand hygiene in accordance with the hospital's P&P.

6. The ECT treatment room and medical equipment were not disinfected between patient use after Patient 13's procedure.

7. The teaching material and validation form for the glucometer cleaning was not consistent with the manufacturers' guidelines.

8. The BP cuff for single-patient use was used for multiple patients.

9. The hospital failed to ensure one IV bag and one IV tubing were labeled as per the hospital's P&P.

These failures had the potential to result in the increased risk of spreading infection to the patients in the hospital.

Findings:

1a. According to the United States Department of Agriculture, Food and Drug Administration 2013 Food Code for safe food handling, except during preparation, PHF shall be maintained at 135 °F or above, or at 41°F or below. In addition, PHF shall be cooled within four hours to 41 °F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness.

During a tour of the kitchen with the EC on 6/19/17 at 1120 hours, multiple containers of prepared salads were noted in the walk-in refrigerator. The surveyor's thermometer and the EC's thermometer were both inserted in the salads and registered the following:

* Quinoa salad - 48 °F and 49 °F, respectively.
* Chicken curry salad - 51.6 °F and 51 °F.
* Imitation crab salad - 56.3 °F and 57.2 °F.
* Tuna salad - 60.9 °F (EC's thermometer).

During an interview on 6/19/17 at 1125 hours, with DS 1, he stated he prepared the salads at 0630 hours, that morning and they were stored in the walk-in refrigerator for almost five hours. DS 1 stated he monitored the temperature of the salads every two hours and documented the temperatures on a log.

A review of the log titled Product Temperature Record dated 6/19/17, showed the following food temperatures:

- at 0600 hours, the tuna salad was 39 °F,
- at 0800 and 1000 hours, the tuna salad was 38 °F,
- at 0630 hours, the chicken curry and crab salads were 40 °F, at 0830 hours, they were 39 °F and at 1030 hours, they were 40 °F, and
- at 0630 hours, the quinoa salad was 39 °F, at 0830 hours it was 38 °F, and at 1030 hours it was 40 °F.

During an interview on 6/19/17 at 1140 hours, the EC stated the salads should be made from refrigerated ingredients. The EC stated cans of tuna should be stored in the refrigerator and he verified there were none in the refrigerator. The EC stated the documentation on the log was not consistent with the actual temperatures observed and the documentation was not accurate. The EC stated the log was signed by FSM 2, indicating the log was checked. The EC verified FSM 2 did not take temperatures of the actual salads to ensure the documentation was accurate.

b. According to the United States Department of Agriculture, Food and Drug Administration 2013 Food Code for safe food handling, cooked PHF shall be cooled: (1) Within two hours from 135 ºF to 70 °F; and (2) Within a total of six hours from 135 ºF to 41 °F or less. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness.

During a tour of the kitchen with the EC on 6/19/17 at 1330 hours, multiple cooked food items were observed stored in the food bank walk-in refrigerator. These cooked foods included meatloaf, cilantro chicken, Alfredo sauce, Mexican rice, and chicken tenders.

A review of the logs titled Cooling Temperature Log dated 6/15, 6/16, 6/17, and 6/18/17, showed these foods were not included on the monitoring logs.

During a concurrent interview with the EC, he stated these foods were cooked in the kitchen, cooled in the blast chiller (equipment used to rapidly chill cooked foods), and then stored in the refrigerator. All the foods were cooked and chilled between 6/16 and 6/18/17. The EC further stated the cooling temperatures were supposed to be logged to ensure adherence to the safe cooling practices. The EC was unable to explain why these foods were not on the log. The EC verified the usual supervisor's monitoring of staff practices was to monitor the information on the logs was consistent with safe cooling. There was no supervisor oversight system to ensure all cooked PHF were logged on the Cooling Temperature Log. The EC verified there was no way to guarantee the foods not on the log were safely cooled.

2. A review of the hospital's P&P titled Hand Washing revised 3/3/16, showed the purpose of the policy was, "To reduce risks for transmission of infection and contaminating food or food contact surfaces." It further stated, "Employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils ....after handling soiled equipment and utensils ...."

During an observation in the pot washing area on 6/19/17 at 1400 hours, DS 2 was asked to demonstrate the proper procedure for washing pots and pans. During the demonstration, DS 2 scraped and racked soiled utensils and placed them in the mechanical dishwasher. DS 2 then removed the clean utensils from the dishwasher and touched the clean utensils without washing his hands.

During an interview on 6/19/17 at 1415 hours, with FSM 1, he confirmed DS 2 did not wash his hands between handling of the soiled and clean utensils. FSM 1 verified DS 2 should have washed his hands.

During a concurrent interview with the AFSM, he stated he was responsible for monitoring the dishwashing staff to ensure they performed the appropriate hand hygiene. The AFSM stated regular audits were conducted to ensure this practice. The AFSM could not explain why DS 2 did not wash his hands between handling the dirty and clean utensils.

3. According to the United States Department of Agriculture, Food and Drug Administration 2013 Food Code for safe food handling, because certain fruits and vegetables are susceptible to infiltration of microorganisms during soaking or submersion, it is recommended that soaking or submerging produce during cleaning be avoided. It is important to follow practices that minimize pathogens in the water or on the surface of produce.

A review of the hospital's P&P titled Procurement, Preparation, and Service of Food revised 3/3/16, showed, "Wash fruits and vegetables thoroughly under running water ..."

A review of the hospital's document titled Nutrition Infection Control (a surveillance tool) showed one of the items audited was "Leafy greens, salads are cleaned under running water, NO soaking."

During an observation and interview with DS 3 in the cold preparation area of the kitchen, DS 3 stated most of the produce the hospital received was pre-washed. DS 3 further stated the procedure for washing produce that was not pre-washed, such as lettuce and fruit, was to fill the sink with water and soak it. DS 3 stated the water would be drained two times and the produce would be re-soaked for a total of three times to ensure it was clean.

During a concurrent interview with the EC and DNS, they verified this was the procedure.

During a follow-up interview with the DNS on 6/21/17 at 0800 hours, she stated the produce should not be soaked, but should be washed with running water.

4. According to the United States Department of Agriculture, Food and Drug Administration 2013 Food Code for safe food handling, damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. If the integrity of the packaging has been compromised, contaminants...may find their way into the food.

During a tour of the kitchen on 6/19/17 at 1145 hours, a large, open bag of panko breadcrumbs was observed on a shelf in a dry ingredient room. The bag was not sealed.

During a concurrent interview with the EC, he stated the bag of panko breadcrumbs was delivered without additional outer packaging. The EC stated once the bag was open, the dietary staff was supposed to remove the contents of the bag and place it in a clean plastic container. The EC verified the bag was not clean and could have contaminated the breadcrumbs.

During a concurrent interview with DS 4, he stated the bag of panko breadcrumbs was not opened that day. DS 4 was not aware of when the bag was opened. DS 4 stated an opened bag should be put in a plastic container and the bag discarded.


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5. Review of the hospital's P&P titled Hand Hygiene revised 6/30/15, showed the following:

lV. Special considerations for hand hygiene in the Endoscopy and Medical Procedure Unit and Operating Room.
A. Indications for Hand Hygiene.
1. Perform hand hygiene in the following situations:
a. Before a patient encounter, even if gloves will be worn.
b. Upon exiting the patient care area after touching the patient or the patient's immediate environment or completing an episode of care.
c. After contact with blood, body fluids or excretions, or wound dressings, or other contaminated surfaces.
d. Prior to performing an aseptic task (e.g. accessing a port, preparing an injection).
e. There are times when there is inadequate time to perform hand hygiene according to the above guidelines. In these circumstances hand hygiene should be performed as soon as patient safety allows.

An observation of the ECT treatment was conducted with the ECT Director on 6/20/17 between 1147 and 1224 hours. The following was identified:

a. At the beginning of the procedure, MD 2 applied the ECG leads to Patient 13 while wearing gloves. Wearing the same gloves, MD 2 then performed multiple patient care activities for Patient 13 which included administration of IV medications, suctioning of mouth secretions, and bag and mask ventilation. MD 2 was not observed to change gloves or perform hygiene at any time during the ECT procedure. MD 2 removed her gloves after the procedure was completed. No hand hygiene was observed after the removal of gloves.

b. During the ECT treatment, RN 2 wore the same gloves while performing multiple activities which included positioning the patient on the gurney, cleaning the patient's head with alcohol swabs and gauze before applying the EEG leads, inserting a mouth guard, applying the ECT electrodes, spiking a bag of IV fluid, and using a computer mouse and keyboard. After the ECT procedure was complete, RN 2 removed the EEG leads and cleaned Patient 13's head with a towel. The RN continued to wear the same gloves used during the procedure.

At 1206 hours, RN 2 removed her gloves and performed hand hygiene with an alcohol-based hand rub, then donned a new pair of gloves. RN 2 then cleaned Patient 13's pulse oximeter (a sensor attached to the finger to detect blood oxygen levels) with an alcohol swab and adjusted the roller clamp on the IV tubing. RN 2 then left the room and returned with a warm blanket while wearing the same gloves.

An interview was conducted with the ECT Director on 6/21/17 at 0944 hours, regarding the ECT observation. The Director verified RN 2 wore the same pair of gloves throughout the procedure for multiple tasks including contact with the patient followed by contact with medical equipment and the computer. The Director also verified RN 2 did not remove her gloves and perform hygiene prior to leaving the room to get the warm blanket. The Director further acknowledged MD 2 did not change gloves or perform hand hygiene during the procedure.

On 6/21/17 at 1404 hours, the above findings were shared with the Medical Director of Infection Control and the Infection Preventionist.


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6. Review of the hospital's standard from the CDC guidelines titled Recommendations - Environmental Services dated 6/6/03, showed to clean noncritical medical equipment surfaces with a detergent/disinfectant. This may be followed by an application of an EPA-registered hospital disinfectant. Do not use alcohol to disinfect over large environmental surfaces.

On 6/20/17 at 1205 hours, cleaning of the ECT treatment room was observed after Patient 13's procedure. RN 2 disconnected Patient 13's EEG leads and wiped down the EEG lead wires using one alcohol swab going from the midpoint between the tip and the connector. The same alcohol swab was used to gather two of the lead wires at the same time, following it down to the tip, and then three lead wires at a time down to the tip. Using the same alcohol swab, RN 2 did a brief swab of the knob controls on the EEG machine with one pass over each knob.

At 1222 hours, MD 2, the anesthesiologist, removed Patient 13's mask and oxygen tubing and the patient was transported by the staff out of the treatment room. MD 2 disconnected the mask and tubing from the anesthesia machine and discarded them into the trash. MD 2 removed her gloves and performed hand hygiene using an alcohol-based hand rub. MD 2 then donned new gloves and gathered a new ambu bag and tubing; however, the MD connected the clean equipment to the anesthesia machine without first disinfecting the machine used in Patient 13's procedure. In addition, the IV pole and IV machine were not disinfected prior to the next patient entering the procedure room.

The ECT Director was interviewed on 6/21/17 at 0951 hours. The Director stated the anesthesiologist was responsible for disinfecting the anesthesia cart, the EKG and vitals sign monitors, and the anesthesia machine between treatment cases.

Review of the Cleaning Procedures Manual: Treatment and Examination Rooms dated 2016 showed the daily cleaning instructions for treatment and examination rooms. However, the document did not identify the staff responsible to perform the turnover cleaning of the treatment room and the disinfection of medical equipment between cases.

On 6/21/17 at 1423 hours, the above findings were shared with the Medical Director of Infection Control and the Infection Preventionist.


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7. Review of the manufacturer's guidelines provided for review for the glucometer used by the hospital showed the meters must be properly cleaned and disinfected between each patient use. The guidelines also showed Clorox Germicidal Wipes were the acceptable active ingredient and product for cleaning and disinfecting the meter.

Review of the manufacturer's guidelines for Clorox Germicidal Wipes showed the disinfected area should remain wet for three minutes for complete disinfection.

Review of the manufacturer's guidelines for the Hydrogen Peroxide Disinfectant Wipes showed the disinfected area should remain wet for one minute for complete disinfection.

On 6/19/17 at 1115 hours, an interview was conducted with RNs 7 and 8 regarding the process for cleaning the glucometer. RN 7 stated he cleaned the glucometer daily with Hydrogen Peroxide Disinfectant Wipes. When asked for the wet time of the solution, RN 8 stated at least one minute to be wet and air dry the glucometer.

On 6/20/17 at 1138 hours, an interview was conducted with RN 9 regarding the process for cleaning the glucometer. RN 9 stated Clorox Germicidal Wipes were never used to clean the glucometer because it could damage the glucometer screen.

Review of the teaching material regarding the glucometer cleaning showed the following:

* Wipe the meter three times vertically with a damp Clorox Germicidal Wipe.
* Wipe the meter three times horizontally with a damp Clorox Germicidal Wipe.
* Allow the surface to remain damp for three minutes, then wipe with a paper towel to dry.
* Clean the meter once per 24 hours, and whenever any potentially infectious material is present.

Review of RNs 7 and 8's glucometer cleaning validation forms showed instructions the meter should remain damp for one minute after wiping with a Clorox Germicidal Wipe. The form also showed the following:

* Clean the meter once per 24 hours and whenever any potentially infectious material is present
* [For another hospital campus]- clean the meter after each use on a patient.

During an interview and concurrent record review with the Assistant Nurse Manager on 6/21/17 at 1530 hours, she stated the validation form should have addressed the meter was to be cleaned between patients as instructed for the other hospital campus.

8. Review of the soft BP Cuff label showed the BP cuff was for single-patient use.

On 6/19/17 at 1115 hours, a tour of the Neighborhood (unit) B in the adult inpatient area was conducted accompanied by the Assistant Nurse Manager. A VS machine was observed in the dining room. A soft cloth blood pressure cuff was connected to the VS machine and labeled with the date 6/19/17. When asked, RN 8 stated the soft BP cuff was used for all patients in Neighborhood B and the cuff was changed daily.

On 6/21/17 at 1400 hours, the Infection Preventionist verified the above findings.


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9. Review of the hospital's P&P titled Intravenous (IV) Therapy-Adults/Peds (Pediatric), Nsg (Nursing) dated 3/2/16, showed to label the IV tubing with the date, time hung, and initial; to label the IV bag with the patient's name, patient's ID, date and time hung, drug name, drug dose, solution type, volume of solution, and the RN's initial.

A tour of the Geriatric/Adult unit dayroom was conducted on 6/19/17 at 1100 hours, accompanied by the Interim Manager. An IV bag of normal saline was observed being administered to Patient 7. The normal saline bag and IV tubing were not labeled as per the hospital's P&P.

The Interim Manager confirmed the finding.

Based on observations, interviews, medical record review, and document review, there was a systematic failure of the facility to provide medical records that documented comprehensive assessments and the treatment given to patients by the facility staff that provided services. Specifically, the facility failed to:

I. Provide social work assessments that reflected the role of the social worker in formulating interventions for the inpatient treatment and discharge recommendations for eight (8) of eight (8) sampled patients (Patients A1, A2, A3, A4, B1, B2, B3, and B4). This failure results in an absence of commitment to specific professional social work treatment services on the Master Treatment Plans, which potentially could delay recovery. (Refer to B108)


II. Provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary requirements to provide active treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically, MTPs had the following missing components:

A. Clearly defined psychiatric problem statements written in behavioral and descriptive terms. (Refer to B119).

B. Individualized short-term and long-term goals written in observable, measurable, and behavioral terms. (Refer to B121)

C. Individualized and specific active treatment interventions with the focus of treatment to address each patient's presenting psychiatric problems and symptoms. (Refer to B122)

D. The staff member responsible for each intervention specifically identified by both name and discipline to ensure accountability for implementation of group and individual treatment sessions. (Refer to B123)

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

III. Ensure that registered nurses and social workers adequately documented active treatment interventions listed on the Master Treatment Plan and unit schedule to show detailed and comprehensive information about treatment for firve (5) of eight (8) active sample patients (A1, A3, B1, B3, and B4). This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124)

IV. Provide an active therapeutic program for significant periods of time on evenings and weekends during their hospital stay for eight (8) of eight (8) sampled patients (Patients A1, A2, A3, A4, B1, B2, B3, and B4). This lack of active therapies results in these patients being hospitalized without all interventions for patient recovery provided to them, potentially delaying their discharge. (Refer to B125-I)

V. Ensure that alternative treatment measures were offered to patients not attending the group treatment program and that groups were held when scheduled for four (4) of four (4) active treatment patients (B1, B2, B3, and B4) housed on 4 North. Specifically, the facility expected that all patients participate in the group treatment program. However, each group was not always held as scheduled and had very few patients attending. Failure to provide alternative active treatment measures to address each patient's need leads to patient problems not being addressed timely and delays progress towards recovery. (Refer to B125-II)

Based on record review, interview and document review, the facility failed to provide social work assessments that reflected the role of the social worker in formulating interventions for the inpatient treatment and discharge recommendations for eight (8) of eight (8) sampled patients (Patients A1, A2, A3, A4, B1, B2, B3, and B4). This failure results in there being no documented social work role expectations in the assessments, which potentially could delay recovery.

Findings include:

A. Record Review

The following Social Work Assessments were reviewed (dates in parentheses): Patient A1 (6/10/17), Patient A2 (6/8/17), Patient A3 (6/10/17), Patient A4 (6/15/17), Patient B1 (3/17/17), Patient B2 (5/26/17), Patient B3 (6/15/17) and Patient B4 (6/12/17). The assessments consisted of gathered data only, and failed to include conclusions and recommendations that reflected the anticipated social worker role in treatment and discharge planning.

B. Document Review

The only document presented by the facility regarding social work assessment content was titled "Assessment/Reassessment Matrix" which provided the time frame for completion of the Social Work assessments.

C. Interview

On 6/20/17 at 2:00 p.m., the Director of Social Work concurred that psychosocial assessments did not reflect the role of the social worker in formulating interventions for the inpatient treatment and discharge recommendations.

Based on record review and staff interview, the facility failed to ensure that psychiatric evaluations included an inventory of specific patient assets for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). The failure to identify patient assets potentially impairs the psychiatrist's ability to plan and select treatment modalities that best utilize the patient's strengths.

Findings include:

A. Record Review

The admission psychiatric evaluations (dates in parentheses) for the following patients failed to include an evaluation of each patient's strengths or assets; there was no section entitled, "Patient Assets" on the psychiatric evaluation section of the electronic record: Patient A2 (6/7/17), Patient A3 (6/10/17), Patient A4 (6/14/17), Patient B1 (3/15/17), Patient B2 (5/24/17), Patient B3 (5/31/17), and Patient B4 (6/10/17). Patient A1 did not have a separate psychiatric evaluation.

B. Interview

During an interview with the Medical Director on 6/20/17 at 11:00 a.m., after reviewing several psychiatric evaluations of active sample patients, he acknowledged that the psychiatric evaluation did not include specific patient strengths or assets to be used in the treatment of patients.

Based on record review, document review, and interview, the facility failed to ensure that Master Treatment Plans (MTPs) had clearly defined and individualized problem statements written in behavioral and descriptive terms for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically, the MTPs included identical or similarly worded problem statements with diagnoses, generalized statements, diagnostic terms, or psychiatric jargon rather than individualized and behaviorally descriptive psychiatric problem statements based on each patient's clinical assessment data. This failure can adversely affect clinical decision-making in formulating goal and intervention statements and results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems.

Findings include:

A. Record review

1. Patient A1's MTP, dated 6/14/17, included the following deficient psychiatric problem statements: "Anxiety Disposition: Acute problem - Manifested By: Insomnia. Impaired cognitive skills: Decreased insight and poor concentration." "Danger to Self/Others: Acute problem - Manifested By: Impulsivity (specify) [left blank]; Danger to Others: Plan (specify) [left blank]; Danger to Self: Suicide attempt (specify) [left blank]; Other/Comments: Pt [Patient] reported she had two previous suicide attempt/plan, 'to drown or hang myself.' " These problem statements failed to describe how the patient manifested the symptoms identified. In addition, there were no descriptors of the danger to others and self despite a prompt in the electronic medical record to specify these behaviors.

2. Patient A2's MTP, dated 6/13/17, included the following deficient psychiatric problem statement: "Danger to Self/Others: Acute problem - Manifested By: Impulsivity (specify) [left blank]; [left blank]; Danger to Self: Suicide attempt (specify) [left blank]; Other/Comments: Attempted to hang self with own clothing." This problem statement failed to describe how the patient precisely manifested the symptoms of impulsivity. There was no information to show if the patient had current ideations or plans related to suicide. There were no descriptors of the danger to others and self despite a prompt in the electronic medical record to specify these behaviors.

3. Patient A3's MTP, dated 6/13/17, included the following deficient psychiatric problem statements: "Anxiety Disposition: Acute problem - Manifested By: Nightmares or disturbing dreams ... Impaired cognitive skills: Decreased insight, Poor problem solving, Indecision and poor concentration." These problem statements included broad generalized statements and diagnostic terms and failed to describe how the patient precisely manifested the symptoms identified such as including the content of nightmares and how they affect the patient, decreased insight, and poor concentration.

4. Patient A4's MTP, dated 6/15/17, included the following deficient psychiatric problem statement: "Danger to Self/Others: Acute problem - Manifested By: Impulsivity (specify) [left blank]; [left blank]; Danger to Self: Current Plan (specify) [left blank]; Other/Comments: To be hit by a train." This problem statement failed to describe how the patient precisely manifested the symptoms of impulsivity and dangerous to self. There was no information to show if the patient had current ideations or how the patient would carry out a plan to commit suicide. There were no descriptors of the danger to self despite a prompt in the electronic medical record to specify these behaviors.

5. Patient B1's MTP, updated 6/13/17, included the following deficient psychiatric problem statements: "Anxiety Disposition: Acute problem - Manifested By: Distractibility/ inattention and Somatic symptoms of anxiety. Impaired cognitive skills: Poor problem solving and poor concentration." "Mood Disturbance Disposition: Acute Problem - Manifested by: Energy Change: Loss of energy, Sleep Change: Insomnia; Appetite Change: Decrease; Mood: Depressed." These problem statements included broad generalized statements and diagnostic terms and failed to describe how the patient precisely manifested the symptoms identified.

6. Patient B2's MTP, dated 5/25/17, included the following deficient psychiatric problem statement: "Danger To Self/Others: Acute problem - Manifested By: Dan
ger to Self: [This was left blank despite prompt on the EMR to specify current intent.]." There were no descriptors at all of this patient's danger to self and others based on clinical assessment data.

7. Patient B3's MTP, dated 6/15/17, included the following deficient psychiatric problem statements: "Anxiety Disposition: Acute problem - Manifested By: Irritability or unpredictable or explosive anger, Distractibility/inattention, Avoidance behaviors (isolation/withdrawl [sic]/agoraphobia) and insomnia. Impaired cognitive skills: poor concentration." "Mood Disturbance Disposition: Acute Problem - Manifested by: Energy Change: Loss of energy, Sleep Change: Insomnia; Weight Change: Loss; Mood: Irritable and Depressed." These problem statements included broad generalized statements, diagnostic terms, and failed to describe how the patient precisely manifested the symptoms of distractibility, insomnia, weight loss, and depressed mood.

8. Patient B4's MTP, dated 6/13/17, included the following deficient psychiatric problem statements: "Anxiety Disposition: Acute problem - Manifested by Irritability or unpredictable or explosive anger, Feeling of impending doom, Distractibility/ inattention and Avoidance behaviors (isolation/withdrawl [sic] /agoraphobia). Impaired cognitive skills: Decreased insight, Poor problem solving, Indecision and poor concentration." "Psychotic Behavior Disposition: Acute problem - Manifested By: ... Disturbed sleep patterns, Disorganization, Poor reality testing ... Decreased motivation / apathy/ avolition ..."There was no information provided regarding how this patient was experiencing avolition.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that included individualized patient-related long-term goals (LTGs) and short-term goals (STGs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Goals failed to identify what the patient would do to lessen the severity of psychiatric problems identified in clinical assessments. In addition, STGs were frequently not stated in observable, measurable, and behavioral terms. Goals were identical or similarly stated and associated with predetermined problem statements in the electronic medical record. Failure to identify individualized treatment goals hampers the treatment team's ability to determine whether the treatment plan is efficient and if it needs to be revised.

Findings include

A. Record Review

The Master Treatment Plans (MTPs) of the following patients were reviewed (dates of plans in parentheses): Patient A1 (6/14/17), Patient A2 (6/13/17), Patient A3 (6/13/17), Patient A4 (6/15/17), Patient B1 (3/17/17 and updated 6/13/17) Patient B2 (6/15/17), Patient B3 (6/15/17), and Patient B4 (6/13/17). This review revealed the long-term goals (LTGs) and short-term goals (STGs) were not written in behavioral, observable, and measurable terms. Despite each patient having different presenting psychiatric symptoms and needs identified in clinical assessments, goal statements were identical or similarly worded on MTPs. Because both problem and goal statements on MTPs lacked individualized symptoms, specific descriptors, and observable behaviors, it was hard to discern how clinical staff evaluated each patient's changes or improvement based on information provided on treatment plans.

1. Five active sample patients (A1, A3, B1, B3, and B4) had the following identical or similarly worded goal statements for the similarly worded problem of, "Anxiety ..." LTG - "Patient reports decreased symptoms of anxiety and the ability to manage symptoms outside of the hospital and Patient will demonstrate individualized coping skills to decrease anxiety symptoms." STG - "To help manage symptoms, patient will describe 2 warning signs of anxiety. To assume control, the patient will identify/practice at least two coping skills that are helpful to decrease anxiety. Patient will identify appropriate discharge plan for self care and Family will verbally identify two strategies to use to assist with managing patient's symptoms at home."

2. Two active sample patients (B1 and B3) had the following identical or similarly worded goal statements for the similarly worded problem of, "Mood Disturbance ..." LTG - "Assume control by identifying two strategies to manage symptoms when out of the hospital. Identify a plan to obtain support when out of the hospital. Patient will report decreased symptoms of mood disturbance ...Family will verbalize importance of supporting the patient after discharge ..." STG - "Initiate interaction with staff and peers at least two times daily. Report decrease in at least two or more symptoms (specify) for two consecutive days [Note: No symptoms were specified] ... Comply with medication regime daily and Family will verbally identify two strategies to use to assist with managing patient's symptoms at home."

3. Four active sample patients (A1, A2, A4, and B2) had the following identical or similarly worded goal statements for the similarly worded problem of, "Danger to Self/Others ..." LTG - "Assume control by stating a safety plan and support system to use when out of the hospital. Report absence of impulse to harm self or others x2 days and Family will verbally identify strategies to support patient's safety plan in the home." STG - "Report decrease (by two points on a scale of 1-10) in suicidal/homicidal/self-injurious thoughts for 2 days. Manage symptoms by identifying 2 antecedents to suicidal/homicidal/self-injurious thoughts. Assume control by identifying at 2 positive coping strategies to use when feeling impulsive ... Family will verbally identify strategies to support patient's safety in the home."

B. Interviews

1. In an interview on 6/19/17 at 10:35 a.m. with RN4. SW3 and SW4, the treatment plans were reviewed in the electronic medical report. They agreed that goal statements were not stated in behavioral terms based on each patient's presenting symptoms. They did not dispute the findings that goal statements were identical or similarly worded on MTPs.

2. In an interview on 6/20/17 at 11:10 a.m. with the Medical Director/CEO, MTPs were discussed. He did not dispute the findings that treatment goals were not behaviorally specific and were identical or similarly worded based on problem statements in the electronic medical record.

3. In an interview on 6/20/17 at 3:00 p.m. with the Director of Social Work, MTPs were discussed. She did not dispute the findings that treatment goals were not behaviorally specific.

Based on record review, document review, and interviews, the facility failed to ensure that Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4) included individualized and specific active treatment interventions based on the unique psychiatric symptoms of each patient. Specifically, intervention statements were generic or routine discipline functions. MTPs also included several intervention statements that failed to identify a focus of treatment and a method of delivery (individual or group sessions). These deficiencies result in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to interdisciplinary treatment and potentially leads to inconsistent and ineffective treatment.

A. Record Review

The master treatment plans for the following patients were reviewed (dates of plans in parentheses): Patient A1 (6/14/17), Patient A2 (6/13/17), Patient A3 (6/13/17), Patient A4 (6/15/17), Patient B1 (3/17/17 and updated 6/13/17), Patient B2 (6/15/17), Patient B3 (6/15/17), and Patient B4 (6/13/17). This review revealed the following findings:

1. Five (5) active sample patients (A1, A3, B1, B3, and B4) had the following identical or similarly worded deficient intervention statements. These interventions were to address the following treatment goals: LTG - "Patient reports decreased symptoms of anxiety and the ability to manage symptoms outside of the hospital and Patient will demonstrate individualized coping skills to decrease anxiety symptoms." STG - "To help manage symptoms, patient will describe 2 warning signs of anxiety. To assume control, the patient will identify/practice at least two coping skills that are helpful to decrease anxiety. Patient will identify appropriate discharge plan for self care and Family will verbally identify two strategies to use to assist with managing patient's symptoms at home."

a. Physician Interventions: "Prescribe and manage medication. Order and interpret results of structural (plain X-ray, CT, MRI) imaging studies as indicated. Order and interpret results of laboratory (blood or other body fluid) tests as indicated. Order and interpret results of neurophysiological functions (EEG, fMRI, PET, etc.)... Order, interpret, and integrate into treatment plan results of subspecialty medical consultations as appropriate." "Order and interpret results of neuropsychological testing as indicated and Order and interpret results of educational testing as indicated." These intervention statements were not individualized and were normal and routine MD job duties, such as prescribing, ordering, and interpreting test results. The MTPs did not show that MDs planned to meet with patients in individual sessions to provide active treatment, such as education and direction regarding specific medications, information about discharge, and instructions regarding successfully managing presenting psychiatric symptoms or problems.

"Perform individual psychotherapy and/or crisis stabilization-intervention and Perform family therapy." These active treatment interventions were generic, non-specific, and failed to identify the focus of treatment for each patient based on specifically identified psychiatric problems, symptoms, and treatment goals. In addition, there was no delivery method (individual or group sessions) identified.

b. Nursing Interventions: "Provide counseling and skill building sessions in group weekly or 1:1 daily sessions to provide: Cognitive behavioral skills, Distress tolerance skills, Relaxation skills. Strategies to rate anxiety on a scale of 1-10 and intervene to decrease the rating ..." "Educate the patient and the patient's family and provide opportunities daily to utilize: Relaxation techniques, Tolerating mild levels of anxiety, Distraction activities, The role of medications. The patient's illness and symptoms and Sensory coping strategies." " ...Involve the patient to establish program that incorporates the elements of good sleep hygiene ..."

These interventions were not individualized since they failed to identify a specific focus of counseling and education based on each patient's behaviorally descriptive and clinically assessed problems.

Social Work Interventions: Social Work Interventions: "Provide Patient Support x2/Week: Encourage patient's identification and expression of thoughts and feelings. Listen and validate patient's feeling. Encourage expression of feelings in group situations in milieu. Identify stressors and assist with problem solving ..." "Patient Education in 1:1 or Group Sessions x2/Week Regarding: Signs, symptoms, treatment, and prognosis of illness. Safety measures at home ..." "Provide Family/Caregiver Education (In Weekly Sessions/Before Discharge): Regarding: Signs, symptoms, treatment, and prognosis of illness. Safety measures at home ..."

The intervention statement regarding listening to and encouraging the patient included normal and routine social worker functions, not active treatment interventions that reflected meeting with patients to assist them to improve presenting psychiatric symptoms. The active treatment interventions regarding patient and family/caregiver education were not specific or individualized based on each patient and family/caregiver's assessed needs. The statement also failed to identify a specific delivery method based on whether individual sessions rather than group sessions would be appropriate for patients.

c. Occupational Therapy Interventions: The following identical or similarly worded interventions were listed for A1, A3, and B3 - "Encourage the patient to participate in therapy sessions scheduled in OT and engage in productive activities ..." "In OT Task Group Skills Group and/or 1:1 treatment focus on teaching the patient: ADL/IADL activities (listed for B3 only), Communication skills, Coping skills to reduce/manage anxiety, Distraction activities, Learning to tolerate mild levels of anxiety, Problem solving/task performance skills and Sensory strategies."

The intervention statement regarding encouraging participation was a routine OT function performed for all patients. The active treatment interventions to be provided in groups or 1:1 were not individualized. They failed to include the specific focus of treatment based on each patient's identified problems, needs, and treatment goals. In addition, the statement failed to state a specific delivery method based whether individual sessions rather than group sessions would be appropriate for patients.

d. Recreational Therapy Interventions: The following identical interventions were listed for A1 and B1. - "Expose patient to and assist with acquiring new interests/skills in a variety of leisure pursuits to improve quality of life and purposeful engagement in recreation/social activities: Problem solving strategies, Relaxation techniques and Social skills."

This intervention statement was non-specific, not individualized, and failed to identify de-escalating and calming techniques that would be appropriate for each patient based on his/her clinically assessed needs. In addition, the statement also did not include whether the intervention would be delivered in individual or group sessions.

2. Two active sample patients (B1 and B3) had the following identical or similarly worded intervention statements for the following similarly worded goal statements: LTG - "Assume control by identifying two strategies to manage symptoms when out of the hospital. Identify a plan to obtain support when out of the hospital. Patient will report decreased symptoms of mood disturbance ...Family will verbalize importance of supporting the patient after discharge ..." STG - "Initiate interaction with staff and peers at least two times daily. Report decrease in at least two or more symptoms (specify) for two consecutive days [Note: No symptoms were specified] ... Comply with medication regime daily and Family will verbally identify two strategies to use to assist with managing patient's symptoms at home."

a. Physician Interventions: "Prescribe and manage medication. Order and interpret results of structural (plain X-ray, CT, MRI) imaging studies as indicated. Order and interpret results of laboratory (blood or other body fluid) tests as indicated. Order and interpret results of neurophysiological functions (EEG, fMRI, PET, etc.) ... Order, interpret, and integrate into treatment plan results of subspecialty medical consultations as appropriate." "Order and interpret results of neuropsychological testing as indicated and Order and interpret results of psychological testing as indicated." These intervention statements were normal and routine MD job duties or functions. The MTPs did not show that MDs planned to meet with patients in individual sessions to provide active treatment, such as education and direction regarding specific medications, information about discharge, and instructions regarding successfully managing presenting psychiatric symptoms or problems.

Patient A1 had an additional intervention- "Perform individual psychotherapy and crisis stabilization and perform family therapy." These active treatment interventions were generic, non-specific, and failed to identify the focus of treatment for the patient based on specifically identified psychiatric problems, symptoms, and treatment goals. In addition, there was no delivery method (individual or group sessions) identified.

b. Nursing Interventions: "Monitor and record vegetative symptoms each shift. Monitor, report, and document mood fluctuation each shift. Provide redirection for impulsive/ intrusive behavior each day. Support Patient by using short and concise explanations or statements each time there is interaction with patient ... Facilitate patient attending weekly support/therapy and skill building groups ..." Monitoring and documenting were routine nursing functions and job duties. These statements do not reflect meeting with the patient to provide information and teaching related to a specific psychiatric problem, and symptoms identified for each patient.

"Educate patient, family/significant other in 1:1 and family sessions twice weekly prior to discharge about: Symptoms, illness, Recent Stressors and Electroconvulsive therapy (these last two topics were listed only for Pt. B3) , Medications and Coping strategies." This active treatment intervention was generic, non-specific, and failed to identify the focus of treatment for each patient based on specific psychiatric problems, symptoms, and treatment goals.

c. Social Work Interventions: "Provide Patient Support x2/Week: Encourage patient's identification and expression of thoughts and feelings. Listen and validate patient's feeling. Encourage expression of feelings in group situations in milieu. Identify stressors and assist with problem solving ..." "Provide Patient Education in 1:1 or Group Sessions x2/Week Regarding: Signs, symptoms, treatment, and prognosis of illness. Safety measures at home ..." "Provide Family/Caregiver Education (In Weekly Sessions/Before Discharge): Regarding: Signs, symptoms, treatment, and prognosis of illness. Safety measures at home ..."

The intervention statement regarding listening to and encouraging the patient included normal and routine social worker functions, not active treatment interventions reflecting meeting with patients to assist them to improve presenting psychiatric symptoms. The active treatment interventions regarding patient and family/caregiver education were not specific or individualized based on each patient and family/caregiver's assessed needs. In addition, the statement failed to state a specific delivery method based whether individual sessions rather than group sessions would be appropriate for patients.

d. Occupational Therapy Interventions: For B3 - "In OT Task Group Skills Group and/or 1:1 treatment focus on: ADL/IADL activities, Communication skills, Coping skills, Occupational Role functioning. Problem solving/task performance skills, Sensory strategies, Social skills and Tasks/topics to assist patient to stabilized mood." The active treatment interventions to be provided in groups or 1:1 were not individualized and did not reflect the specific focus of treatment based on each patient's identified problems, symptoms, and treatment goals. Also, the statement failed to state a specific delivery method based on whether individual sessions instead of group sessions would be more appropriate for patients.

e. Recreational Therapy Interventions: For B1 - "Expose patient to and assist with acquiring new interests/skills in a variety of leisure pursuits to improve quality of life and purposeful engagement in recreation/social activities: Self-esteem building, Coping skills and Social Skills." This intervention statement was non-specific, not individualized, and failed to specify the focus of coping and social skills identified for each patient based on assessed psychiatric problems, symptoms, and treatment goals. In addition, the statement did not include whether the intervention would be delivered in individual or group sessions.

3. Three active sample patients (A1, A2, A4, and B2) had the following identical or similarly worded interventions statements for the similarly worded goal statements. LTG - "Assume control by stating a safety plan and support system to use when out of the hospital. Report absence of impulse to harm self or others x2 days and Family will verbally identify strategies to support patient's safety plan in the home." STG - "Report decrease (by two points on a scale of 1-10) in suicidal/homicidal/self-injurious thoughts for 2 days. Manage symptoms by identifying 2 antecedents to suicidal/homicidal/self-injurious thoughts. Assume control by identifying at 2 positive coping strategies to use when feeling impulsive ... Family will verbally identify strategies to support patient's safety in the home."

a. Physician Interventions: "Prescribe and manage medication. Order and interpret results of structural (plain X-ray, CT, MRI) imaging studies as indicated. Order and interpret results of laboratory (blood or other body fluid) tests as indicated. Order and interpret results of neurophysiological functions (EEG, fMRI, PET, etc.) ... Order, interpret, and integrate into treatment plan results of subspecialty medical consultations as appropriate." "Order and interpret results of neuropsychological testing as indicated and Order and interpret results of psychological testing as indicated." These intervention statements include routine MD job duties or functions. The MTPs did not show that MDs planned to meet with patients in individual sessions to provide active treatment, such as education and direction regarding specific medications, information about discharge, and instructions regarding successfully managing presenting psychiatric symptoms or problems.

Patient A4 MTP included the following deficient intervention statements that were normal and routine MD job duties. "1. Coordinate treatment planning process in collaboration with multidisciplinary team; 2. Monitor and record changes in target symptoms. 5. Supervise team efforts to collect additional clinical history if needed ... 6. Assess for and document need for continued inpatient or partial hospitalization ... 10. Oversee coordination of post-discharge treatment plan ... " These statements did not reflect active treatment interventions showing contact with the patient in individual or group sessions to provide information, teaching, or directions regarding specifically identified target symptoms and discharge needs.

Patient A4 also had the following active treatment intervention - "Provide patient and family education regarding symptoms, disorders ..." This statement failed to include the focus of patient and family education based on specific symptoms and disorders identified in clinical assessments. In addition, the statement did not include a frequency of contact or whether the intervention would be delivered in individual or group sessions.

b. Nursing Interventions: "Place patient on status consistent with history, risk factors and current potential for patient to harm self or others daily: Close observation." "Provide 1:1 or group sessions daily to teach patient coping skills. Discuss and identify internal and external antecedents to behaviors dangerous to self or others. Explore with patient alternative strategies to maintain safety." The intervention statement regarding placing the patient on close observation was a routine nursing duty or function, not an active treatment intervention that required meeting with patients to assist them to improve presenting psychiatric symptoms.

"Teach patient to identify and utilize cognitive and behavioral techniques to cope with agitation, anxiety, anger ..." This active treatment intervention regarding patient teaching was not individualized and failed to identify a specific or appropriate cognitive or behavioral technique based on each patient's assessed need.

c. Social Work Interventions: "Provide Patient Support x2/Week: Encourage patient's identification and expression of thoughts and feelings. Listen and validate patient's feeling. Encourage expression of feelings in group situations in milieu. Identify stressors and assist with problem solving ..." "Provide Patient Education in 1:1 or Group Sessions x2/Week Regarding: Signs, symptoms, treatment, and prognosis of illness. Safety measures at home ..." "Provide Family/Caregiver Education (In Weekly Sessions/Before Discharge): Regarding: Signs, symptoms, treatment, and prognosis of illness. Safety measures at home ..."

The intervention statement regarding listening to and encouraging the patient included normal and routine social worker functions, not active treatment interventions that required meeting with patients to assist them to improve presenting psychiatric symptoms. The active treatment interventions regarding patient and family/caregiver education were not specific or individualized based on each patient and family/caregiver's assessed needs. Also, the statements failed to state a specific delivery method based whether individual sessions rather than group sessions would be appropriate for patients.

d. Occupational Therapy Interventions: "Provide safe structure in all OT groups." "Teach coping skills to deal with injurous [sic] thoughts and emotions regarding oneself and/or others in OT Task Group, Skills Group, and/or 1:1 treatment focus on: Personal safety and Sensory strategies ..." The active treatment interventions to be provided in groups or 1:1 were not individualized and did not reflect the specific focus of treatment based on each patient's identified problems, symptoms, and treatment goals. Also, the statement failed to state a specific delivery method based on whether individual sessions instead of group sessions would be more appropriate for patients.

e. Recreation Therapy Interventions: "Teaching calming techniques for personal de-escalation." "Expose patient to and assist with acquiring new interests/skills in a variety of leisure pursuits to improve quality of life and purposeful engagement in recreation/social activities: Problem solving strategies, Active physical activity and Social Skills." This intervention statement was non-specific, not individualized, and failed to identify which de-escalating and calming techniques would be appropriate for each patient based on his/her clinically assessed needs. In addition, the statement also did not include whether the intervention would be delivered in individual or group sessions.

B. Interviews

1. In an interview on 6/19/17 at 10:35 a.m. with RN4, SW3, and SW4, the treatment plans were reviewed in the electronic medical report. They agreed that intervention statements were generic and routine discipline functions. They did not dispute the finding that intervention statements were not individualized and were identical or similarly worded on MTPs.

2. In an interview on 6/20/17 at 11:10 a.m. with the Medical Director/CEO, MTPs were discussed. He did not dispute the findings that MD interventions were generic, routine MD functions, and were not based on each patient's presenting psychiatric symptoms. He agreed they were identical or similarly worded associated with problem statements in the electronic medical record. He agreed that psychiatrists did more than ordering and prescribing, but acknowledged interventions on MTPs did not show that MDs planned to meet with patients in individual sessions to provide information, teaching, and direction regarding specific medications, managing discharge, and how to successfully handling presenting psychiatric symptoms, problems, and needs.

3. In an interview on 6/20/17 at 3:00 p.m. with the Director of Social Work, MTPs were discussed. She did not dispute the findings that intervention statements were not individualized and were identical or similarly worded statements.

Based on record review, document review, and interview, the facility failed to ensure that the staff member responsible for each intervention was specifically identified in eight (8) of eight (8) Master Treatment Plans (Patients A1, A2, A3, A4, B1, B2, B3, and B4). This failure resulted in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented.

Findings include:

A. Record Review

1. Patient A1 (Master Treatment Plan dated 6/14/17) had no designation of the staff member responsible for each intervention. The treatment plan was signed by several staff, but no specific designation of responsibility was noted.

2. Patient A2 (Master Treatment Plan dated 6/13/17) had no designation of the staff member responsible for each intervention. The treatment plan was signed by several staff, but no specific designation of responsibility was noted.

3. Patient A3 (Master Treatment Plan dated 6/13/17) had no designation of the staff member responsible for each intervention. The treatment plan was signed by several staff, but no specific designation of responsibility was noted.

4. Patient A4 (Master Treatment Plan dated 6/15/17) had no designation of the staff member responsible for each intervention. The treatment plan was signed by several staff, but no specific designation of responsibility was noted.

5. Patient B1 (Master Treatment Plan dated 3/17/17 and updated 6/13/17) had no designation of staff member responsible for each intervention. The treatment plan was signed by several staff, but no specific designation of responsibility was noted.

6. Patient B2 (Master Treatment Plan dated 5/25/17) had no designation of the staff member responsible for each intervention. The treatment plan was signed by several staff, but no specific designation of responsibility was noted.

7. Patient B3 (Master Treatment Plan dated 6/15/17) had no designation of the staff member responsible for each intervention. The treatment plan was signed by several staff, but no specific designation of responsibility was noted.

8. Patient B4 (Master Treatment Plan dated 6/12/17) had no designation of the staff member responsible for each intervention. The treatment plan was signed by several staff, but no specific designation of responsibility was noted.

B. Document Review

The facility policy titled "Treatment Planning, NPH 1330" and last reviewed on 5/1/2014 stated, "specific treatment modalities/interventions utilized, including description of planned services, activities and programs, [must have] initials of responsible service provider (or team member)."

C. Interview

1. On 6/21/17 at 1:00 p.m., the Director of Nursing agreed that there was no designated nurse noted as accountable for the nursing interventions.

2. On 6/21/17 at 11:00 a.m., the Director of Activity Therapy concurred that there was no designated activity therapist staff noted as accountable for the activity therapy interventions.

Based on record review and interview, the facility failed to ensure that registered nurses and social workers adequately documented active treatment interventions listed on the Master Treatment Plan and unit schedule to show detailed and comprehensive information about treatment for five (5) of eight (8) active sample patients (A1, A3, B1, B3, and B4). Specifically, documentation in the electronic medical record did not consistently include the patients' attendance or non-attendance, specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions.

Findings include:

A. Record Review

The master treatment plans for the following patients were reviewed (dates of plans in parentheses): Patient A1 (6/14/17), Patient A2 (6/13/17) Patient A3 (6/13/17), Patient A4 (6/15/17), Patient B1 (3/17/17 and updated 6/13/17), Patient B2 (5/25/17), Patient B3 (6/15/17), and Patient B4 (6/13/17). This review revealed the following findings regarding treatment notes for treatment interventions assigned to registered nurses and social workers.

1. Five (5) active sample patients (A1, A3, B1, B3, and B4) with the following identical and similarly worded intervention statements, had deficiencies in documenting treatment notes related to the following similarly worded goal statements: LTG - "Patient reports decreased symptoms of anxiety and the ability to manage symptoms outside of the hospital and Patient will demonstrate individualized coping skills to decrease anxiety symptoms." STG - "To help manage symptoms, patient will describe 2 warning signs of anxiety. To assume control, the patient will identify/practice at least two coping skills that are helpful to decrease anxiety. Patient will identify appropriate discharge plan for self care and Family will verbally identify two strategies to use to assist with managing patient's symptoms at home."

a. Nursing Interventions: "Provide counseling and skill building sessions in group weekly or 1:1 daily sessions to provide: Cognitive behavioral skills, Distress tolerance skills, Relaxation skills. Strategies to rate anxiety on a scale of 1-10 and intervene to decrease the rating ..." "Educate the patient and the patient's family and provide opportunities daily to utilize: Relaxation techniques, Tolerating mild levels of anxiety, Distraction activities, The role of medications. The patient's illness and symptoms and Sensory coping strategies." " ...Involve the patient to establish program that incorporates the elements of good sleep hygiene ..."

Patients A1, A3, B1, B3, and B4: A review of nursing notes in the electronic medical record (EMR) from 6/12/17 through 6/20/17 revealed that there were no notes regarding assigned interventions which were to be provided in group sessions weekly or 1:1 daily. This review revealed that there were no treatment notes that documented specific topics discussed during 1:1 interventions. Notes titled, "End of shift Summary" were primarily progress notes and failed to discuss meeting with the patient to provide counseling. There was no information documented regarding counseling provided to patients about specific cognitive behaviors skills, distress tolerance skills, and relaxation skills. There was no documentation about the number and duration of contacts with patients. In addition, there was no documentation to show the patient's response to interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions. There was no mention of any contact with the family to provide education.

A review of the education entries by nurses in the electronic medical record titled, "Safe & Effective Use of Medications ..." submitted for active sample patients A1, A3, B1, B3, and B4 failed to reveal the specific topics, such as the name and/or category of medications discussed. Documentation was general and vague, such as a note for active sample patient B1, dated 6/12/17, that reported, "Discussed medications offered especially as needed for anxiety, discussed plan of care and precautions to take during ECT." There was no specific information about actual medications prescribed or information provided about adherence. Similarly, in a note for Patient B3, dated 6/20/17, under the title, "Medication Education," the RN documented the following general and vague statement about the intervention: "Educated on medication indications and significance." There was no documentation regarding specific medications or the patient's response to this discussion with the patient except "verbalizes understanding" without identifying what the patient understood.

The section of the EMR regarding assigned intervention "CBT [Cognitive Behavioral Therapy] Skills" contained no documentation by nursing staff at all for active sample patients A1, B1, and B3. Two nursing notes, dated 6/17/17 and 6/18/17, were documented for active sample patient B4, with general and vague information about the intervention: On 6/17/17 - "Safety and psychotic behaviors reviewed with pt. [patient]" and on 6/18/17 - "Plan of care reviewed with pt." These notes had no relationship to CBT skills, and there was no documentation of the patient's response to the interventions except "verbalizes understanding" with no information about what the patient understood.

Social Work Interventions: "Patient Education in 1:1 or Group Sessions x2/Week Regarding: Signs, symptoms, treatment, and prognosis of illness. Safety measures at home ..." "Provide Family/Caregiver Education (In Weekly Sessions/Before Discharge): Regarding: Signs, symptoms, treatment, and prognosis of illness. Safety measures at home ..."

A review of social worker notes in the electronic medical record from 6/12/17 through 6/19/17 revealed that there were no treatment notes that documented specific topics discussed during 1:1 and group interventions.

Patient A1: The following notes dated 6/15/17 and 6/19/17 were reviewed and revealed that there were no notes regarding the "Process Group" provided that included the specific topics discussed, the patient's level of understanding, behaviors exhibited and specific comments made during sessions. A note, dated 6/15/17, documented that a family session occurred. However, there was no documentation regarding what specific education was provided the family during this session. There were no notes regarding the topics outlined in the intervention identified above ("Signs, symptoms ... Safety measures at home.")

Patient A3: The following notes dated 6/12/17, 6/14/17, and 6/19/17 were reviewed and revealed that there were no notes regarding the "Process Group" provided that included the specific topics discussed, the patient's level of understanding, behaviors exhibited and specific comments made during sessions. A note, dated 6/15/17, documented a family session occurred. However, there was no documentation regarding what specific education was provided the family during this session.

Patient B1: Notes dated 6/13/17 and 6/16/17 were reviewed and revealed that there was no content regarding treatment interventions provided in 1:1 or group sessions at all. There was also no documentation to show attendance and non-attendance in group sessions.

Patient B3: Notes dated 6/13/17, 6/15/17, 6/16/17, 6/19/17 were reviewed and revealed that there was no content regarding treatment interventions provided in 1:1 or group sessions that included the specific topics discussed, the patient's level of participation, the level of understanding, behaviors exhibited, and specific comments made during sessions. There was no documentation regarding family education provided in 1:1 or group sessions.

Patient B4: Notes dated 6/13/17, 6/14/17, and 6/15/17 were reviewed. There was note that provided general information about a group session titled, "SW Group" held on 6/13/17. This note did not include the specific information about the topics discussed, the patient's level of participation, the level of understanding, behaviors exhibited, and specific comments, if any, made during group sessions. Since the "SW Group" was also scheduled on 6/14/17 and 6/15/17, there was no documentation regarding this patient's attendance or non-attendance on these dates. There was no documentation family education provided in 1:1 or group sessions.

B. Interviews

1. In an interview on 6/19/17 at 10:35 a.m. with RN4, SW3, and SW4, treatment plans were reviewed in the electronic medical record. RN4 agreed that treatment notes about the nursing interventions provided did not contain specific information about topics discussed or comprehensive information about how the patient responded to interventions.

2. In an interview on 6/19/17 at 4:10 p.m. with RN5, documentation of the "Nursing Group" was discussed. She reported that she documented general information about the group and stated, "I don't document anything for the patients who refuse to come to the group."

3. In an interview on 6/20/17 at 2:15 p.m., after the SW group, treatment notes were discussed with SW 2. She did not dispute the findings that treatment notes did not include specific information about topics discussed, the level of participation, the level of understanding, or comments made by patients during group sessions.

4. In an interview on 6/21/17 at 11:40 a.m. with the Director of Social Work, treatment notes regarding patient and family education were discussed. She did not dispute that treatment notes regarding family education as assigned on the treatment plan were not consistently documented.

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

I. Based on document review and interview, the facility failed to provide an active therapeutic program for significant periods of time on evenings and weekends during their hospital stay for eight (8) of eight (8) active sample patients (Patients A1, A2, A3, A4, B1, B2, B3, and B4). This lack of active therapies results in these patients being hospitalized without all interventions for patient recovery provided to them, potentially delaying their discharge.


Findings include:

A. Document Review

1. The 4th Floor North A programming schedule (Geriatric/Adult Psychiatry Unit) had no therapeutic programming noted after 4:00 p.m. on Monday through Friday. In addition, it had one RT (Recreational Therapy) group on Saturday and two Nursing Groups on Sundays before 3:00 p.m. There was no therapeutic evening weekend programming.

2. The 4th Floor North B programming schedule (Adult) had no therapeutic groups scheduled after 4:00 p.m. on Monday through Friday. In addition, it had only one Nursing Group before 4:00 p.m. on Saturday and no groups on Sunday. There was no evening weekend therapeutic programming.

3. The 4th Floor West A programming schedule (Eating Disorders) had no therapeutic groups scheduled after 5:30 p.m. on Monday through Friday. There were three groups on Saturday before 4:30 p.m. and one OT (Occupational Therapy) group on Sunday at 11:00 a.m. There was no therapeutic evening therapeutic programming.

4. The 4th Floor West B programming schedule (Acute Adolescent) had no therapeutic groups after 5 p.m. on Monday through Friday. In addition, there were two therapeutic groups on Saturday and Sunday before 4:00 P.M. and no evening programming.

5. The 4th Floor West C (Child Unit) had no therapeutic programming after 5:00 p.m. on Monday through Friday. In addition, there was only one RT (Recreational Therapy) group on Saturday at 10:00 a.m. and no therapeutic programming on Sunday (day or evening).

6. The 4th Floor East C (Adult Unit) had no therapeutic programming after 3:30 p.m. on Monday through Friday. In addition, there was no therapeutic programming on Saturdays or Sundays (day or evening).

B. Interviews

1. On 6/20/17 at 2:00 p.m., the Director of Activity Therapy agreed that there was little if any programming on evenings or weekends for the 6 units.

2. On 6/20/17 at 1:30 p.m., the Director of Nursing agreed that the programming on evenings and weekends was inadequate.

II. Ensure that alternative treatment measures were offered to patients not attending the group treatment program and that groups were held when scheduled for four (4) of four (4) active treatment patients (B1, B2, B3, and B4) housed on 4 North. Specifically, the facility expected that all patients participate in the group treatment program, and review of Master Treatment Plans revealed the plans did not identify particular groups, merely noting "1:1 or group sessions" for most of the intervention statements. However, each group was not always held as scheduled and had very few patients attending. Failure to provide alternative active treatment measures to address each patient's need leads to patient problems not being addressed timely, and delays progress towards recovery.

Findings Include:

A. Observations and Interviews

1. During an observation on 6/19/17 at 10:40 a.m. on 4 North B, a group on the unit schedule titled "OT Task" was being conducted. A total of nine (9) out 17 patients including active sample patient (B4) attended this group. No other active treatment measures were scheduled during this period. The other eight (8) patients not attending the group were documented on the Rounds Sheets to be in their rooms, often watching TV, or walking in the hallway during this scheduled group time from 10:30 to 11:30 a.m. During a discussion on 6/19/17 at 11:00 a.m., RN 6 stated, "We don't provide anything alternative or other activity during this time." She noted that one patient was assigned physical therapy, and that 1:1 contact with patients not attending was sometimes offered. When asked if that occurred that day, she stated, "No."

2. During an observation on 6/19/17 at 11:10 a.m., on 4 North A, a group the unit schedule titled "RT Group" and scheduled from 11:00 a.m. to 12:00 p.m. did not start until 11:20 a.m. Four (4) patients out eight (8) patients on the unit attended this group. The four patients not attending the group were documented on the Rounds Sheets to be in their rooms during this period. No alternative active treatment measures were offered during this period. During an interview on 6/19/17, RT2 stated that the group started late because she had a team meeting. RT2, "When patients don't attend we sometimes take a guitar to their rooms to play music for them." However RT2 admitted that this was not done consistently.

3. During an observation on 6/19/17 at 2:38 p.m. on 4 North B, a group on the unit schedule titled "OT Skills" was being conducted. Eight (8) out of seventeen (17) patients on the unit were in attendance. The nine (9) patients not attending this group were documented on the Rounds Sheets as being in their rooms on in the hallway.

4. During an observation on 6/19/17 at 4:00 a.m. on 4 North B, a group on the unit schedule titled, "Nursing Group" was being conducted. Six (6) out of seventeen (17) patients attended this group including active sample patients B3 and B4 who left after 5 minutes. The Rounds Sheets showed that the other 11 patients were recorded as being in their rooms or the hallway during this group period. No other alternative active treatment measures were provided or offered for patients not attending the scheduled group sessions.

5. During an observation on 6/20/17 at 10:30 a.m. on 4 North A, a group on the unit schedule titled, "Music/Craft/Coloring" was scheduled from 10:30 a.m. to 11:00 a.m. This group was not held as scheduled. During a discussion, RN6 stated that a care partner [Mental Health Worker] would be assigned to run a music group at 11:00 a.m. and admitted that this was not as noted on the unit schedule.

6. During an observation on 6/20/17 at 1:15 p.m. on 4 North B, a group on the unit schedule titled, "SW Group" was being conducted with five (5) patients attending. No other or alternative active treatment measures were provided or offered for the twelve (12) patients not attending or assigned this group.

Based on record review, document review and interview, the facility failed to ensure that patient discharge summaries were completed in a timely fashion defined by hospital policy requirements for one (1) of five (5) discharged patients (Patient C3). This deficiency compromises the effective transfer of the patient's care to the next provider.

Findings include:

A. Record Review

The discharge summary for Patient C3 (discharged 6/2/17) was dated 6/4/17.

B. Document Review

Facility policy "Discharge of Patients from Inpatient Service, NPH 1503" and last reviewed 6/20/17, stated, "The Discharge Summary shall be entered or dictated within 24 hours of discharge, including weekends or holidays."

C. Interview

On 6/21/17 at 11:00 a.m., the Medical Director agreed that all discharge summaries must be completed within 24 hours per the facility policy.

Based on record review, document review, and interview, the facility failed to ensure that the date and time for follow-up appointments were included in the discharge summaries of two (2) of five (5) discharge records reviewed (Patients C4 and C5). The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices which they find difficult to do, and therefore may fail to do.

Findings include:

A. Record Review

1. Patient C4 (discharge summary dated 6/1/17) had no specific follow-up appointments noted.

2. Patient C5 (discharge summary dated 6/2/17) had no specific follow-up appointments noted.

B. Document Review

The facility policy, "Discharge of Patients from Inpatient Service, NPH 1503" and last reviewed 6/20/17, stated, "Prior to determining a patient's discharge date, the physician, nurse and/or social worker shall complete all discharge plans for those patients who require transfer to another facility, home care, transportation assistance or other post-hospital services." It further stated, "The Discharge Summary shall include arrangements for aftercare including medications, future treatment, and disposition."

C. Interview

1. On 6/21/17 at 11:00 a.m., the Medical Director agreed that specific follow-up appointments were absence from the discharge summaries of Patients C4 and C5.

2. On 6/21/17 at 2:00 p.m., the Director of Social Work acknowledged that follow-up appointments were absence from the discharge summaries of Patients C4 and C5.

Based on observation, record review, document review, and interview, the Medical Director failed to monitor and provide adequate medical oversight to ensure quality medical services. Specifically, the Medical Director failed to:

I. Ensure that psychiatric evaluations included an inventory of specific patient assets for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). The failure to identify patient assets potentially impairs the psychiatrist's ability to plan and select treatment modalities that best utilize the patient's strengths. (Refer to B117)

II. Provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary elements to provide treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4)

Specifically, MTPs had the following missing components:

A. Clearly defined psychiatric problem statements written in behavioral and descriptive terms. (Refer to B119)

B. Individualized short-term and long-term goals written in observable, measurable, and behavioral terms. (Refer to B121)

C. Individualized and specific active treatment interventions with the focus of treatment to address each patient's presenting psychiatric problems and symptoms. (Refer to B122)

D. The name of staff responsible for each intervention specifically identified to ensure accountability for implementation of group and individual treatment sessions. (Refer to B123)

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

III. Provide an active therapeutic program for significant periods of time on evenings and weekends during their hospital stay for eight (8) of eight (8) active sample patients (Patients A1, A2, A3, A4, B1, B2, B3, and B4). This lack of active therapies resulted in these patients being hospitalized without all interventions for patient recovery provided to them, potentially delaying their discharge. (Refer to B125-I)

IV. Ensure that alternative treatment measures were offered to patients not attending the group treatment program and that groups were held when scheduled for four (4) of four (4) active treatment patients (B1, B2, B3, and B4) housed on 4 North. Specifically, the facility expected that all patients participate in the group treatment program. However, each group was not always held as scheduled and had very few patients attending. Failure to provide alternative active treatment measures to address each patient's need leads to patient problems not being addressed timely and delays progress towards recovery. (Refer to B125-II)

V. Ensure that all aspects related to a suicidal death (3/19/17) were reviewed and that a reliable, evidence-based tool for assessing suicidality was initiated. This failure results in patients not being assessed properly and their safety maintained.

Findings include:

A. Record Review

1. The record of Patient D1 revealed that he/she was admitted on 1/16/17 with the diagnoses of Major Depressive Disorder. The patient was assessed regularly using the facility's suicide assessment tool. The patient remained hospitalized until his/her suicide by hanging on 3/19/17. The facility began the Root Cause Analysis process on 3/20/17.

2. The facility had initiated corrective infrastructure projects to remove possible fixtures that could be used in hanging in response to the death, but this project was still incomplete in areas where there were presently no patients.

3. The facility's "Daily Suicide Risk Assessment" was completed on each patient each shift. This assessment consisted of 12 questions regarding self-harm/suicidality. However, this assessment provided no weight to the individual questions and did not provide a method of uniform scoring to provide effective, uniform assessments. This document has remained unchanged since the suicide. There was no mention of any reconsideration of the current suicide assessment in the Root Cause Analysis, although the facility was aware the assessment tool needed to be replaced.

B. Interview

1. On 6/20/17 at 1:30 p.m., the Director of Nursing stated that the facility was considering other assessments that would provide scoring weights.

2. On 6/21/17 at 1:10 p.m., RN 2 agreed that the current suicide assessment was inadequate in providing a comprehensive, uniform assessment.

VI. Ensure that the patient discharge summary was completed in a timely fashion defined by hospital policy requirements for one (1) of five (5) discharged sample patients (Patient C3). This deficiency compromises the effective transfer of the patient's care to the next provider. (Refer to B133).

VII. Ensure that the date and time for follow-up appointments were included in the discharge summaries of two (2) of five (5) discharge records reviewed (Patients C4 and C5). The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices which they find difficult to do, and therefore may fail to do. (Refer to B134)

Based on record review, document review, and interview, the Director of Nursing failed to:

I. Ensure that Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4) included individualized and specific nursing interventions based on the unique psychiatric symptoms of each patient. Specifically, intervention statements were generic or routine discipline functions. Intervention statements were identical or similarly worded despite the different clinical presentations of patients. MTPs also included several intervention statements that failed to identify a focus of treatment based on clinical assessments. These deficiencies result in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to interdisciplinary treatment and potentially leads to inconsistent and ineffective treatment. (Refer to B122)


II. Ensure that the nursing staff responsible for each intervention was specifically identified for 8 of 8 active sample patients (Patients A1, A2, A3, A4, B1, B2, B3, and B4). This failure results in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented. (Refer to B123)

III. Ensure that registered nurses adequately documented nursing interventions related to those listed on the Master Treatment Plan to show detailed and comprehensive information about treatment for five (5) of eight (8) active sample patients (A1, A3, B1, B3, and B4). This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124)

IV.. Ensure that active programming was provided to the patients for significant periods of time on evenings and weekends for eight (8) of eight (8) active sample patients (Patients A1, A2, A3, A4, B1, B2, B3, and B4). This lack of active therapies resulted in these patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their discharge. (See B125-I)

V. Ensure that alternative treatment measures were offered to patients not attending the group treatment program and that groups were held when scheduled for four (4) of four (4) active treatment patients housed on 4 North. Specifically, the facility expected that all patients participate in the group treatment program. However, each group was not always held as scheduled and had very few patients attending. Failure to provide alternative active treatment measures to address each patient's need leads to patient problems not being addressed, and delays progress towards recovery. (Refer to B125-II)

Based on record review, document review, and interview, the Director of Social Work failed to:

I. Ensure that social work assessments reflected the anticipated role of the social worker in formulating interventions for inpatient treatment and discharge recommendations for eight (8) of eight (8) sampled patients (Patients A1, A2, A3, A4, B1, B2, B3, and B4). This failure results in an absence of commitment to specific professional social work treatment services on the Master Treatment Plans, which potentially could delay recovery. (Refer to B108)

II. Ensure that Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4) included individualized and specific social work interventions based on the unique psychiatric symptoms of each patient. Specifically, intervention statements were identical or similarly worded despite the different clinical presentations of patients. MTPs also included several intervention statements that failed to identify a focus of treatment based on clinical assessments. These deficiencies result in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to interdisciplinary treatment and potentially leads to inconsistent and ineffective treatment. (Refer to B122)


III. Ensure that the social worker responsible for each intervention was identified in the master treatment plans for eight (8) of eight (8) active sample patients (Patients A1, A2, A3, A4, B1, B2, B3, and B4). This failure resulted in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented. (Refer to B123)

IV. Ensure that social workers adequately documented active treatment interventions related to those listed on the Master Treatment Plan to show detailed and comprehensive information about treatment for five (5) of eight (8) active sample patients (A1, A3, B1, B3, and B4). This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124)

V. Ensure that active programming was provided to the patients for significant periods of time on evenings and weekends for eight (8) of eight (8) sampled patients (Patients A1, A2, A3, A4, B1, B2, B3, and B4). This lack of active therapies related to social work expectations resulted in these patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their discharge. (Refer to B125-I)

Based on document review and interview, the facility failed to provide an active therapeutic program for significant periods of time on evenings and weekends during their hospital stay for eight (8) of eight (8) active sample patients (Patients A1, A2, A3, A4, B1, B2, B3, and B4). This lack of active therapies results in these patients being hospitalized without all interventions for patient recovery provided to them, potentially delaying their discharge. (Refer to B125-I)