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Based on interview and record review the facility failed to implement hospital policy on Annual Performance Evaluation (APE) and Competency Skills (CS) for three Personnel (Staff 1, 2 and 4) when:
1. For Staff 1, the 2019 APE and CS were not done in a timely manner.
2. For Staff 2, the 2019 APE and CS were not done in a timely manner.
3. For Staff 4, the 2019 APE and CS were not done in a timely manner.

These deficient practices had the potential to negatively impact the care and services rendered to patients.

Definition:
"Performance Evaluation (P Eval) process provides a means for discussing,planning and reviewing the performance of each employee. It also provides management/leadership with an opportunity to assess the learning needs of staff. ...", according to hospital policy.

Competency Skills is a combination of observable and measurable knowledge, skills, abilities and personal attributes that contribute to enhanced employee performance and ultimately result in organizational success. (on-line search, definition by the University of Nebraska, Human Resource).

Findings:

1. During a concurrent review of the Personnel File (PF) with the Chief of Human Resource Officer (CHRO) on 7/10/19 at 2:05 PM, the CHRO searched the PF of Staff 1 and verified the last Annual Performance Evaluation (APE) was completed and signed by Staff 1 on 11/10/17 and the Department Supervisor (DS) on 11/9/17. The CHRO verified the last "Certified Nurse's Assistant (CNA) Competency Verification" was completed on 2/8/18. The CHRO stated APE and Competency Skills (CS) should be done annually.

2. During a concurrent record review of the PF of Staff 2 on 7/10/19 at 3:02 PM, the CHRO verified the last APE of Staff 2 was done and signed by Staff 2 and the DS on 9/12/16. The CHRO verified the last "RN (Registered Nurse) Skills Evaluation (RNSE)" was completed and signed by Staff 2 on 9/12/16. The CHRO stated APE and CS should be done annually.

3. During a concurrent record review of the PF for Staff 4 on 7/10/19 at 3:15 PM, the CHRO searched the PF of Staff 4 and verified the last APE was done and signed by Staff 4 on 10/24/16 and the DS signed on 10/17/16. The CHRO verified the last RNSE for Staff 4 was completed and signed by Staff 4 on 10/24/16. The CHRO stated APE and CS should be done every year.

During a concurrent record review of the PF for the three employees (Staff 1, 2, and 4) and interview on 7/11/19 at 8:10 AM, the Nurse Manager (NM) acknowledged the APE and CS for the three employees were not done in a timely manner, it should be done "annually". The NM stated it was necessary to make sure the staff met the required competency skills and met what was required in their job descriptions.

Review of the hospital policy titled: "Performance Evaluation" with effective date of 7/1/19 indicated: "Purpose: To establish ... to ensure each ... employee receives a performance evaluation, which included a competency assessment, ... policy: It is the policy ... to conduct ... annual performance reviews which shall included department-specific, ... competency assessments. ... Department Head maintains ... that performance evaluations and competency assessments are completed in a timely manner. ... Performance Review Schedule: ... Performance evaluations are conducted on an annual basis. ... Facility Assessment: ... The Annual review of competencies will be completed in conjunction with the Facility Assessment process. ... . "

Based on interview and record review the hospital failed to develop at least a three year capital plan. The deficient practice eliminated accountability that such a plan existed, and had the potential to cause inadequate resources to be available for necessary capital expenses.

Findings:

Review of the documents provided by the hospital regarding budget and capital plan indicated they included incomes, revenues and expenses for the current the two preceding years and the current year to date; an income statement per month, balance sheet with net operating income/loss. A separate document listed a "Fiscal Year 2020 Capital Budget". None of the documents listed proposed capital expenditures beyond FY 2020.

During an interview with the hospital CEO on 7/9/19 at 1:00 PM, he stated, "We don't have a three years capital expenditure plan. We did not know we were required to have one..."

Based on observation, interview and record review, the facility did not ensure a safe setting minimizing potential adverse events in twelve of twelve patients rooms, and in a common patient shower room, when:
1. There was no evidence of an environmental risk assessment to identify risk factors, including ligature risk, for the potential of patients self harm and suicide.
2. An electrical panel door in the unit hallway was found unlocked.

Failure to identify the environmental risk for patient's self-harm, may lead to an increase in adverse events including patient suicide.

Findings:

1. During the initial tour on 7/8/19 at 8:30 am, escorted by the Director of Social Services, (DSS), the Nurse Manager (NM) and the Program Director, (PD 2); in each of twelve patient rooms the following items were noted: the entrance door handles on each side of the door protruded from the door, three standard size hinges held the room door entrance and were not ligature resistant; the toilet vertical pipes and the hand sink pipes were exposed, soap dispensers and paper towel dispensers protruded 3 to 4 inches from the wall; a sturdy plastic box encased the room's thermostat six feet from the ground; and the room entrance doors were noted to remain closed at all times by a self closing device installed on the outer upper edge of the door. NM stated "Yes, you are right...We do patient rounds every 15 minutes...we have done an environmental risk assessment to check for ligature risk...". A copy of the assessment was requested.

During an observation on 7/8/19 at 9:25 am in the locked patient's common shower room, escorted by the two Program Directors (PD 1 and PD 2); it was noted: two metal fixtures for towel or clothes hanging protruded from the wall about 2.5 inches, two shower heads each situated 74 inches (6 feet and 2 inches) from the floor; was about 3.5 inches thick with an upper edge on an obtuse angle of about 95 degrees with the wall. The lower edge was straight from the wall, at 90 degrees; two shower handles and pipes were exposed. During a concurrent interview, PD 1 acknowledged the observations and stated "Yes, this room is where our patients take showers at different times during the day...we have identified some of these items...This is not an old building...we have requested capital budget approval for improvements..." A copy of any documentation identifying items as well as a copy of the capital improvements budget was requested.

During an interview and concurrent record review with PD 1 and PD 2 on 7/8/19 at 1:20 PM, PD 1 submitted a copy of the "...environment of care assessment tool we used...." The document was undated, 14 pages long and titled, "MHEOCC for Locked Mental Health Units, Criteria for Bathrooms" (MHEOCC stands for Mental Health Environment of Care Checklist, a tool developed for Veterans Affairs Hospitals to use to review inpatient mental health units for environmental hazards. The purpose is to identify and abate environmental hazards that could increase the chance of patient suicide or self-harm. The checklist has been used in all VA mental health units since October 2007). The document included components for "Mental Health Environment of Care Checklist for Bathrooms" audits with three columns for "Met/ Partially Met/ Not Met". There were no entries.

Page two indicated for "Paper Towel Holders, Are paper towel dispensers free of all anchor points?...An anchor point can also be created on some paper towel dispensers by knotting the end of a bath towel, sheet, or other ligature and....". Page 4 indicated about "Toilets...are all pipes and plumbing that could be used as an anchor point enclosed?...". Page 5 indicated about "Sinks...supply and waste plumbing concealed and inaccessible...? Showers...Are showers free of anchor points?..."

During a follow up interview with PD 1, on 7/8/19 at 1:45 PM, she stated "...Yes, I understand, if the assessment is not completed and in writing, it has not been completed...We don't have it writing..."

On 7/10/19 at 2 PM, seven Governing Body meeting minutes dated : 4/24/19, 2/27/19, 1/9/19, 12/5/18, 11/1/18, 8/21/18 and 6/27/18; were reviewed. The minutes did not include reference to the APU QAPI program, and to facility approach to minimizing the ligature risk of patients in the APU.

During an interview with PD 1 and the Assistant Director of Facility Operations (FO) on 7/11/19 at 8:05 am, when asked about a rationale for the self closing device on each room entrance door of all patients rooms keeping the door closed, PD 1 stated "Yes, that is correct, we can not install door holders...we encourage patients to come out to activities...we do rounds every 15 minutes on all patients..." FO stated "These are fire doors, my understanding is we can not install door holders..." Both PD 1 and FO were asked to provide documentation justifying keeping the patients room doors closed.

Record review of a one page printed document from "cms.gov" submitted by NM 1 on 7/11/19 at 12:10 PM, indicated a reference to door protecting corridors "...There is no impediment to the closing of doors...". The same document stated below "Hold open devices that release when the door is pushed or pulled are permitted."

During a follow up interview with NM on 7/11/19 at 12:35 PM, she stated "...I guess we could have door holders installed...I will follow up with FO..."

During an interview with the PD 2 on 7/10/19 at 1:30 PM, she stated "We don't have a safety plan...we have other things, I was not aware we are required to have one..."

Review of https://psnet.ahrq.gov/ on 4/2019, a website from Agency for Healthcare Research and Quality AHRQ Patient Safety Network (PSNet), a national web-based resource featuring the latest news and essential resources on patient safety; and of CDC.gov; Centers for Disease Control and Prevention, a government agency website, indicated regarding suicide risk in the hospital: "...Of the 35,000 or more suicides per year in the United States, about 1800 (6%) are inpatient suicides...In psychiatric hospitals, the most frequent method of suicide is hanging, and 75% of inpatient suicides occur in the patient's bathroom, bedroom, or closet...It only takes 4 or 5 minutes of adequate pressure on the carotid arteries in a person's neck to produce death by oxygen deprivation to the brain. Thus . . . 15-minute suicide watches tend to allow a patient sufficient time to commit suicide...Common areas for concern on psychiatric inpatient units are ligature attachment points that pose a hanging risk from a sitting or kneeling position. It is well known that the greatest risk areas are where patients are provided privacy or are otherwise unobservable by staff... Plumbing fixtures also provide hanging risks..."


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2. During the initial tour on 7/8/19 at 8:38 AM, accompanied by the Director of Social Services (DSS) and the Nurse Manager (NM), the panel door of the Circuit Braker (CB is an automatically operated electrical switch designed to protect an electrical circuit from damage caused by excess current, typically resulting from an overload or short circuit. Its basic function is to interrupt current flow after a fault is detected) on the wall, near patient's room 632, was closed but was left unlocked. The NM called the attention of the Director of Maintenance (DM) who happened to be on the unit.

During an interview on 7/8/19 at 8:41 AM, the NM stated it should be locked because patients could do something to harm themselves.

During an interview on 7/8/19 at 8:43 AM, the DM came and checked the panel door, "it's unlocked" and stated it should be locked.

Based on interview and record review, the facility failed to document that its governing body had reviewed and approved the ongoing QAPI and safety program. The Acute Psychiatric Unit (APU) quality improvement activities were not identified in the 2018 QAPI Plan. The APU did not have a Patient Safety Plan.

The deficient practice reduced the governing body's leadership role regarding quality assessment and performance improvement (QAPI) and may adversely impact patients quality of care.

Findings:

During an interview with NM, PD 1 and PD 2 on 7/10/19 at 11 AM the QAPI program was reviewed. NM stated "Our QA Committee members are the nurse manager, the program directors, medical director, and the infection control preventionist..." Pharmacy was not listed as a member. NM described current indicators under monitoring included: falls, episodes of seclusion and restraints, and suicide risk. QAPI program documentation regarding improvement projects, process of approval including frequency with detail of data collection and the patient safety plan was requested.

On 7/10/19 at 2 PM, seven Governing Body meeting minutes dated : 4/24/19, 2/27/19, 1/9/19, 12/5/18, 11/1/18, 8/21/18 and 6/27/18; were reviewed. The minutes did not include reference to the APU QAPI program approval of projects, components, data collection, etc.

During an interview with NM and PD 1 on 7/10/19 at 1:10 PM, PD 1 stated "We do not have a Patient Safety Plan...I was not aware we are required to have one...we have other things..."

During an interview with NM and PD 1 on 7/11/19 at 8:20 AM, they acknowledged there was no evidence of the APU QAPI program projects, process of approval and oversight by the governing body. NM stated "Thank you for the transparency..."

Record review of a 14 page copy of the facility's "QAPI Plan 2018" indicated a "Effective Date: 19 Feb 2019" and a provider number corresponding to a long term care program in the same building. The document included "...Guiding Principles...Care and Services...Defining and Measuring Goals...Specific metrics are established, which can be updated throughout the year to reflect progress on QAPI activities...The QAPI Committee is responsible for providing an annual report on the QAPI Program to the Board of Trustees [Governing Body]...Monitoring...". The document did not make reference to the Adult Psychiatric Unit.

Record review of a facility policy with Effective Date: 11/28/17, titled QAPI Program-General indicated under "Purpose: To establish a policy and procedure that prompts the creation of a comprehensive QAPI program. Policy: It is the policy of the [Facility Name] to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life..."

Based on, interview and record review the facility failed to ensure Telephone/Verbal Orders (T.O./V.O.) for two Patients (Patients 4 and 6) were authenticated by the prescribing physicians within 48 hours as per hospital policy when:1. For Patient 4, the pre-printed Physician's Order document titled: "Supplemental Sheet", dated 7/5/19 by the Registered Dietitian (RD) with order for for Nutritional Supplements (NS, such as Beneprotein and Boost Glucose Control) was not authenticated by the physician. Patient 4 was given the NS (Beneprotien and Boost Glucose Control) as indicated in the Medication Administration Record (MAR) dated July, 2019.
2. For Patient 6, the T.O. dated 6/20/19 for Megace (drug to treat loss of appetite), Intravenous Fluids (IVF) for Normal Saline, and calorie count were not signed by the prescribing physician. This deficient practice had the potential for Medication Error(s) to happen.

Definitions:
1. "Telephone Order and Verbal Order is an order not directly written by the physician".
"Telephone orders are those orders received verbally over the telephone. Verbal orders are orders in a face to face situation", as define in the "General Knowledge" section of the hospital policy.
2. Medication Error(s) is "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of a healthcare provider, patient, or consumer". This definition is based on the one stated by the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP).

Findings:

1. Review of the Face Sheet indicated Patient 4 was admitted to the hospital on 6/23/19 at 1:55 PM. The Admission Psychiatric Assessment document dated 6/23/19 indicated a diagnoses that included generalized anxiety disorder (group of mental disorders characterized by significant feelings of anxiety and fear. Anxiety is a worry about future events, and fear is a reaction to current events); and major depression (mood disorder).

During a record review of the pre-printed Physician's Orders (POs) document dated 7/5/19 at 2:50 PM, it indicated: "RD (Registered Dietitian) Evaluation ... Boost Glucose Control (BGC) 8 (eight) oz (ounce) Q (every) meal, ... Beneprotien 1 (one) scoop Q meals, ...", and the line that stated "Above recommendation reviewed & (and) ordered by: ___, M.D. (Physician)" was not signed.

During a review of the July, 2019 Medication Administration record (MAR) it indicated the Beneprotein was given on 6/7/19 at 8:00 AM and the BGC was given on 6/7/19 at 8:00 AM and 12 Noon as evidence by the Licensed Nurses (LNs) initials.

During a concurrent record review of the POs document dated 7/5/19 and interview with the Nurse Manager (NM) on 7/8/19 at 1:00 PM, the NM verified Patient 4 received both NS and the order was not authenticated by the prescribing physician before it was given. The NM stated POs should be authenticated "within 48 hours" as per policy.

2. Review of the Face Sheet indicated Patient 6 was admitted to the hospital on 6/11/19 at 1:20 PM. The Admission Psychiatric Assessment document dated 6/12/19 indicated diagnoses that included major depressive disorder and cognitive dysfunction (loss of intellectual functions such as thinking, remembering, and reasoning of sufficient severity to interfere with daily functioning), signed by the physician on 6/14/19.

During a concurrent record review of the the POs document dated 6/20/19 at 6:30 PM and interview on 7/8/19 at 2:42 PM, it indicated a Telephone Order (T.O.) to continue "D5 (dextrose 5 %) normal saline at 50 ml (milliliter)", start "Megace" 400 mg (milligrams) tablet daily, and 3 (three) day calorie count. The NM acknowledged the T.O. dated 6/20/19 was not authenticated by the prescribing physician. The NM stated T.O. should be authenticated "within 48 hours" as per policy.

Review of the hospital policy titled: "Telephone and Verbal Orders" with last revised date of 10/16 indicated: "Purpose of Statement: To ensure the accurate recording of telephone and verbal orders. Policy: 1. ... 3. Telephone orders must be signed, dated, and timed by the physician within 48 hours of being given per regulations ... General knowledge: ... Procedure: 1. ... 6. Verbal orders must be signed immediately. 7. Telephone orders ... must be signed, dated and timed by the prescriber within 48 hours".

Based on interview and record review the facility failed to ensure the Discharge Summary (DS) was completed for one patient (Patient 12) when the DS was not done within 14 days post discharge as per policy. This deficient practice had the potential to negatively impact the follow-up and continuity of care of the patient.

Definition: 1. "A Discharge Summary (DS) discusses the outcome of the hospitalization, the disposition of the patient, and provisions for follow-up care. Follow-up care provisions include any post hospital appointments, how post hospital patient care needs are to be met, and any plans for post-hospital care by providers such as home health, hospice, nursing homes, or assisted living.", as define in the State Operations Manual (SOM), Appendix A.

Findings:

During a closed record review the Admission Psychiatric Assessment document dated 3/22/19 indicated Patient 12 was admitted to the hospital on 3/21/19 "on a 5150 (the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) for grave disability (Welfare and Institutions code section 5008 (h)(1) (A) defines the term "gravely disabled" as a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter)" with the diagnoses that included schizophrenia (a chronic mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others) and chronic kidney disease (a type of kidney disease in which there is gradual loss of kidney function over a period of months or years), signed by the physician on 3/25/19 at 12:30 PM.

During a concurrent record review of the Physician's Order (PO) document dated 6/12/19 and interview with the Nurse Manager (NM) on 7/9/19 at 12:38 PM, the NM read the order dated 6/12/19 at 1:30 PM, to give Lorazepam (drug that belongs to a class of medications called benzodiazepines, which produce a calming effect on the brain and nerves) 0.5 mg (milligrams) by mouth tomorrow prior to transport to another facility. The NM stated patient was discharged on 6/13/19 to a locked facility.

During a concurrent review of the Medical Records (MR) and interview on 7/9/19 at 12:45 PM, the Nurse Manager (NM) searched the entire MR and verified there was no Discharge Summary (DS) on file. The NM stated she checked with the physician who followed the patient and was told the DS would be completed "today". The NM stated the DS should be done within 14 days post discharge as per policy.

Review of the hospital policy titled: "Physician Supervision of Patient Care" with the last revised date of 11/18 indicated: "Purpose: ... Procedure: 1. ... 5. Patients must have a physician order for transfer to another facility. ... A progress notes shall be completed ... and diagnosis at time of transfer. 5. The patient shall be discharge only with written order of the physician. 7. A discharge summary shall be completed within fourteen (14) days of discharge. ... ."

Review of the Medical Bylaws, Medical Staff Rules and Regulations, with the last reviewed/ revised date and signatures of hospital leadership on 3/19/19 indicated: "The Purpose of the Medical Staff is to support ... mission, and provide quality medical and psychiatric care to designated population. ... N. Completeness: 1. 3. If the medical record is not complete at the time of discharge, the following action will be taken by the Hospital: a) ... b) If the practitioner fails to complete the medical record within fifteen (15) days of discharge, actions, ... will be initiated pursuant to the Medical Bylaws. Failure to complete medical records will result in corective action in accordance with procedures specified in the Medical Bylaws. .. . "

Based on interview and record review, the hospital pharmacist failed to provide the pharmaceutical services described in the contracted services. The pharmaceutical services were not evaluated routinely and no quarterly assurance report was prepared as required by the contract.

Failure to keep an oversight of pharmaceutical services may negatively impact quality of care by potential adverse events, including medication errors.

Findings:

During an interview with the Facility Pharmacist (FPharm) on 7/9/19 at 9:15 AM, to review pharmaceutical services provided, FPharm stated "Pharmacy was a contracted service I am the pharmacist assigned to the Acute Psychiatric Unit APU... I don't check the medications room or the medications cart used in this unit...I do not do consulting services...I am not involved with reviewing nursing staff medications pass...I don't check controlled substances other than replacing those when the emergency kit supply is used. Only if there is a problem I would be involved...I don't do reports..."

Record review of a 20 page copy of the "Pharmacy Provider Agreement" (PPA) between a pharmaceutical company and the "Facility", and two 4 pages attachments each, indicated "Background A. Facility is engaged in the business and operation of providing long-term care services for which it requires pharmacy products in accordance with applicable local, state and federal laws and regulations..." The documents made no reference to the pharmaceutical services provided to the APU hospital, an entity of 13 licensed beds, sharing the building with a large long term care facility.

During a concurrent interview with the Nurse Manager (NM), PD 1 and PD 2, on 7/10/19 at 8:25 AM, they acknowledged the PPA language contract did not spell out services to be provided in the facility APU and there was no specific reference to the APU describing the provision of pharmaceutical services. The responsibilities of the pharmacist were not clearly defined and did not include developing supervision and coordination of all the activities of pharmacy services. There was no evidence of monitoring of medication room and med cart integrity, pharmacy involvement with staff proficiency skills for med administration, tracking of med errors, adverse drug reactions, potential drug incompatibilities etc. PD 1 stated "Yes...I think the APU is embedded in the contract language...It should be spelled out..."

During a concurrent interview with NM, PD 1 and PD 2 on 7/10/19 at 11 AM to review Quality Assurance, NM stated "Our QA Committee members are the nurse manager, the program directors, medical director, and the infection control preventionist..." Pharmacy was not listed as a member.

During an interview with NM and PD 1 on 7/11/19 at 8:20 AM, they acknowledged there was no evidence of the APU QAPI program projects, process of approval and oversight; as well as the evaluation of the Pharmacy services as stated in the current facility contract, by the governing body. NM stated "Thank you for the transparency..."

California Code of Regulations Title 22 70265 stipulates that a pharmacist shall have overall responsibilities for the pharmaceutical service. He shall be responsible for the procurement, storage, and distribution of all drugs as well as the development, coordination, supervision and review of pharmaceutical services in the hospital. The pharmacist shall be responsible to the administrator and shall furnish written reports and recommendations regarding the pharmaceutical services within the hospital. Such reports shall be provided no less than quarterly.

Based on observation, interview, and record review the facility failed to ensure records of Scheduled Drugs ("Drugs and other substances that are considered controlled substances under the Controlled Substances Act (CSA) are divided into five schedules. An updated and complete list of the schedules is published annually in Title 21 Code of Federal Regulations (C.F.R.) §§ 1308.11 through 1308.15. Substances are placed in their respective schedules based on whether they have a currently accepted medical use in treatment in the United States, their relative abuse potential, and likelihood of causing dependence when abused". On-line search: https://www.deadiversion.usdoj.gov/schedules/index.html#) were reconciled when:
1. Four (4) doses of Lorazepam (Schedule IV CS, also known as Ativan, belongs to a class of medications called benzodiazepines, which produce a calming effect on the brain and nerves) 2 mg (milligrams)/ml (milliliter) vials taken out of the Emergency Kit (E-Kit) in 2017 were not reconciled.
2. One (1) dose of the Lorazepam 2 mg/ml taken out of the E-Kit on 3/30/18 was not reconciled.
3. The receipt of the "Controlled Substances (CS)" documents were not signed and dated by the receiving Licensed Nurses (LNs).
These deficient practices could not guarantee accountability of CS and had the potential for Drug Diversion to happen.


Definitions:
Controlled Substances: "The term 'controlled substance' means a drug or other substance, or immediate precursor, included in schedule I, II, III, IV, or V of part B of this subchapter", as define in Title 21 (United States Code (USC), Controlled Substance Act, Subchapter 1 - Control and Enforcement, Part A, 802: Definitions (6).

Drug diversion: "is the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber", as defined by the Center for Medicare & Medicaid Services (CMS).

Emergency Kit: E-kit, are those drugs and supplies which may be required to meet the immediate therapeutic needs of clients and which are not available from other authorized sources in sufficient time to prevent risk or harm to clients.


Findings:

1. During the initial tour of the Medication Room and interview on 7/8/19 at 10:10 AM, the Registered Nurse (RN) 1 opened the Medication Refrigerator and verified there were four (4) vials of Lorazepam 2 mg (milligrams) per milliliter (ml) inside the Emergency Kit (E-kit).

During a concurrent record review of the 2/14/17 to 6/26/19 Scheduled Drug Record (SDR) document for Lorazepam 2 mg/ml and interview with RN 1, it indicated there were 4 (four) vials of Lorzepam 2 mg/ml delivered and received on 2/14/17 and the signatures of the receiving Licensed Nurses were missing. The RN 1 verified LNs signatures were missing on the SDR document.

The SDR document indicated Lorazepam 2 mg/ml were taken out of the E-kit on 3/30/17, "administered 0.25 ml, 0.75 wasted", and on 9/26/17, 10/23/17 and 10/29/17, it indicated, "0.5 ml /1 mg wasted". The names of the patients who received the doses of the Lorazepam were not mentioned on the SDR document.

The RN 1 acknowledged the name of the patients who received the doses of Lorazepam were not mentioned on the SDR document and stated the name of the patients were documented on a separate form called the "Emergency Supply Sign Out Log (ESSL)" kept in a separate binder. The RN 1 and the Nurse Manager (NM) searched patients Medical Records, including the ESSL documents, but could not provide evidence the Lorazapem were administered to patients in 2017.

2. During a concurrent record review of the SDR document dated 1/5/18 to 11/15/18 and the March 2018 ESSL documents, with the RN 1 and interview on 7/8/19 at 10:22 AM, the RN 1 acknowledged the dose of Lorazepam given on 3/30/19 at 12:30 PM could not be reconciled. The RN 1 and the Nurse Manager (NM) searched every patient's Medication Administration Records (MARs) but could not provide evidence the dose of Lorazepam taken out of the E-kit on 3/30/19 was reconciled.

During a concurrent record review of the SDR document dated 2/14/17 to 6/26/19 and interview on 7/9/19 at 9:16 AM, the Facility Pharmacist (F Pharm) stated Pharmacy was a contract service which included delivering medications and providing delivery receipt, reconciling medications in the E -kit, and participating in the development of policies but not Medication Cart (MC), "I don't check med cart", no Med Pass review, "I don't check controlled substance", only the E-kit. The F-Pharm further acknowledged having no oversight provided for the use of CS, but would get involved only if there would be a problem.

Review of the hospital policy titled "Emergency Pharmacy Service and Emergency Kits" dated 12/17 indicated: "Policy: Emergency pharmacy service .... for medications are met by using the facility's approved emergency medication supply ... Procedures: A. ... G. ... 6) Use of emergency medication is noted on the resident's medication administration record (MAR). ... L. The kits are monitored/inventoried by the [consultant pharmacy/provider pharmacy] at least thirty (30) days. ... ."

3. During a concurrent record review of the undated, unsigned documents titled "Controlled Substances (CS)" and interview on 7/8/19 at 10:14 AM, the Registered Nurse (RN) 1 stated the CS documents were receipts of the CS, such as Clonazepam (Schedule IV CS, is a benzodiazepine, it affects chemicals in the brain that may be unbalanced), Lorazepam (Schedule IV CS, belongs to a class of drugs known as benzodiazepines which act on the brain and nerves (central nervous system) to produce a calming effect) methylphenidate (another is Ritalin, Schedule II CS, central nervous system stimulant. It affects chemicals in the brain and nerves that contribute to hyperactivity and impulse control), Hydrocodone, (Schedule II CS, group of drugs called narcotic pain relievers), Morphine (Schedule II CS, opioid pain medication), for different patients received by the License Nurse(s) (LNs) when it were delivered to the hospital by the contracted pharmacy. The CS documents contained the names of the patients, records of the name and amount of precribed drugs, and the name of the prescribing physician. At the bottom of the CS document, it read: "By signing below you acknowledge that the items above have been received:". The signatures and dates of the "Supervising Nurse" and another "Nurse" were missing. The RN 1 acknowledged the signatures of two (2) LNs on the documents were missing and stated, "we don't sign it." The RN 1 further stated, "we accept the count of narcotics and we print the date, but we don't sign it."

During concurrent record review of the undated, unsigned CS documents and interview on 7/8/19 at 10:28 AM, the Nurse Manager (NM) stated she started her new position about three months ago and acknowledged the CS documents were not signed and dated by the receiving LNs, "yes, it is the practice." The NM stated staff should signed the CS documents, there should be two (2) LNs to sign CS documents upon receipt. When asked, the NM stated it was necessary to ensure staff accountability and to prevent drug diversion.

During a concurrent record review of the undated, unsigned CS document and interview on 7/9/19 at 9:19 AM, the F Pharm acknowledged having no oversight provided for the use of CS, but would get involved only if there would be a problem.

Review of the hospital policy titled Receiving Controlled Substances dated 12/17 indicated: "Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances ... are subject to special ordering, receipt and record keeping requirements ... in accordance with federal and state laws regulations. Procedures: A. ... K, Only licensed personnel may receive controlled substances ... . Procedures for receiving controlled substances include: 1) ... 2) A nurse reconciles controlled substances orders ... 5) Controlled substance inventory sheets are completed, ... per state regulations.... . "

Based on observation, interview, and record review the facility failed to implement Infection Control practices when:
1. The signage for Contact Precaution was not posted outside the door of Patient 6's room.
2. Expired medical supplies such as: two (2) vacutainer tubes (a vacutainer blood collection tube is a sterile glass or plastic test tube with a colored rubber stopper creating a vacuum seal inside of the tube, facilitating the drawing of a predetermined volume of liquid. Vacutainer tubes may contain additives designed to stabilize and preserve the specimen prior to analytical testing) with gray top, three (3) blood culterrettes tubes, and two (2) individually packed sputum swabs, were stored in the Supply Cabinet inside the Medication Room.
These deficient practices had the potential for transmission of communicable diseases and other Healthcare Associated Infections (HCIA).

The following definitions are found in the hospital's policy on "Infection Control Prevention and Control Program" dated 3/2019.

Contact Precautions: "Measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment."

Healthcare Associated Infection: (HAI), "an infection that residents acquire, that is associated with a medical or surgical intervention (e.g. podiatry, wound care debridement) within a nursing home and was not present or incubating at the time of admission."

Communicable Disease: "an infection transmissible (e.g. from person-person) by direct contact with unaffected individual or individual's body fluids or by indirect means (e.g. contaminated object)".

Personal Protective Equipment (PPE): "Protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-contamination.", as define in the hospital policy.

Standard Precaution: "Infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. Standard precaution is based on the principle that all blood, body fluids, secretions, excretions except sweat, regardless of whether they contain visible blood, non-intact skin, and mucous membranes may contain transmissible infectious agents."

Transmission-based Precautions: "(a.k.a. "Isolation Precautions") Actions (precautions) implemented, in addition to standard precautions, that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections."

Findings:

1. Review of the Face Sheet indicated Patient 6 was admitted to the hospital on 6/11/19 at 1:20 PM. The Admission Psychiatric Assessment dated 6/12/19 indicated the diagnoses that included major depressive disorder (mood disorder) and cognitive dysfunction (loss of intellectual functions such as thinking, remembering, and reasoning of sufficient severity to interfere with daily functioning), signed by the physician on 6/14/19.

During the initial tour on 7/8/19 at 9:03 AM, the door to Patient 6's room was closed and there was no signage posted outside the door. The Nurse Manager (NM) knocked at the closed door, slightly opened the door and introduced herself, called patient's name and walked inside the room with no Personal Protective Equipment (PPE). Patient 6 verbalized she did not want any visitor at this time.

During an interview on 7/10/19 at 9:17 AM, the Infection Control Preventionist (ICP) stated the urine culture dated 7/2/19 indicated "MRSA" (Methicillin-resistant Staphylococcus aureus, is an infection caused by a strain of bacteria that are resistant to certain antibiotics, making it challenging to treat). The ICP stated she decided to place Patient 6 on Contact Precaution (CP) when the culture came back on 7/5/19 and instructed the License Nurse (LN) to get an order for CP. The ICP further stated, for CP there should be a signage outside the door that would read, "Contact Precaution", staff should be wearing Personal Protective Equipment (PPE) such as gown, mask and gloves when caring for patient and PPE were kept in the Nurse's Station for this particular unit for safety reason.

During review of the urine culture result dated 7/2/19 it indicated: "Culture result: 50,000 - 75,000 CFU (colony-forming unit, is a measure of viable bacterial or fungal cells. CFU measures only viable cells. For convenience the results are given as CFU/ml (colony-forming units per milliliter) for liquids, and CFU/G (colony-forming units per gram) for solids) / ml (milliliter), Methicillin-resistant Staphylococcus aureus, Organism 1: Staphylococcus aureus (MRSA)."

During a concurrent review of the Physician's Order (POs) dated 7/5/19 with the ICP, it indicated an order to start antibiotic for 10 (ten) days for "MRSA -urine." The ICP searched the entire medical records and verified there was no written order for "Contact Precaution".

During an observation accompanied by the ICP and interview on 7/10/19 at 9:25 AM, the door to Patient 6's room was closed, there was no signage posted outside the door. The ICP stated there should be a sign outside the door indicating patient was on CP.

During an interview with the ICP and the Certified Nurse Assistant (CNA) 1 on 7/10/19 at 9:45 AM, the CNA 1 stated she was just told Patient 6 was on CP and had put the signage inside the patient's room, near the bathroom. The ICP stated the signage should be posted outside the door.

Review of the hospital policy titled: "IPCP (Infection Prevention and Control Program) - How to Use Standard Precautions and When to Use Transmission- Based Precautions" with the last review date of 2/2019 indicated: "Purpose: ... Policy: XXX (name of the hospital) policies will ensure a system ... designed to provide a safe, sanitary ... to help prevent the development and transmission of communicable diseases and infections ... . How and When to use transmission-Based Precautions: ... When a resident is placed on transmission-based precautions, the facility staff will implement the following: ... Place a signage in a conspicuous place outside the resident's room such as the door ... identifying the CDC (Center for Disease Control) category ... (e.g. contact, droplet, or airborne) ... . Contact Precautions: ... are intended to prevent transmission of infections that are spread by direct ... or indirect contact ..., and require the use of appropriate PPE ... ."

2. During an observation of the Medication Room (MR) with the Nurse Manager (NM) on 7/8/19 at 9:23 AM, expired medical supplies were stored in the Supply Cabinet: two (2) vacutainer tubes with gray top had expiration dates of 2/28/19, three (3) blood culterrette tubes had expiration dates of 6/30/19, and 2 (two) sputum swabs had expiration dates of 6/30/19.

During an interview on 7/8/19 at 9:48 AM, the NM acknowledged the items were expired and stated expired items could not be used for patients.

Review of the hospital policy titled Medical Supply Management with the effective date of 7/19, indicated: "Purpose: To ensure medical supplies used in the care of our patients ... are current and had not expired. Policy: ... Procedure: Central Supplies Responsibilities: ... Nursing Units and Department Responsibilities: ... Expired supplies will be removed from use ... ."

This condition is not met as evidenced by:

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

I. Ensure that collaborative, individualized multidisciplinary treatment plans were developed for all patients. (refer to B118)

II. Ensure that the Master Treatment Plans (MTPs) are modified and updated based on patients' current physical and psychiatric condition. A failure to do so jeopardizes a timely, coordinated treatment process. (refer to B118 and B125)

III. Ensure active treatments, including alternative treatments, were provided to patients who are unable or unwilling to participate in routine unit programs. (refer to B125)

Based on observation, record review and interview it was determined for one (1) of eight (8) patients (A3), the facility failed to perform and document a comprehensive physical examination identifying all of the physical problems, including neurological problems, requiring ongoing evaluation and/or treatments. The absence of this patient information limits the treatment team's ability to accurately diagnose the patient's condition and to provide a measure of baseline functioning, thereby potentially adversely affecting patient care.

Findings include:

A. Record review:

Patient A3 was hospitalized on 6/22/19 with a diagnosis, per psychiatric assessment of 6/22/19, of, "Primary diagnosis: 1) Schizoaffective disorder, bipolar type. 2) Unspecified anxiety disorder by history, 3) History of drug induced parkinsonism. Secondary diagnosis: Benign essential tremor, sleep apnea with CPAP, history of thrombocytopenia to Depakote on higher doses, fatty liver, hyperlipidemia, bilateral glaucoma, prediabetes, peripheral edema." The Multidisciplinary Treatment Plan (MTP) of 6/24/19, and weekly reviews on 6/28/19 and 7/5/19, had listed and included various interventions for "History of Drug-Induced Parkinsonism, Benign Essential Tremor, Bilateral Glaucoma, Respiratory Problem, Cardiac Problem, High Risk for Falls." Review of patient's "Admitting History & Physical" (H&P), completed on 6/24/19, under neurologic examination stated patient as "confused" and all of the cranial nerve examinations as "normal." The final part of this document, "Problem List," had "Problem #1 Schizoaffective Disorder, Problem #2 Questionable overdose." and no physical problems were identified.

The Admission Nursing Assessment, completed on 6/22/19, indicated under "Ambulation: 2-person assist, with device: Type- Wheelchair." Under Gastrointestinal: "Incontinent of BM (Bowel Movement)." Under Genitourinary: "Bladder incontinent" was checked off. The daily risk assessment screening from 6/22/19 to 7/5/19 indicates a score of 29, indicating the patient as "High risk for a fall."

B. Observation and patient interview:

The patient A3 was observed on 7/10/19 at 2:45 p.m. The patient was in the bed with 1:1 staffing. The patient upon interview exhibited extreme psychomotor retardation and answered most questions with "I don't know." On 7/11/19 at 12:40 p.m. patient A3 was observed in bed and he/she was being fed by 1:1 staff. Upon inquiring about his/her mobility, the patient admitted to being unsteady on his/her feet and stated, "need help to walk." Hand tremors were observed.

C. Staff interview:

In a meeting with the Medical Director on 7/11/19 at 3:00 p.m., the above deficient practices regarding the "History & Physical" examinations were reviewed. He did not dispute the findings and further described the H&P as "not satisfactory."

Based on record review, policy review and interview the facility failed to collaboratively develop comprehensive, individualized Master Treatment Plans (MTPs) for 8 of 8 active sample patients, A1 (MTP dated 6/29/19), A2 (MTP dated 6/26/19), A3 (MTP dated 6/24/19), A4 (MTP 6/24/19), A5 (MTP dated 5/3/19), A6 (MTP dated 6/12/19), A7 (MTP dated 6/21/19), and A8 (MTP dated 7/1/19).

I. The treatment interventions developed were generic and not individualized. (See B122)

II. The MTPs consisted of separate sections for Social Work and Recreation Therapy [RT]. These included different goals from the goals identified by the physician and nurse in the front of the MTP.

III. The MTPs for one (1) of eight (8) active sample patients (Patients A3) were not revised to reflect that they were unable/unwilling to attend scheduled groups and did not include alternative treatment interventions. (See B125)

IV. For four (4) of eight (8) sample patients (A2, A4, A5 and A6), the MTPs did not reflect interventions provided by the psychologist.

The absence of an integrated, comprehensive and collaborative Master Treatment Plan resulted in a lack of coordinated and organized treatment; potentially prolonging patients' stays.

Findings:

A. Record Review

1. All 8 selected sample patients had MTPs with separate sections for Social Work and Recreation Therapy. These consisted of additional goals which were developed by Social Work and Recreation Therapy independent of the goals developed by the physician and nurse. The resulting document structure did not indicate that the MTP was developed in a collaborative manner with by all disciplines.

2. Patient A3's MTP was not revised to reflect that s/he was unwilling/unable to attend groups and did not include alternative interventions. Although the facility offers 3-4 groups daily, the patient had only attended 1 between admission on 6/22/19 and 7/9/19. The RT note of 7/9/19 states the patient as saying, "I can't stand up by myself so how can I go?" The patient had ambulatory problems. (see B109)

As of 7/10/19 the intervention stated:

"[Patient] will voluntarily attend at least 3 groups for at least 15 minutes in the next 7 days."

3. The psychologist completed the following progress/treatment notes indicating treatment provided, but did not include these interventions in the MTPs:

Patient A2: Psychologist note dated 7/8/19. There were no psychology interventions in the MTP.

Patient A4: Psychologist notes dated 7/8/19 and 7/10/19. There were no psychology interventions in the MTP.

Patient A5: Psychologist note dated 7/8/19. There were no psychology interventions in the MTP.

Patient A6: Psychologist note dated 7/2/19. There were no psychology interventions in the MTP.

B. Policy Review

1. The facility policy titled "Assessment/Reassessment Treatment Plans and Documentation" and last reviewed 9/18 stated, "The treatment plan is developed in collaboration with the interdisciplinary team."

2. The facility policy titled "Treatment Planning/Interdisciplinary Team Process" and last reviewed 12/18 stated, "Treatment Plans are revised as needed and reviewed/updated at least weekly as the patient's condition dictates or in preparation for discharge."

C. Interviews

1. On 7/11/19 at 2:00 p.m., the Director of Social Work stated, "I understand that the plan needs to be more integrated."

2. On 7/11/19 at 2:45 p.m., the Medical Director did not dispute that the treatment plans had not been revised.

3. On 7/11/19 at 1:00 p.m., the Program Director stated that psychology interventions were not included in the MTPs because the psychologist "is on a contract."

Based on record review, policy review and interview, the facility failed to develop individualized treatment interventions for eight (8) of eight (8) active sample patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8). The interventions were generic discipline functions. The Social Work interventions were identical for the 8 patients. This deficiency resulted in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention and potentially resulted in inconsistent and/or ineffective treatment.

Findings:

A. Record Review

1. Patient A1 had the following nursing intervention for the Problem of Major Depressive Disorder, "Nursing teaching 1:1 on medication indication and potential side effects such as: dizziness, dry mouth, nausea, headache, sleep problem, strange dreams."

Patient A1 had the following social work interventions for the Problem of Depression: "Meet with patient at admission to discuss [their] preferences in discharge. Make appointments with appropriate providers for follow up. Offer patient opportunity to sign release of information forms for all providers to facilitate continuity of care. Fax prescriptions to patient's pharmacy, ensure they were received and ensure hard copies are created for medications that require them. Review initial treatment plan with [patient]. Discuss the treatment plan, request input, answer questions and offer copy. Coordinate family meetings to facilitate communication regarding patient care and safe discharge."

Patient A1 had the following recreation therapy interventions for the Problem of Major Depression: "Staff will build rapport. Staff will invite and escort out to groups. Staff will promote time out of bed and encourage and promote active attendance in all groups programs."

These interventions were generic discipline functions and were not individualized to meet the patient's needs.

2. Patient A2 had the following nursing interventions for the Problem of Status Post Suicide Attempt: "Nursing teaching 1:1 on medication indication and potential side effects such as: drowsiness, weakness, constipation, vision changes, insomnia."

Patient A2 had the identical social work interventions as noted on Patient A1.

Patient A2 had the following recreation therapy interventions for the Problem of Suicidal Ideation: "Staff will provide a therapeutic atmosphere encouraging [patient] to be relaxed and in a better mood. Staff will encourage a positive attitude through positive engagement and rapport."

These interventions were generic discipline functions and were not individualized to meet the patient's needs.

3. Patient A3 had the following nursing intervention for the Problem of Schizoaffective Disorder: "Nursing teaching 1:1 on medication indication and potential side effects."

Patient A3 had the identical social work interventions as previously noted.

Patient A3 had the following recreation therapy interventions for the Problem of Schizoaffective Disorder: "Staff will invite and escort to daily groups. Staff will promote relaxation."

These interventions were generic discipline functions and were not individualized to meet the patient's needs.

4. Patient A4 had the following nursing intervention for the Problem of Generalized Anxiety Disorder: "Nursing teaching 1:1 on medication indication and potential side effects."

Patient A4 had the identical social work interventions as previously noted.

Patient A4 had the following recreational therapy interventions for the Generalized Anxiety Disorder; "Staff will invite and escort to programs and encourage attendance. Staff will encourage [patient] to self- regulate."

These interventions were generic discipline functions and were not individualized to meet the patient's needs.

5. Patient A5 had the following nursing intervention for the Problem of Paranoid Schizophrenia: "Nursing teaching on medication indication and potential side effects."

Patient A5 had the identical social work interventions as previously noted.

Patient A5 had the following recreation therapy interventions for the problem of Paranoia: "Staff will invite and escort to daily groups. Staff will monitor for improving or worsening mood."

These interventions were generic discipline functions and were not individualized to meet the patient's needs.

6. Patient A6 had the following nursing intervention for the Problem of Major Depressive Disorder: Nursing teaching 1:1 on medication indication and potential side effects."

Patient A6 had the identical social work interventions as previously noted.

Patient A6 had the following recreation therapy interventions for the Problem of Major Depressive Disorder: "Staff will invite and escort to daily treatments. Staff will allow for expression of thoughts and feelings."

These interventions were generic discipline functions and were not individualized to meet the patient's needs.

7. Patient A7 had the following nursing intervention for the Problem of Psychotic Disorder: "Nursing teaching on medication indication and potential side effects."

Patient A7 had the identical social work interventions as previously noted.

Patient A7 had the following recreation therapy interventions for the Problem of Psychotic Disorder: "Staff will invite and escort to daily programs. Will provide reminders as needed and orient to the unit as needed."

These interventions were generic discipline functions and were not individualized to meet the patient's needs.
8. Patient A8 had the following nursing intervention for the Problem of Schizophrenia: "Nursing teaching 1:1 on medication indication and potential side effects."

Patient A8 had the identical social work interventions as previously noted.

Patient A8 had the following recreational therapy interventions for the Problem of Schizophrenia: "Staff will invite and escort to daily treatments. Staff will provide gentle cueing and support to help promote increased ability to track content."

These interventions were generic discipline functions and were not individualized to meet the patient's needs.

B. Policy Review

The facility policy titled "Treatment Plan, Master" and last reviewed 11/18 stated, "The Master Problem List and Interdisciplinary Treatment Plan are utilized to develop patient specific treatment plans."

C. Interviews

1. On 7/10/19 at 3:30 p.m., the Director of Nursing agreed that the nursing interventions were generic and not individualized.

2. On 7/11/19 at 2:00 p.m., the Director of Social Work agreed that the social work interventions were generic discipline functions and not individualized.

3. On 7/11/19 at 1:15 p.m., the Director of Recreation Therapy confirmed that the recreation therapy interventions were not specific to each patient.

Based on record review, policy review and interview, the facility failed to provide active treatment measures or purposeful alternative interventions for two (2) of eight (8) active sample patients (Patients A3 and A8). This lack of active therapies resulted in these patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement and discharge.

Findings:

I. Patient A3

A. Record Review

Patient A3 was hospitalized on 6/22/19 with a "Primary diagnosis" of, per Psychiatric Assessment dated 6/22/19, "Schizoaffective disorder, bipolar type, Unspecified anxiety disorder by history, History of drug - induced parkinsonism." The facility's "Therapeutic Programs/Treatments & Daily Schedule" lists 4 groups on weekdays, 3 groups on Saturdays and 2 groups on Sundays, which all patients' are expected to attend. Review of Patient A3's "Non-Participation Log" since admission on 6/22/19 to 7/9/19 indicates that this patient had not attended any of the groups scheduled, except one Recreation Therapy group on 7/2/19. Staff was asked to provide nursing, social services and recreation therapy progress/treatment notes for 1 week between 7/1/19 and 7/8/19 for review. These notes do not indicate any evidence of alternative treatments being provided to this patient. Further, the treatment plan reviews for weeks 1 and 2 (6/28/19 and 7/5/19) were not modified to address this patient's lack of participation in therapeutic activities.

B. Interview

Patient 3 upon interview by the surveyor on 7/10/19 and 7/11/19, exhibited extreme psychomotor retardation, admitted to not attending groups and being unsteady on his/her feet stating, "need help to walk." The patient was maintained on 1:1 status for safety.

II. Patient A8

A. Record Review

Patient A8's Psychiatric Assessment, dated 6/30/19, noted initial diagnoses of Schizophrenia, Rule Out Mild Neurocognitive Impairment and Rule Out Delirium. A review of this patient's "Non- Participation Log" since admission on 6/29/19 and until 7/11/19 revealed that this patient had failed to attend any scheduled groups. There were no progress notes that indicated that the patient was provided any alternative therapies during this period of time.

B. Policy Review

The facility [Who? Need a source for this] stated that they had no policy related to alternative therapies for patients who were unwilling/unable to attend groups.

C. Interviews

1. On 7/10/10 at 10:30 a.m., the Patient A8 told the surveyor, "No, I do not attend any of their groups. I haven't since I came here."

2. On 7/10/19 at 3:30 p.m., the Director of Nursing stated, "Nursing does not do alternative treatment for patients who do not attend groups."

3. On 7/10/19 at 3:45 p.m., the Director of Recreation Therapy stated, "I see what you are saying about lack of active treatment for people who don't go to groups."

4. On 7/11/19 at 1:45 p.m., the Director of Social Work stated, "I have not been doing alternative therapy f2or patients who do not go to groups."

Based on record review and interview, the Social Services staff failed to document progress notes for two (2) of eight (8) active sample patients (Patient A3 and A8). These patients were unwilling/unable to attend scheduled groups and there were no progress notes indicating that alternative programming was provided. This deficiency resulted in an absence of assessment and monitoring of patient response to interventions.

Findings:

A. Record Review

A review of the progress notes documented on Patients A3 and A8 for 1 week between 7/1/19 and 7/8/19 revealed no notes indicating that alternative treatment was provided.

B. Interview

On 7/11/19 at 2:00 p.m., the Director of Social Services concurred that there were no social worker's progress notes on these two patients indicating that alternative therapies were offered.

Based on record review and interview, the Recreation Therapy staff failed to document progress notes for two (2) of eight (8) active sample patients (Patient A3 and A8). These patients were unwilling/unable to attend scheduled groups but there were no progress notes indicating that alternative programming was provided. This deficiency resulted in an absence of assessment and monitoring of patient response to interventions.

Findings:

A. Record Review

A review of the progress notes documented on Patients A3 and A8 for 1 week between 7/1/19 and 7/8/19 revealed no notes indicating that alternative treatment was provided.

B. Interview

On 7/11/19 at 12:10 p.m., the Director of Recreational Therapy concurred that there were no recreation therapy progress notes on these two patients indicating that alternative therapies were offered.

Based on record review and staff interview the Medical Director failed to ensure that;

I. The History and Physical examinations for Patient A3 was comprehensive and identified and documented relevant neurological and physical conditions including treatment recommendations. (refer to B109).

II. The interdisciplinary MTP a) were developed collaboratively and reflected and included the treatment team's agreed upon treatment goals and interventions, b) included treatment interventions that were individualized to patients' clinical reality and functional capacity, and c) were revised to address patients' needs. (refer to B118 and B122)

III. Active treatments, including alternative treatments, were provided to patients (A3 and A8) who were unwilling or unable to attend routine unit activities. (refer to B125)

These deficiencies result in a failure to guide treatment staff in providing patient-focused individualized treatments and potentially, negatively affecting patients' treatment and discharge.

Based on record review, policy review and interview, the Director of Nursing failed to develop individualized nursing interventions for eight (8) of eight (8) sample patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8). This deficiency resulted in a failure to guide treatment staff regarding the specific treatment modality and its purpose and potentially resulted in inconsistent and/or ineffective treatment. (See B122)

The Director of Social Work failed to ensure the quality and appropriateness of services provided by the social work staff. Specifically, the Director failed to ensure that the staff, a) Identified and provided patient specific individualized treatment interventions [refer toB122], b) Identified and provided alternative interventions to patients who are unable or unwilling to attend routine programming activities [refer to B125], and c) Documented treatment/progress notes reflecting patients' progress or lack of progress towards treatment goals [refer to B128]. This failure resulted in a lack of professional social work information in treatment planning.

Based on record review, policy review and interview, the Director of Recreation Therapy failed to:

1. Develop individualized recreation therapy interventions for eight (8) of eight (8) sample patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8). This deficiency resulted in a failure to guide treatment staff regarding the specific treatment modality and purpose and potentially resulted in inconsistent and/or ineffective treatment. (See B122)

2. Provide active treatment measures or purposeful alternative interventions for two (2) of eight (8) sample patients (Patients A3 and A8). Both patients were unwilling or unable to attend scheduled groups. This deficiency resulted in these patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (See B125)

3. Document progress notes for two (2) of eight (8) sample patients (Patients A3 and A8) who were unable/unwilling to attend scheduled groups indicating that they received alternative active therapies. This deficiency resulted in an absence of assessment and monitoring of patient response to interventions. (See B127)