HospitalInspections.org

Based on medical record review and staff interview, in 11 of 13 medical records reviewed, it was determined the facility failed to (a) provide patient's rights information in a language and manner the patient understands and (b)
provide patients or their representative the notice regarding "An Important Message from Medicare (IM)," as per regulatory requirement. (Patients #14, 16, 17, 18, 20, 23, 24, 27, 28, 29 & 30).

Findings include:

A) Review of the medical record for Patient#20 identified: The Screening admission notes dated 1/30/19 indicated that this patient 54-year-old male was Spanish speaking only and required an interpreter. The Patient Treatment Plan review for 8/27/19 was in English. The Healthcare Proxy and the Voluntary Request for Admission forms signed by the patient, were in signed in English.
There was no evidence that a Spanish interpreter was used to discuss the treat plan and the forms that were signed by the patient.

Review of medical record for patient #23 showed, the Office of Mental Health (OMH) Standardized Nursing Assessment form for Patient, indicated that this patient preferred language for care is Spanish. The patient's Treatment Plan Review, done on 8/29/19 and signed by the patient, was in English. There is no documentation to show that a Spanish interpreter was used to translate this document.

Review of medical record for Patient #24 identified Admission screening dated 7/2019 noted her primary language as Spanish and need for translator. It was noted that a Health Care Proxy form and Psyche Consent form both in English was signed by the patient. There is no documented evidence showing that a Spanish interpreter was used to translate this document.

The facility's policy titled "Cultural and Linguistic Competence," last revised 2/2019 states: "Rockland Psychiatric Center (RPC)staff shall take reasonable steps to ensure that all Limited English Proficient (LEP) patients and surrogate decision-makers are able to understand their health/mental health conditions and treatment option, so that patient care is provided to our LEP patients. Patients/ surrogate decision-makers who are LEP shall have all significant health/mental health services provided to them in their primary language or have an interpreter services provided to them during the delivery of such services. Interpreter services shall be available within reasonable time, at no cost to patients/surrogate decision-makers.

During interview on 11/1/19 at 11:50 AM, Staff SS, Nurse Manager, confirmed the findings.



B) Review of medical record for Patient#14, revealed this medicare beneficiary patient was admitted on 9 /30 /2003. There was no documentation that the IM notice was provided to this patient or the patient's representative.

Similar findings were noted in medical records #16, 17, 18, 27, 28, 29 & 30, for medicare beneficiary patients who did not receive the IM notice..

The findings were confirmed by the Nurse Manager, Staff SS, on 10/28/19 and 11/1/19.

Based on document review and interview, it was determined that the facility did not investigate and provide patients or their representatives with information regarding the resolution of their grievances.
This was evident in four (4) of six (6) medical record reviewed. (Patients#21, 22, 25 & 26).


Findings include:

Review of the facility Grievance Reports from December 2018 to October 2019, identified that the hospital staff did not provide response to grievances and did not conduct a through investigation of allegations made by patients.

Review of the medical record for patient #21 identified: a 66 year old male with a long history of mental illness and multiple hospitalizations. On 5/20/19, he filed a grievance alleging that a significant amount of money was moved from his account without his permission.

During interview on 11/1/19 at 12:10 PM, the patient confirmed that he made the above allegations and never received a response from the hospital. At the time of this interview, the patient appeared alert and oriented times 3 and was able to describe the allegation without any difficulties.

Facility email correspondence confirmed the validity of the patient's allegation that monies were transferred from one account to another without his permission. There was no documented evidence that this allegation was thoroughly investigated or that the patient was advised of the outcome.


Review of the medical record for Patient #22 identified: a 50 year old male with a history of mental illness and multiple hospitalizations. His most recent hospitalization to this facility was 10/18/18.
On 1/07/19, he filed a grievance with an affiliated regulatory agency and requested to have his concerns addressed.
1. The patient stated "does not feel comfortable filing an internal grievance."
2. Side effects of some of the medication he was taking.
3. Even though there are five usable bathrooms on the unit, only one is open at a time for 27 patients. "Sometimes is on the verge of going in his pants."
4. Because of the bathroom limitation, staff are putting patients on water restriction.
5. Lack of food variety, medications, staff inattentiveness and "misappropriation of funds".

During interview on 11/1/19 at 11:25 AM, Patient #22 acknowledged that he filed the above grievance and that he never received a response from the hospital or the agency that he filed it with. He stated that the issues remain unresolved. This interview was witness by Staff Y, Treatment Team Leader. The patient was alert and oriented and had no difficulty describing the events in his grievance.

The patient grievance log, showed no evidence that the facility conducted a through investigation of these allegations.
There was no documented evidence that the facility responded to the patient or the reporting agency.

Observation of patient care units from 10/28/19 to 11/1/19 showed that all patient bathrooms were locked and accessible only by patient asking staff to open them.


Review of the medical record for Patient #25 identified: a 35 year old male with a history of depression. He uses a wheelchair for ambulation. He lives in the community with his brother and receives outpatient psychiatric services at this facility.
On 6/22/19, he wrote a letter to the hospital complaining that after therapy he was unable to leave the building as the elevator was not working and the courtyard exit was locked.

There is no documented evidence that the hospital conducted a through investigation and provided a written response to the patient.


Review of the medical record for Patient #26 identified: a 30 year old male with a history of Schizophrenia and violence.
On 3/15/19, he wrote a letter to the hospital expressing his dissatisfaction about the removal of night stand, drawers and other furniture from his room. He believed that they should be "replaced with something that can be safe for all immediately."

There was no documented evidence that a response was provided to the patient.


Review of the Hospital's Policy and Procedure titled "Patient/Family Complaint Resolution Process, last reviewed 07/2019 notes: "Complaints means any formal written or verbal grievance that is made by a patient when the grievance issue cannot be resolved before the end of the shift in which the issue was brought to the attention of the staff."
The policy also states that the Facility Director must review all complaints and render a determination in a written decision that shall be communicated to the patient in a language and manner that patient understands.

During interview on 10/31/19 at 11:00 AM, Staff TT, Director of Risk Management, acknowledged the findings and stated that she was responsible for receiving and reviewing patients' grievances/complaints. She was not aware of the time frame and or that a response is required.

Based on document review and interview, it was determined that the facility failed to incorporate review of the grievance process in its Quality Improvement Program


Findings include:
Review of the minutes for the facility's quality review from December 2018 to October 2019, showed no evidence that the grievance process was addressed during the meetings.

The facility's "Performance Improvement Plan 2019," does not include patient grievance as an area for review.

During interview on 10/29/19 at 10:30 AM, Staff G, Director of Quality, acknowledged the findings.

During interview on 10/31/19 at 11:00 AM, Staff AA, Director of Risk Management, acknowledged the findings and stated that she was unaware that a quality review is required for patient grievances.

Based on document review and interview, it was determined the facility failed to provide the appropriate number of registered nurses (RN), licensed practical nurses (LPN) and mental health technical aides (MHTA) on two (2) of 13 Inpatient Psychiatric Units.

Findings:

Review of the Nursing Department staffing schedules revealed the staffing schedule during 11:00 PM - 7:00 AM as follows:

On 10/24/19 - Unit #405 (twenty-seven bed unit); one (1) RN and three (3) MHTAs were scheduled. The patient census was 27.

On 10/21, 10/23, 10/24 & 10/27/19 - Unit #204 (thirty bed unit); one (1) RN and three (3) MHTAs were scheduled. The patient census was 29, 30, 30, and 30 respectively.

Review of the policy titled, "Nursing Staffing Minimum," effective 8/18 states: "Nights shift minimum staff including RN/LPN/MHTA for Unit 204 is five and for Unit 405 is six.

There was no documented evidence that there was coverage for the RNs during their breaktime.

During an interview conducted on 11/01/19 at 11:15 AM, Staff G, Director of Quality acknowledged this finding.

Based on observation and document review, staff failed to follow the facility's policy for the storage and disposal of expired medication.

Findings:

During a tour of the facility on October 30, 2019 at 11:55 AM, seven (7) vials of Lorazepam (controlled substance) with expiration date September 01, 2019, were observed in the refrigerator in the Medication Room of Unit 406.

Review of facility's policy "Medication Storage," Revised: 05/19, revealed that "All expired, damaged, stored improperly, and/or contaminated medication must be stored separately from medication available for administration and must be returned to the Pharmacy."

These observations were witnessed by Staff W, RN and Staff X, RN.

Based on record review and document review, the facility did not ensure that all staff who conducts nutritional assessments, are qualified.

Review of the medical record of Patient #31 revealed a Nutrition Progress Note completed by Staff U, Dietitian 2.

During interview on 10/29/19 at 11:15 AM, the Food Service Director provided a list of dietitians assigned to the units to conduct nutritional assessments, and Staff U was included on the list.

Review of Staff U's personnel file identified there was no current license as a Certified Dietitian/Nutritionist, which is required by State law.

Based on interview, and in two (2) of five (5) Medical Records (MR) reviewed, the dietitian failed to monitor the patient's monthly weights and identify significant weight losses which may have affected the patient's nutritional care.
(Patient #31, #32).

Findings include:

Review of the medical record for Patient #31 identified that the patient experienced a significant weight loss which was not addressed in the "Nutrition Progress Note" completed on 10/28/19 by Staff U, Dietitian 2.

The patient's weight record showed the following:
4/1/19 - 163.2 lbs.
5/1/19 - 160.8 lbs.
6/14/19 - 152.8 lbs.
7/8/19 - 151 lbs.
8/1/19 - 153.2 lbs.
9/1/19 - 151.2 lbs.
10/2/19 -153 lbs.
10/17/19 -146.8 lbs.
Per the weight record, the patient had lost 16.4 lbs. or ten (10) percent of his body weight in the past six (6) months. The dietitian noted "Patient's b/s {blood sugar} has not improved with 17 lbs. weight gain."

During an interview with Staff U, Dietitian 2 on 10/30/19 at approximately 11:30 AM, in the presence of Staff K, Quality Improvement, Staff U stated that the weight gain that was documented was not an error and that he looked at the patient's weight from the past year. Past weight record on 10/7/18 was 164.2 lbs.

The patient's medical record demonstrated that he had a history of weight loss and that he continued to lose weight.


Similar finding on documented weight loss was found in the medical record of Patient #32 who was admitted on 6/6/19 with an admission weight of 185 lbs. Weight record showed the following changes:

7/2/19 - 173.8 lbs.
8/2/19 - 170 lbs.
9/1/19 - 167.2 lbs.
9/12/19 - 167.2 lbs.
The patient had a significant weight loss of 11.2 lbs. or six (6) percent in one (1) month after his admission. The patient's weight loss was not addressed until 9/20/19 when the dietitian documented in the quarterly Nutrition Progress Note.

The facility's policy and procedure titled "Patient Nutritional Care," last revised 2/19, stated: "Progress Notes/Re-screening- At a minimum, a Progress note must include...plans for nutrition intervention, monitoring and evaluation."

Per interview on 10/29/19 at approximately 11:30 AM, Staff Bbb, Nutrition Services Administrator 2, stated all weight changes of +/- five (5) lbs. must be reported to the medical specialist.

Based on document review and interview, the facility failed to fully implement its Utilization Review Plan.


Findings include:

The hospital Policy and Procedure titled "Utilization Review Plan," last revised 08/19, describes the Utilization Review Process as follows:
A. Admission Review: Inpatient.
B. Continued Stay Review: Initial and Subsequent Reviews: Inpatient.
C. Certificate of Needs Reviewed: Inpatient.
D. Admission Review: Outpatient.
E. Continued Stay Reviews: Initial and Subsequent Reviews: Outpatients.
F. Review of Patients on CPL Status.

The (UR) Utilization Review Minutes from 10/25/18 to 3/28/19 showed no evidence that the facility conducted review on the above data that is described in the plan.

During interview on 11/1/19 at 1:20 PM, Staff VV, Director of Utilization Review, acknowledged the findings and stated that additional information is on a computer in her office.
When the surveyor asked to review this information, Staff G, Supervisor, stated that "all the information was already provided to the Surveyor".

Based on observation, the hospital failed to maintain its physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.

Findings include:

Tour of Building 58 - West Mall:
On 10/28/2019, during a Tour of Building 58 - West Mall, the following findings were identified in the presence of the Staff Yy, Director of Administration:

1. The handles, locks in the storage cabinets presented ligature hazard and are potential for the risk of looping.
2. Water faucet, cabinet handles and drawer handles in the kitchenette area presented ligature hazard and are potential for the risk of looping.

Room # W146 - Social Room:
1. The wiring of Air Hockey table presented ligature hazard and are potential for the risk of looping.
2. The door handle was from the regular type and presented ligature risk and looping hazard.
3. The cord of the wall phone was long and presented ligature risk and looping hazard.
4. The electric outlets were from the regular type and not tamper resistant and presented risk of harm to self or others.

Room-W144 -Group Activity Room:
1. The wall phone was mounted to the wall at Height > 5 feet from the ground and had long cord which presented risk of ligature and is potential for looping risk.
2. The door handle was from the regular type and presented ligature risk and looping hazard.
3. The electric outlets were from the regular type and not tamper resistant and presented risk of harm to self or others.
4. The handles of the storage cabinets presented ligature risk and looping hazard.
5. The handles of the refrigerator presented ligature risk and looping hazard.
6. The openings of the air supply and the exhaust vent are approximately ¼ inch and present ligature risk and looping hazard.

Health& Fitness Room W122:
1. The electric outlets were from the regular type and not tamper resistant and presented risk of harm to self or others.
2. The wiring and electric cord of the TV and a fan in the room were not secured and they presented ligature risk and looping hazard.
3. The handle of the room door presented ligature risk and looping hazard.


Education Room - W-124:
The electric outlets were from the regular type and not tamper resistant and presented risk of harm to self or others.

Class Room W126:
1. The electric outlets were from the regular type and not tamper resistant and presented risk of harm to self or others harm.
2. The wiring and electric cord of the TV and a fan in the room were not secured and they presented ligature risk and looping hazard.
3. The handle of the room's door presented ligature risk and looping hazard.

Art Rooms - W130 and W131:
1. The electric outlets were from the regular type and not tamper resistant and presented risk of harm to self or others.
2. The handles of the storage cabinets presented ligature risk and looping hazard.
3. There were (3) three metal shelving units which presented ligature risk and looping hazard.
4. The handle of the room door presented ligature risk and looping hazard.
5. The double sink faucets were not ligature resistant and presented looping hazard.

ADL Room - W134:
1. The handles of the kitchenette cabinets presented ligature risk and looping hazard.
2. The faucet of the water sink was not ligature resistant and presented looping hazard.
3. The handles of the refrigerator presented ligature risk and looping hazard.
4. The night lamp was not secured, and its wiring presented looping hazard.
5. The electric cord of the microwave was not secured and presented looping hazard.
6. The door handles of the room and its bathroom were not ligature resistant and presented looping hazard.
7. The bathroom door hinges were not piano hinges and ligature resistant and presented looping hazard.
8. The sink in the bathroom was mounted to the wall leaving gap between the wall that presented looping hazard.
9. The faucets and knobs of the water sink were not ligature resistant and presented looping hazard.
10. The mirror mounted in that bathroom presented looping hazard.
11. The toilets are floor mounted with detachable seats that are not integral part of the bowl, which creates ligature opportunities. Its pluming is a looping hazard.

The Barber Shop:
1. The electric outlets were from the regular type and not tamper resistant and presented risk of harm to self or others.
2. The cord of the wall phone was long and presented ligature risk and looping hazard.
3. The handles of the storage cabinets presented ligature risk and looping hazard.
4. The door handle of the room was not ligature resistant and presented looping hazard.
5. There were 3 large glass mirrors mounted to the wall and a hand-held glass mirror which presented risk of injury to self or others.
6. The coat hanger presented looping hazard.

Many rooms were found to be missing their signage. These rooms included but were not limited to:
Patient shower room of Unit 204 - Building 58, W 555, W 448 and Treatment Room in Unit 405, Building 60.


On 10/28, 10/29, 10/30 and 10/31/2019, during tours of the facility's Building 58: Units 204, 504, 404 and Building 60: Units 405,406, 506, 205, 305, 306, it was observed that:

Fixtures in unsupervised patient areas and supervised patient areas, were not of an Office of Mental Health (OMH) approved type and were not designed to prevent ligature from looping over them; These Items include:
1. Paper towel dispensers, toilet towel dispensers and soap dispensers in the patient bathrooms and patient shower rooms are not ligature resistant or break away.
2. The toilets are floor mounted with detachable seats that are not integral part of the bowl, creating ligature opportunities.
3. The sinks in some patient bathrooms are detached from the walls and presented looping hazard.

The above deficiencies were identified in all bathrooms and shower rooms throughout the facility. Examples included but were not limited to Rooms E 211, E 229, E 228, W 528, W 529, W 555, W 558, E 429, E 428, E 438,
E 439, W 429, and W 428.

Building 60, Units 204, 504, 404 and Building 60, Units 405, 406, 506, 205,305, 306, have the following deficiencies:
1. Small and large Day Rooms have free anchoring points at top of the doors. Door hardware was not ligature resistant.
2. Dayroom TVs are encased in a wooden box with Plexiglas front cover to limit access to the TV. The Plexiglas has large holes for ventilation and sound which pose a ligature risk.
3. The mounting brackets that affix the TV boxes to the walls presented ligature risk.
4. The chairs in the day room were not Office of Mental Health (OMH) approved type furniture and were not designed to prevent a ligature from being looped over them.
5. The long and short hallways have wall mounted exit signs which are not ligature resistant.
6. The hand rails in the hallways do not have continuous bracket enclosures, leaving an opening between the walls and hand rails, which is big enough to loop a ligature through.

Seclusion Rooms:
The seclusion rooms are padded to prevent self- injury or harm. The small vision panel on the door is covered by Lexan that is protruding above the padding material, which presented risk of injury or self-harm.

Handrail on the Corridors:
The handrails of the corridors were mounted to the walls, leaving gaps that presented ligature and looping hazard.

Patient's bedrooms:
1. Plexiglas mirrors in some rooms were from the regular security screws and were not flush mounted to the surface, which presented risk of self-harm or injury.
Examples included but were not limited to: E 430, E 431, E 435, E 436, E 440, E 441, E 442, and
E 443.
2. There were picture frames with sharp edges mounted in the rooms, which presented risk of injury to self or others. Examples were found but are not limited to the following rooms: Comfort rooms -W 526, and E 426.


Medical and Dental Clinic:

On 10/31/2019 at 10:55 AM, during a tour of 2nd floor of Building 57, in the presence of the Chief of Safety and Security, the following were identified:

Patient Waiting Room:
1. TV was mounted to the wall at >6 ft height from the floor with its mounting brackets leaving gap between the TV and the wall that presented looping hazard.
2. The electric outlets were not tamper- resistant and presented risk of injury to self or others.

Dental Lab:
1. The dental lab room has one hand-wash sink. Staff used the sink for both of brushing and cleaning the dental instruments and hand-washing.
This practice is potential for cross contamination.

2. The facility is using the one room for mixed use; handling soiled items and clean (sterile items) in the same room. That practice is potential for infection control problems.

Medical Clinic:
The electric outlets in this clinic were from the regular type, not the TR type that is required for the psych hospital. Examples included but were not limited to rooms: S 220, S 221.

Patient bathrooms in the Medical Clinic and Dental Clinic:
1. The paper towel dispensers, the toilet tissue dispensers were mounted to the walls at level of 5 ft and 3 feet from the floor and they are not ligature resistant or easy breakaway which present looping hazard.
2. The toilets are floor mounted with detachable seats that are not integral part of the bowl, creating ligature opportunities.
3. The sinks in some patient bathrooms are detached from the walls and presented looping hazard.

Waiting Areas (Children and Adult) :
1. TV was mounted to the wall at >6 ft height from the floor with its mounting brackets leaving gap between the TV and the wall, which presented looping hazard.
2. The TV cord and wiring of the TV were not secured and imposed risk of ligature.
3. The electric outlets in the clinic were from the regular type, not the TR type that is required for the psych hospital.

These findings were discussed with Staff Aaa, Plant Superintendent; Staff Z, Quality Compliance; Staff Yy, Director of Administration, and Staff Zz, Chief of Safety and Security, at the time of observations.

Based on observation and interview, the facility failed to maintain the condition of the physical plant, free of pest, to ensure an acceptable level of safety and the well-being of patients.

Findings Include:

During a tour of the facility on 10/28/2019 at approximately 11:45 AM, the following were observed on the inpatient units:
1. Building 58, Unit 404: Wasps were observed in Seclusion Room E 352.
2. Building 60: Wasps were observed in Seclusion Room W 152.
3. Fruit flies were observed in the big Day Room on unit E 504.

These findings were discussed with Staff Aa, Plant superintendent and Staff Z, Quality Compliance, at the time of observation

Based on observation and interview, the facility failed to ensure that soap, water, and a sink are not readily accessible in appropriate locations.
This practice is a potential for infection control problems.

Findings:
During a tour of the patient care areas, it was observed patient's bathrooms were locked and not easily available for use and for handwashing. For example:

Patient Care Unit 405 on 10/28/19 at 11:50 AM - all patient's bathrooms were locked and not easily available for use.
Patient Care Unit 304 on 10/29/19 at 2:10 PM - all patient's bathrooms were locked and not easily available for use.
Patient Care Unit 203 on 10/30/19 at 2:00 PM - all patients bathrooms were locked. and not easily available for use.
Patient Care Unit 504 on 11/1/19 at 10:15 AM - all patient bathrooms were locked and not easily available for use.
Patient Care Unit 506 on 11/1/19 at 11:15 AM - all patient bathrooms were locked and not easily available for use.

During interview on 10/30/19, at 12:00 PM, Staff L, Infection Control Nurse, she stated that "bathrooms are locked for safety reasons. Staff is easily available to open the door to have access to sinks."

During interview on 11/1/19 at 11:45 AM, Staff G, Director of Quality acknowledged the findings and stated that all staff have keys to the bathroom and will open them at patient's request.

Based on record review and interview psychosocial assessments failed to document a psychosocial summary and/or recommendation regarding the anticipated social work role in treatment and discharge planning for eleven (11) of eleven (11) active sample patients for whom psychosocial documents were reviewed (Patients C4, C25, E27, E28, I13, I26, K5, K15, L23, M1 and M26). This failure hindered treatment and discharge planning for each patient.

Findings include:

A. Record Review

Psychosocial Assessments were reviewed for eleven (11) active sample patients (assessment dates in parentheses): C4 (12/3/18); C25 (7/16/19); E27 (10/8/19); E28 (10/18/19); I13 (2/9/16 with update of 5/24/19); I26 (8/30/19); K5 (8/14/19); K15 (1/18/19); L23 (10/8/19); M1 (5/24/19) and M26 (10/23/19). In all eleven (11) assessments there was failure to document a psychosocial summary and/or recommendation regarding the anticipated social work role in treatment and discharge planning. Specific findings were as follows:

1. A psychosocial summary was absent in ten (10) of ten (10) assessments reviewed for the summary: Patients C4, E27, E28, I13, I26, K5, K15, L23, M1 and M26.

2. Recommendations regarding the anticipated social work role in treatment and discharge planning was deficient in

a. Patient C4: Generic recommendations were stated as "when discharged, [Patient] will need ...supportive counseling, and group support. [Patient] will need a supervised residence in which [s/he] feels safe and comfortable. [Patient] would benefit from a social group or program to assist [him/her] with becoming comfortable in the community."

b. Patient E27: Generic recommendations were stated as "SW will provide individual counselling [sic] two times a week for 15 minutes." "SW will assist [him/her] to secure appropriate [sic] housing and follow up."

c. Patient E28: Generic recommendations were stated as "SW will assist [him/her] to secure appropriate [sic] housing and follow up upon discharge." "SW will involve appropriate collaterals in the treatment planning process if and when available."

d. Patient I13: No specific social work recommendations were documented for this patient.

e. Patient I26: No specific social work recommendations were documented for this patient.

f. Patient K5: Modalities for treatment were generic, stated without focus based on individual patient needs: "Individual Supportive Therapy for 15 minutes 2 times weekly; and Group Counseling including Interview Skill group/Discharge Readiness group once weekly for 1 hour will be provided."

g. Patient K15: The only recommendation for the social work role was a generic statement: "Engage in discharge planning with SW."

h. Patient L23: No social work recommendations were documented for this patient.

i. Patient M1: Generic recommendations were stated as "SW will provide individual counselling [sic] for 15 minutes per week." "SW will assist [him/her] to secure appropriate housing, and follow up upon discharge."

j. Patient M26: Generic social work recommendations were stated as "Individual session with social worker 25 minutes per week." "Assist [him/her] to secure appropriate housing and follow up upon discharge."


B. Interview

During interview with review of psychosocial assessments on 10/29/19 at 1:05 p.m., the Director of Social Work verified the above documented findings.

Based on interview and record review the facility failed to develop and document Comprehensive Treatment Plans (CTPs) based on the individual needs of twelve (12) of twelve (12) active sample patients (C4, C25, E27, E28, I13, I26, K5, K15, L15, L23, M1 and M26).

The majority of goals and interventions in all CTPs were the same regardless of the stated problem. Patient goals were statements of treatment compliance, including attendance at programming activities rather than outcome behaviors reflecting evidence that the identified problem had been reduced or resolved. Staff interventions were generic role function statements or the identified modality failed to include focus of treatment. This approach to treatment planning failed to provide individualized plans to guide staff in the implementation and evaluation of the treatment provided and revisions of the plans based on the individual patient's responses to treatment.

Findings include:

A. Review of Treatment Plans:

Review of Comprehensive Treatment Plans (CTPs) revealed failure to document individualized patient goals and specific modalities/interventions based on the patient's needs for 12 of 12 active sample patients (treatment plan dates in parentheses): C4 (6/13/19); C25 (8/2/19); E27 (10/16/19); E28 (10/22/19); I13 (9/16/19); I26 (9/10/19); K5 (8/15/19); K15 (5/20/19); L15 (3/21/19); L23 (10/3/19); M1 (1/8/19) and M26 (7/2/19). The majority of short-term goal(s) were treatment compliance statements rather then outcome behavioral statements reflecting evidence that the stated problem had been reduced or resolved. These goals included "Continue to adhere to medication regimen daily for next three months;" "Will meet with social Worker to discuss discharge options weekly for the next three months;" "Will participate in psychosocial treatment groups daily for the next three months;" "Will attend on unit and treatment mall programming to support engagement in treatment over the next three months;" and "Will be able to complete admissions assessments with the psychologist over the next 30 days."

In all 12 CTPs the majority of staff interventions for clinical disciplines were generic role function statements or a list of modalities without focus of treatment rather than interventions aimed at assisting the patients to address the identified
problem. Interventions included "Provide and monitor medications;" "Provide individual sessions and Discharge Readiness Skills on the Treatment Mall;" "Provide specialized psychology groups on treatment mall (see current schedule) and individual sessions as needed;" "Individual sessions and wellness group;" "Provide rehabilitation groups on the treatment mall and encourage participation in rehab [rehabilitation] programs;" "Medication management and monitoring by MD. Psychoeducation Group" and "Psychologist will provide supportive counseling as needed."

B. Interviews:

1. During interview on 10/29/19 at 11:00 a.m., with review of treatment plans for Patients M1 and M26, Physician 1 and SW 2 verified above findings.

2. During interview on 10/29/19 at 1:05 p.m., the Director of Social Work verified the documented findings for goals and interventions on the treatment plans.

3. During interview on 10/29/19 at 3:30 p.m. the Acting Director of Nursing and RN3 verified the findings for goals and nursing interventions.

Based on interview and document review, the facility failed to ensure that at least one Registered Nurse (RN) was present on all shifts and at all times for 6 of 13 units (303-Admissions, 304 - Admissions, 305 - Geriatric, 306 - Male continuing care, 405 - Medical/continuing care and 406 - Continuing care) on the day and evening shifts. RNs were required to attend events (Code Blue, meals and meetings) which took them off their assigned units during the course of their shift. During these periods of absences, there might be only the Licensed Practical Nurse (LPN) or Mental Health Therapy Aids (MHTAs) on the units. This pattern of staffing resulted in units being supervised by para-professionals who are not clinically qualified to assess and monitor patient care needs and failed to provide supervision and direction for para-professionals staff (LPNs and MHTs). This failure created potential risk for the health of all patients on the units and a safety risk for patients and staff. (Refer to B150)

Based on interview and record review the Director of Medical Services failed to monitor and take corrective action to ensure the development and documentation of Comprehensive Treatment Plans (CTPs) based on the individual needs of twelve (12) of twelve (12) active sample patients (C4, C25, E27, E28, I13, I26, K5, K15, L15, L23, M1 and M26). The majority of goals and interventions in all CTPs were the same regardless of the stated problem. Patient goals were statements of treatment compliance rather than outcome behaviors reflecting evidence that the identified problem had been reduced or resolved. Staff interventions were generic role function statements or the identified modality failed to include focus of treatment. This approach to treatment planning failed to provide individualized plans to guide staff in the implementation and evaluation of the treatment provided and revisions of the plans based on the individual patient's responses to treatment. (Refer to B118)

Based on interview and document review, the Director of Nursing failed to ensure that at least one Registered Nurse (RN) was present on day and evening shifts, on all units and at all times for 6 of 13 patient care units (303 Admissions, 304 - Admissions, 305 - Geriatric, 306 - Male continuing care, 405 - Medical/continuing care and 406 - Continuing care). RNs were required to attend events (Code Blue, meals and meetings) which took them off their assigned units. During these periods of absences, there might be only the Licensed Practical Nurse (LPN) and Mental Health Therapy Aid (MHTA) on the units. This pattern of staffing resulted in one unit being without a RN to assess and monitor patient care, provide immediate response to crisis interventions, and supervise and direct/guide para-professionals (LPNs and MHTAs) in their performance of nursing care duties. This failure will affect the quality of patient care and increase the timeliness for crisis resolution and a safety risk for the patients and staff. (Refer to B150)

Based on document review and interview, the facility failed to ensure that at least one Registered Nurse (RN) was present on all shifts and at all times for 6 of 13 units (303-Admissions, 304 - Admissions, 305 - Geriatric, 306 - Male continuing care, 405 - Medical/continuing care and 406 - Continuing care) on the day and evening shifts. RNs were required to attend events (Code Blue, meals and meetings) which took them off their assigned units during the course of their shift. During these periods of absences, there might be only the Licensed Practical Nurse (LPN) or Mental Health Therapy Aids (MHTAs) on the units. This pattern of staffing resulted in units being supervised by para-professionals who are not clinically qualified to assess and monitor patient care needs and failed to provide supervision and direction for para-professionals staff (LPNs and MHTs). This failure created potential risk for the health all patients on the units and a safety risk for patients and staff.

Findings include:

A. Document Review

1. Review of the nursing policy "Staffing Deployment Plan" with a last review date of 8/19, stated, "A Registered Professional Nurse is assigned as Charge Nurse on each Unit/each shift." This policy requirement was not met.

2. The "Direct Nursing Staffing Form" completed by the Nursing Director for seven (7) days (10/21 through 10/28/19) included the first day of the survey, revealed that the following units on several occasions had 1 Register Nurse assigned. These Units are on opposite sides of each other and one RN was required to provide coverage for the other when one nurse must be absent from their assigned unit.

Unit 303: Had a census of 29 patients on 10/24/19, 10/ 26/19 and 10/27/19. One (1) RN was assigned each day to the evening shift and on 10/27/19 one (1) RN was assigned to the day shift.

Unit 304: Had a census of 31 patients on 10/24/19, 10/26/19 and 10/27/19. 1 RN was assigned each day to the evening shift and on 10/27/19, 1 RN was assigned to the day shift.

Unit 305: Had a census of 30 patients on 10/24/19. One (1) RN was assigned to the day shift and 10/25/19 one (1) RN was assigned to the evening shift.

Unit 306: Had a census of 30 patients on 10/24/19. 1 RN was assigned to the day shift and on 10/25/19, 1 RN was assigned to the evening shift.

Unit 405: Had a census of 31 patients on 10/25/19 and 10/26/19. 1 RN was assigned on the day shift each day and on 10/26/17 and 10/27/19, 1 RN was assigned each day to the evening shift.

Unit 406: Had a census of 27 patients on 10/25/19 and 10/26/19. 1 RN was assigned on the day shift each day and on 10/26/19 and 10/27/19, 1 RN was assigned each day to the evening shift.

Interview:

1.During interview on 10/28/19 at 12:25 p.m., RN1 reported that when there was only 1 RN assigned to the unit, s/he let the RN on another unit know that s/he was going to be off the unit and let that nurse know "what is going on in the Unit." At these times s/he "left the keys with the LPN." S/he reported that sometimes s/he had to leave the unit (without RN coverage) "to go talk with the nursing supervisor downstairs."

2. During interview on 10/29/19 at 10:15 a.m. RN7 reported that when there was only 1 RN on the Unit s/he would get an RN from another unit to come to cover his/her assigned unit while s/he is off the unit. S/he stated that if this was not possible, s/he would leave the LPN in charge of the Unit. RN 7 added that s/he sometimes had to leave his/her assigned unit to go to Building 57 (Administration) for a "justice review" of patients.

3. During interview on 10/29/19 at 10:40 a.m. RN 10 stated that s/he works on several units (204, 304, 404, 203). S/he reported that s/he had to leave the unit at times; when this occurred s/he "[would leave] the keys with the LPN." S/he reported that at times s/he had to leave his/her assigned unit to "attend a Code Blue." S/he added, "If there is an LPN, I go to the code."

4. During interview on 10/29/19 at 3:30 p.m. with the Acting Director of Nursing and RN 3 (Nursing Administration staff), the Acting Director of Nursing did not refute the above documented findings. She stated, "We'll have to implement something to make it clear. We will work on it and get it done. We will get it right."