HospitalInspections.org

Based on observation, record review, and interview, the facility failed to ensure the right to personal privacy in 1 of 2 inpatients (Patient #7) in 2 of 4 rooms (Room #119 and #115) with camera monitoring during the survey, failed to define time frames for follow-up of their grievance process's in 1 of 1 grievance policies, failed to ensure the confidentiality of patient records in 1 of 1 medical records department, failed to ensure an active treatment plan when seclusion is initiated in 3 of 4 restraint/seclusion records (Patients #7, #17 and #18) reviewed, and failed to inform patients of their visitation rights in 1 of 1 Patient Rights Brochure. These deficient practices have the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

The hospital failed to ensure the right to personal privacy (see Tag A-143).
The hospital failed to define time frames for follow-up of their grievance process (see Tag A-122).
The hospital failed to ensure the confidentiality of patient records (see Tag A-146).
The hospital failed to ensure an active treatment plan when seclusion is initiated (A-164).
The hospital failed to inform patients of their visitation rights (see Tags A-216 and A-217).

The cumulative effect of these deficiencies does not ensure protection and promotion of each patient's rights.

Based on record review and interview, staff at this facility failed to ensure that the grievance process identifies time frames for review or follow up responses in 1 of 1 grievance policy reviewed. Failure to identify time frames for grievances has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

The facility's policy titled, "Client Rights/Confidentiality-Client Rights and the Grievance Process," dated 7/2013, was received for review on 6/12/2017 at 1:07 PM.

The policy does not specify a time frame that grievances will be reviewed or when a response will be provided to the grievance.

This finding was discussed with, and confirmed by Administrator C and Social Services Manager B on 6/13/2017 at 4:30 PM. Manager B stated, "We don't have anything for timeframe's for our grievance process."

Based on record review, interview, and observation, the facility failed to ensure the right to personal privacy in 1 of 2 inpatients (Patient #7) in 2 of 4 rooms (Room #119 and #115) with camera monitoring during this survey. This deficient practice has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

Review of policy titled "Camera Surveillance Rooms" Policy # 2060626 (origination date of 3/2001, last revised 12/2015) on 6/13/2017 states under Procedure: "b. Use of this added surveillance shall be considered for any client identified with risk factors other than suicide. c. A Limitation of Client Rights form will be initiated. Examples (not all-inclusive): Mute/catatonic behavior, extreme confusion, acute anxiety, restlessness in bed, hallucinating client, etc."
The policy does not address protection of personal privacy.

On 6/12/2017 at 3:20 PM after seeing Patient #7's underclothes lying on bed in Patient #7's room, interviews were conducted with RN FF, RN GG and RN HH who confirmed that Patient #7 did change clothes in front of the camera.

Record review of Patient #7's medical record on 6/13/2017 revealed a psychological evaluation dated 5/12/2017 that indicated that on admission, Patient #7 is alert and oriented to time, place and person but not to situation. S/he had psychomotor agitation, mood and affect are irritable and thought content shows Patient #7 to be having delusions of persecution and grandiosity. S/he has a diagnosis of bipolar disorder and postpartum psychosis. Review of Limitation of Client Rights form was filled out on Patient #7's chart, on the client signature line it states refused to sign.

Observation on 6/13/2017 at 12:50 PM with RN M revealed Patient #7 being monitored per camera in Room 119. The video for Room #119 and Patient #7 was located at the nursing station and visible to visitors, housekeeping, and unauthorized staff.

Interview with RN M on 6/13/2017 at 12:50 PM stated that they did have privacy screens on the monitors but when the monitors were replaced the privacy screens did not fit and were not replaced.

On 6/13/2017 at 2:40 PM notified Hospital Administrator C of the Immediate Jeopardy related to the facilities failure to ensure their patient's right to personal privacy as evidenced by the ability to view the camera monitoring from the common area visible to visitors, unauthorized staff, or anyone coming onto the unit.

Observation on 6/14/2017 at 9:50 AM with CNA E revealed monitors in nursing station to have privacy screens which allowed viewing of monitors from nursing station only, no longer visible to common areas.

Received Plan of correction for IJ on 6/14/2017 at 12:46 PM from Hospital Director C, C stated that they had immediately relocated the monitors to an area not observable from the common area when notified of IJ on 6/13/2017. Immediate education was provided to the current nursing staff and a read and sign written in-service was provided to each staff member prior to the start of his/her shift to ensure the privacy screen remains over the safety surveillance monitor. The immediacy was confirmed abated on 6/14/2017 at 9:50 AM.

Based on observation and interview, the facility failed to ensure that the confidentiality of patient records is secured in 1 of 1 medical records department. This deficient practice has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

On 6/13/17 at 8:15 AM observed in Medical Records room that closed records for the inpatient psych unit and nursing home patients are stored in the same room and not secured by unit.

An interview was conducted on 6/13/17 at 8:15 AM with Health Information Manager D, D stated that after hours the only people with access to medical records are the charge nurse from the in patient psych unit and the nursing home. Health Information Manager D agreed that the current storage arrangement would allow the nursing home access to patient psych records.

Based on record and facility policy review, the facility failed to ensure active treatment plan (care plan) was updated when seclusion is initiated or removed when seclusion is discontinued, in 3 of 4 restraint/seclusion records (Patients #7, #17 and #18) reviewed. This deficiency directly affects Patient #7 (currently an inpatient) and potentially all restrained or secluded patients at this facility.

Findings include:

The facility policy titled "Seclusion, Physical and/or Chemical Restraint: Emergent Use" #3393891 dated 03/2017 was reviewed on 6/14/17 at 11:25 AM. This document does not state any guidelines for adding or discontinuing problems on active treatment plan with initiation or discontinuation of seclusion or restraint.

Patient #7's medical record was reviewed on 6/14/17 at 10:15 AM, the care plan did not reflect the initiating and discontinuing of seclusion each time that patient was ordered seclusion or discontinuation of the problem when seclusion was ended. Patient #7 has been an inpatient in the facility for 31 days at the time of survey, medical record documents 27 physician orders for seclusion during that time. A problem was initiated on active treatment plan (care plan) on 5/14/17, 3 days after admission, that remains actively on treatment plan and Patient #7 is not currently in seclusion.

Patient #17's medical record was reviewed on 6/13/17 at 2:25 PM the patient was placed in seclusion on 1/10/17 at 6:55 PM and remained there until 7:55 PM. Review of active treatment plan reveals that seclusion problem was still "Active" as a problem on 1/19/17 when patient was discharged.

Patient #18's medical record was reviewed on 6/14/17 at 11:00 AM the patient was placed in seclusion on 12/15/16 at 2:15 PM and remained there until 3:45 PM. Review of active treatment plan dated 12/15/16 revealed no problem addressing seclusion either active or resolved.

Based on record review and interview, the facility failed to inform each patient of his/her visitation rights in 1 of 1 Patients Rights Brochure. This deficient practice has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

Per review of Client Rights and Grievance Procedure Brochure for Inpatient Services on 6/13/2017 at 3:50 PM, the brochure dated 6/16/2011 does not include visitation rights.

Per interview with Social Service Manager B on 6/13/2017 at 3:50 PM, B confirmed that visitation rights are not listed in their Client Rights or in any other information given to patients.

Based on record review and interview, the facility failed to inform each patient of their right to have unbiased visitation in 1 of 1 Patients Rights Brochure. This deficient practice has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

Per review of Client Rights and Grievance Procedure Brochure for Inpatient Services on 6/13/2017 at 3:50 PM, the brochure dated 6/16/2011 does not include the information that the facility may not restrict visitation based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.

Per interview with Social Service Manager B on 6/13/2017 at 3:50 PM, B confirmed that to have unbiased visitation rights are not listed in their Clients Rights or in any other information given to patients.

Based on record review and interview, the facility failed to maintain performance improvement projects based on data driven and ongoing audits for 1 of 1 quality assessment and performance improvement program to ensure staff and departments function in a safe and effective manner. This deficient practice has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

The cumulative effect of these systemic problems results in the hospital's inability to have a functioning quality assessment and performance improvement (QAPI) program.

Based on record review and interview, the facility failed to maintain performance improvement projects based on data driven and ongoing audits for 1 of 1 quality assessment and performance improvement program to ensure staff and departments function in a safe and effective manner. This deficient practice has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

The facility policy reviewed 6/13/17 at 3:30 PM entitled "Quality Assurance Performance Improvement" (QAPI) #3709195 dated 06/2017 page 2 under "FUNCTION:" "Design and maintain QAPI structure and processes that support continuous quality improvement, including measurement, analysis, intervention and re-measurement." and "Define, implement, evaluate, and document the effectiveness of corrective actions as related to client care improvement." The "Quality Assurance and Performance Improvement Plan 2017" reviewed on 6/14/17 at 9:00 AM under "Objectives" states "Establish clinical and service monitors and guidelines that reflect epidemiological characteristics of the residents, including benchmarks and performance goals for periodic monitoring and evaluation." "Establish priorities for the investigation and resolution of concerns and problems focusing on those with the greatest potential impact on client care outcomes and client satisfaction." "Define, implement, evaluate, and document the effectiveness of corrective actions as related to client care improvement."

An interview was conducted with Hospital Administrator C and Health Information Manager D on 6/14/17 at 9:00 AM. Health Information Manager D states he/she is responsible for the Quality information at this site and provided a spread sheet with all active Quality Assurance Projects 31 currently being completed in all departments. Per review of spreadsheet, there are no areas indicating intervention, re-measurement, corrective actions or effectiveness. There are no goal/end date on collection of data, implementation of new procedures based on data, nor re-evaluation of implementation or new procedures placed based on data collection. Hospital Administrator C and Health Information Manager D confirmed the need for goal dates, implementing process changes, completed projects, corrective actions and follow up on all Quality Assessment projects and verbalized agreement that "the circle is not complete".

Based on record review and interview, the medical staff failed to ensure that 1 of 1 Medical Director (P) credentials and eligibility were reviewed by medical peers based on governing body criteria. This deficient practice has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

The Medical Staff Bylaws, dated 11/10/16, were received for review on 6/13/2017 at 8:30 AM. In regards to the appointment (reappointment) process, the Bylaws state in part, "At the next regular Medical Staff meeting after referral from the Clinical Director, the Medical Staff shall review the application and related materials and shall make a recommendation that the practitioner be either provisionally appointed to the Medical Staff..."

The Clinical Director's (Doctor P) credential file was reviewed on 6/14/2017 at 12:30 PM. Doctor P's recredentialing process began in January 2017 and approved for reappointment by Executive Director N on March 28, 2017.

There is no evidence that the medical staff reviewed or approved Doctor P's reappointment application.

In an interview with Executive Director N on 6/14/2017 at 12:52 PM regarding the approval process for reappointment, Director N stated, "There should be something in the file signed by another physician." After reviewing the credential file, Director N stated that there is nothing in the file signed by another physician.

Based on record review and interview, staff at this facility failed to ensure that the Clinical Director maintains accountability and oversight of the medical staff per 2 of 2 staff interviews (Staff N and P). This deficient practice has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

The Medical Staff Bylaws, dated 11/7/16, were received for review on 6/13/2017 at 8:30 AM. The Bylaws define the Clinical Director as follows: "Refers to the psychiatrist appointed by the governing body to manager the affairs of the Medical Staff."

The Bylaws define the Medical Director as follows: "Refers to the individual appointed to coordinate and manage all medical services to clients and employees in the Nursing Home and as directed by the Clinical Director provide medical care to patients in the psychiatric hospital."

Under duties of the Clinical Director, the Bylaws state in part, "Be accountable to the governing body, through the executive sessions, for monitoring the quality and efficiency of clinical services and the effectiveness of quality assessment and improvement functions delegated to the Medical Staff."

The Clinical Director's (Doctor P) employment contract, dated January 1, 2017, was received for review on 6/14/2017 at 12:50 PM. The contract states in part, "3.3 Administrative and Miscellaneous Duties and Responsibilities...Physician shall provide appropriate supervision and review of services rendered by other physicians, nurse practitioners and other non-physicians involved in the direct medical care of County's patients."

During interview on 6/14/17 at 11:30 AM, Medical Director P was unable to provide evidence of monitoring of clinical services including the quality and appropriateness of services and treatment provided by the medical staff.

In an interview with Executive Director N on 6/14/2017 at 12:50 PM regarding the role of the Clinical Director (Doctor P), Director N stated that Doctor T is the Medical Director and Doctor P is the Clinical/Psychiatric Director.

Director N stated, "Doctor P would not oversee the whole medical team."

Based on observation and interview the facility failed to ensure that 3 of 3 drugs are dispensed under the supervision of a pharmacist. This deficient practice has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

On 6/13/17 at 9:46 AM observed in medication room samples of medications (Abilify-sleep medication, Aristuda-used for schizophrenia and Vraylar-given for atypical psychosis) in a locked cupboard.

An interview was conducted with Registered Nurse CC at the time of observation, CC stated that there is no record kept of receiving samples or who, where and when they are dispensed. Registered Nurse CC believes that they come from the outpatient unit.

Based on observation, record review and interview, kitchen staff at this facility failed to maintain a clean and sanitary environment and follow sanitary food standards in 1 of 1 kitchen observed. Failure to maintain a clean and sanitary kitchen has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

In an interview with Dietician G and Food Service Supervisor F on 6/12/2017 at 11:10 AM, Dietician G stated that the facility follows the FDA (Food and Drug Administration) food code as a standard of practice.

The FDA food code states in part, "The PERSON IN CHARGE shall ensure that: EMPLOYEES are properly SANITIZING cleaned multiuse EQUIPMENT and UTENSILS before they are reused, through routine monitoring of solution temperature and exposure time for hot water SANITIZING, and chemical concentration, pH, temperature, and exposure time for chemical SANITIZING."

A tour of the kitchen was conducted on 6/12/2017 at 11:40 AM accompanied by Food Service Manager F and Dietician G. The following observations were made:
-At 11:45 AM in the roll in cooler, several slide rungs (slots for holding food) had dried whipped cream along the runners. Per interview with Supervisor F at the time of the observation, F stated, "Yes, they should have cleaned it."
-At 11:51 AM Cook H was observed dishing out cucumber salad into individual dishes with gloves on. Cook H left the food station with the gloves on to retrieve extra food trays in a different part of the kitchen, returned to the food station and began dishing out the cucumber salad again, with the same gloves on. Per interview with Supervisor F at the time of this observation, F stated that Cook H should have removed the gloves before leaving the food station and do hand hygiene.
-At 11:55 AM a bread slicer, which was in a corner covered with a drape, was found to have a build up of bread crumbs along the internal channels. Per interview with Supervisor F at the time of this observation, F stated that the slicer should be cleaned every time it is used, and went on to say, "No, that does not look clean."

A review of the dish machine temperature logs was completed on 6/13/2017 at 2:30 PM. Between January and February of 2017 the temperature log directions state to monitor the temperature at every meal the machine is used (breakfast, lunch, and dinner). For March-June the frequency on the log was decreased to 2 times per day. There were 60 entries missed, where temperatures were not recorded, between January 1, 2017 and June 12, 2017.

These findings were discussed with, and confirmed per interview with Supervisor F and Dietician G on 6/13/2017 at 2:55 PM. Supervisor F stated that the dish machine temperature recording has been a focus for quality assurance for "a couple of years," and attributes non-compliance with the expectations partially to staffing issues. The facility does not have a policy for monitoring the dish machine.

Based on observation, interview and record review the facility failed to provide a safe environment, properly constructed and maintained to protect the health and safety of patients based on the following.

Findings include

K271 - failure to maintain one exit discharge;
K345 - failure to maintain the fire alarm system;
K374 - failure to provide a code compliant door in one smoke barrier;
K521 - failure to provide access panels on air ducts for maintenance of fire dampers; and
K919 - failure to provide clear work space in front of electrical equipment

Based on observation, interview and record review the facility failed to provide a safe environment, properly constructed and maintained to protect the health and safety of patients based on the following.

Findings include

K271 - failure to maintain one exit discharge;
K345 - failure to maintain the fire alarm system;
K374 - failure to provide a code compliant door in one smoke barrier;
K521 - failure to provide access panels on air ducts for maintenance of fire dampers; and
K919 - failure to provide clear work space in front of electrical equipment

Based on observation, record review and interview, staff at this facility failed to follow standards of practice and policy for hand hygiene after use of gloves in 3 of 3 staff observations (Staff J, K, and M) that involved 1of 1 patient (Patient #2), and failed to specify contracted laundry construction standards in 1 of 1 laundry contract. Failure to follow protocol for infection control has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

An interview regarding standards of practice for infection control in the facility was conducted with former Infection Preventionist, covering current Nursing Home Director of Nursing A on 6/13/2017 at 10:05 AM. Director A stated that the facility follows the CDC (Centers for Disease Control) for hand hygiene practices and stated that hand hygiene should be performed, "When hands are visibly soiled, after patient contact, between serving trays, anytime you take off your gloves."

The facility policy titled, "Precautions: Standard, Airborne, Droplet, Contact," was received for review on 6/14/2017 at 12:06 PM. The policy states in part, "Standard Precautions: 1. Hand cleaning must occur: ...before and after use of gloves..."

Environmental Services:
An interview with Housekeeping Manager I was conducted on 6/12/2017 at 1:35 PM. Regarding glove use and hand hygiene, Manager I stated that housekeeping staff follow the same guidelines as the rest of the facility. They follow the Centers for Disease Control.

An observation of housekeeping staff J and K was conducted on 6/12/2017 at 2:25 PM. Both J and K applied gloves without doing hand hygiene first, then proceeded to clean a discharged patient room. When finished both J and K removed their gloves and went on to other tasks without performing hand hygiene.

These observations were discussed per interview with Manager I on 6/12/2017 at 2:40 PM who stated, "Oh, they didn't do that? (shook head) Ok."

Laundry Contract:
-The facility laundry contract was received for review on 6/12/2017 at 4:05 PM. The contract does not specify that the contracted facility is in accordance with FGI (Facility Guideline Institute) (formerly AIA-American Institute of Architects) construction standards. This finding was discussed with and confirmed in an interview by Administrator C on 6/13/2017 at 7:50 AM.

Inpatient Unit:
An observation for medication administration for Patient #2 was made with Registered Nurse M on 6/13/2017 at 11:40 AM. After applying gloves to open Patient #2's medication, Nurse M removed gloves, gathered water cup and medication cup and left the medication room without performing hand hygiene.


37420

On 6/13/17 at 9:50 AM observed the medication refrigerator in the nurses medication room had free standing water on plastic case containing insulin and injection supplies, the refrigerator door and 2 boxes of influenza vaccines in manufacturer's cardboard box were saturated with water. An interview with RN CC at the time of observation confirmed these findings.

An interview with Hospital Administrator C on 6/14/17 at 10:00 AM, C stated that "if this refrigerator is not working appropriately it will be replaced".

Based on record review and interview this facility failed to include documentation of discharge planning as part of the medical record per policy for 13 of 13 (#10, 16, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47) medical records reviewed for discharge planning activities out of a total universe of 30 medical records reviewed. This deficient practice has the potential to affect all patients admitted to this facility (patient census on 6-12-2017 of 16, 6-13-2017 of 13, 6-14-2017 of 11).

Findings include:

The facility policy titled "Discharge Planning and Discharge Procedure" last revised 12/2015 was reviewed on 6/12/17 at 1:39 PM. This document states under "Special Considerations... 4. Planning for discharge will include continuing care needs, activity restrictions, diet modifications, medications, treatments, follow up care, community placement/housing, education and client and family education." This document also states under "Procedure: 1. An initial discharge plan is identified on the Integrated Care Plan upon admission by the RN. This plan is expanded by the treatment team and may include plans for housing, outpatient follow up, medication, diet, activity, treatment regimes, or continuing care needs....5. Discharge planning is revised/updated as evaluation of client progress in treatment occurs."

Patient # 10, 16, 42, 43, 44, 45, 46, and 47 Medical Records were reviewed on 6/13/17 between 8:00 AM and 4:00 PM. Patient #10, 16, 42, 43, 44, 45, 46 and 47 had documentation entered on their treatment plan under "discharge planning" on the date of admission. This documentation was never updated or changed based on the patients' needs during the inpatient hospitalization. This documentation was not updated to be specific to each patient's discharge needs including the environment for which each patient would discharge to, the community resources each patient would need, whether the patient has an on-going case worker and any outpatient treatment needs each patient would require upon discharge. Discharge Planning was not update or revised as the client progressed in the treatment.

An interview was conducted with Social Services Manger B on 6/13/17 at 4:35 PM. Social Services Manger B stated the initial discharge plan is written on the treatment plan. Social Services Manger B stated the discharge plan is discussed in the Interdisciplinary Team meeting daily (Monday through Friday) on each patient and this meeting/discussion is not always documented as part of the patients medical record. Social Worker B stated some discharge planning may be noted in the patient's progress notes. Social Services Manger B confirmed the medical records for Patient #10, 16, 42, 43, 44, 45, 46 and 47 do not reflect the discharge planning process. Social Services Manger B stated discharge planning is not properly reflected in each medical record although the discussions are taking place daily.



37419


Patient #37, 38, 39, 40 and 41 Medical Records were reviewed between 6/13/17 at 15:50 PM and 6/14/17 at 11 AM. Patient #37, 38, 40 and 41 had documentation entered on their treatment plan under "discharge planning" on the date of admission. This documentation was never updated or changed based on the patients' needs during the inpatient hospitalization. This documentation was not updated to be specific to each patient's discharge needs including the environment for which each patient would discharge to, the community resources each patient would need, whether the patient has a on-going case worker and any outpatient treatment needs each patient would require upon discharge. Discharge Planning was not update or revised as the client progressed in the treatment.

Patient #39 had documentation of interventions entered on their treatment plan under "discharge planning" on the date of admission (4/12/2017) and 4/13/2017 and on 5/03/2017 under Interventions and Goals it was documented "(WILL CONTINUE AS OF 05/03/2017)". Patient #39 was discharged 5/08/2017. This documentation was never updated or changed based on the patients' needs during the inpatient hospitalization. This documentation was not updated to be specific to Patient #39's discharge needs including the environment for which each patient would discharge to, the community resources each patient would need, whether the patient has an on-going case worker and any outpatient treatment needs each patient would require upon discharge. Discharge Planning was not update or revised as the client progressed in the treatment.

An interview was conducted on 6/14/2017 at 11 AM with the Electronic Medical Record Coordinator L, L stated all the discharge planning notes and information were supplied at the time of the request stating "there are no other discharge planning notes".

Based on record review and interview, the facility failed to have a mechanism in place for ongoing reassessment to track readmissions rates and identify potentially preventable readmissions and the effectiveness of the discharge planning and include in the hospital wide Quality Program in 1 of 1 discharge planning process. This deficiency has the potential to affect all readmission patients in the facility.

Findings include:

Received a document titled "30 Day Readmissions" on 6/13/17 at 10:00 AM. This document contains a list of nine patients in April 2017 five patients in May 2017.

An interview was conducted with Social Services Manager B on 6/12/17 at 1:40 PM. Social Services Manager B stated this facility began tracking 30 day readmission in April 2017. Social Services Manager B stated the facility has not reevaluated the readmissions to explore potential problems with the discharge planning at this time. Social Services Manager stated the facility does not review all readmissions as part of the Quality Improvement Program at this time.

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

I. Provide social work assessments that included a social evaluation of strength/deficits, high risk psychosocial issues, conclusions, and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in discharge planning for eight (8) of eight (8) sample patients (2, 4, 6, 7, 9, 10, 11, and 12). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Refer to B108)

II. Ensure that six (6) of seven (7) active sample patients (2, 4, 6, 7, 11, and 12) who had physical examinations completed received an examination containing a descriptive neurological examination indicating what tests were performed to assess neurological functioning. This failure to document current neurological status precludes accurate diagnosis and future comparative reexamination to measure any change in baseline function. (Refer to B109)

III. Ensure that seven (7) of eight (8) active sample patients (2, 4, 7, 9, 10, 11, and 12) received a psychiatric evaluation containing sufficient information to justify diagnoses and planned treatment. This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate master treatment plan. (Refer to B110)

IV. Ensure that the psychiatric evaluations of eight (8) of eight (8) active sample patients (2, 4, 6, 7, 9, 10, 11, and 12) included an inventory of descriptive patient assets that could be used in treatment planning. Failure to identify patient assets impairs the ability of the treatment team to develop interventions, utilizing the individual strengths of each patient. (Refer to B117)

V. Develop and document comprehensive treatment plans based on the individual needs of eight (8) of eight (8) sample patients (2, 4, 6, 7, 9, 10, 11 and 12). The treatment plans were based on a computerized program with a menu set of problems, with goals and interventions from which to choose. The treatment plans did not include a substantiated diagnosis. Many of the documented goals in the treatment plans were non-measurable or were based on compliance with treatment rather than on the patient's specific problem. The majority of staff interventions were role functions without patient individualization. In addition, interventions for care of patients' safety problems (e.g. violence to self and others) were insufficient. This practice results in "sameness" from one plan to another and in absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118 Part I)

VI. Review and revise treatment plans for four (4) of eight (8) active sample patients (2, 7, 9 and 10) based on patient needs and changing behaviors. This failure jeopardizes a timely, coordinated, responsive treatment process. (Refer to B118 Part II)

VII. Ensure that active treatment measures, such as group and individual treatment and therapeutic activities, were provided for four (4) of eight (8) active sample patients (2, 7, 9 and 10) who were unable, unwilling or not motivated to attend or participate in assigned active treatment groups on each patient's individual activity schedule. Although Master Treatment Plans included multiple group therapies, the patients regularly and repeatedly did not attend or participate in assigned groups. Treatment plans for these patients failed to include alternative interventions for these patients. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement. (Refer to B125)

VIII. Provide physician progress notes that contained information to specifically address patient progress and response to treatment as related to goals in the treatment plan. Failure to record the psychiatric progress of patients prevents the treatment teams from monitoring progress or deterioration in the psychiatric condition of patients. (Refer to B126)

Based on record review and interview, the facility failed to provide social work assessments that included a social evaluation of strength/deficits, high risk psychosocial issues, conclusions, and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in discharge planning for eight (8) of eight (8) sample patients (2, 4, 6, 7, 9, 10, 11, and 12). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions.

Findings include:

A. Record Review

The social work assessments of the sample patients (dates of assessments in parentheses) were reviewed as follows: Patient 2 (6/8/17), Patient 4 (6/6/17), Patient 6 (6/6/17), Patient 7 (5/12/17), Patient 9 (6/3/17), Patient 10(5/3/17), Patient 11 (6/1/17), and Patient 12 (6/8/17). The social work assessments (dates in parentheses) did not include a social evaluation of strength/deficits, high risk psychosocial issues, conclusions, and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in discharge planning.

B. Interview

1. Interview with the Medical Director on 6/14/17 at 11:30 a.m. revealed that the Medical Director acknowledged that the psychosocial assessments for the sample patients did not contain a social evaluation of strength/deficits, high risk psychosocial issues, conclusions, and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in discharge planning.


2. During an interview with the Director of Social Work on 6/14/17 at 9:00 a.m., the Director of Social Work acknowledged that the psychosocial assessments for the sample patients did not contain did not include a social evaluation of strength/deficits and high risk psychosocial issues, conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in discharge planning from which treatment interventions and discharge plans could be formulated.

Based on record review and staff interview, the facility failed to ensure that six (6) of seven (7) active sample patients (2, 4, 6, 7, 11, and 12) who had physical examinations completed received an examination containing a descriptive neurological examination indicating what tests were performed to assess neurological functioning. This failure to document current neurological status precludes accurate diagnosis and future comparative reexamination to measure any change in baseline function.

Findings include:

A. Record Review:

The physical examinations (dates in parentheses) for the following patients were reviewed: Patient 2 (6/7/17), Patient 4 (6/5/17), Patient 6 (6/5/17), Patient 7 (5/12/17), Patient 11 (6/1/17), and Patient 12 (6/7/17). The only neurologic examination information
documented was identical for all patients and stated "Cranial Nerves - Details, Pertinent Negatives: grossly normal."

B. Staff Interview:

During a review of neurological examinations with the Medical Director on 6/14/17 at 11:30, the Medical Director acknowledged that the neurological examinations were incomplete and did not indicate tests performed to assess current neurological functioning.

Based on record review and interview, the facility failed to ensure that seven (7) of eight (8) active sample patients (2, 4, 7, 9, 10, 11, and 12) received a psychiatric evaluation containing sufficient information to justify diagnoses and planned treatment. This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate master treatment plan.

Findings include:

A. Record Review

1. The Psychiatric Evaluation for Patient 2, dated 6/9/17, listed the diagnoses as "Schizophrenia" and "Tetrahydrocannabinol (THC) use disorder." The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify these diagnoses according to the DSM-5 or ICD-10 criteria for schizophrenia and cannabis use disorder.

2. The Psychiatric Evaluation for Patient 4, dated 6/5/17 at 2:29 p.m., listed the diagnoses as "Major Depression," "Obsessive-compulsive disorder," "Polysubstance use disorder," and "Body dysmorphic disorder." The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify these diagnoses according to the DSM-5 or ICD-10 criteria for major depressive disorder, obsessive compulsive disorder, a substance use disorder, or body dysmorphic disorder.

3. The Psychiatric Evaluation for Patient 7, dated 5/12/17 at 11:50 a.m., listed the diagnosis as "Bipolar disorder." The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify this diagnosis according to the DSM-5 or ICD-10 criteria for a bipolar disorder.

4. The Psychiatric Evaluation for Patient 9, dated 6/5/17 at 10:10 a.m., listed the diagnoses as "Schizoaffective disorder with acute psychotic symptoms" and "Anxiety disorder not otherwise specified." The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify these diagnoses according to the DSM-5 or ICD-10 criteria for a schizoaffective disorder or anxiety disorder.

5. The Psychiatric Evaluation for Patient 10, dated 5/3/17 at 10:45 a.m., listed the diagnosis as "Bipolar disorder with psychosis." The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify this diagnosis according to the DSM-5 or ICD-10 criteria for a bipolar disorder.

6. The Psychiatric Evaluation for Patient 11, dated 6/1/17 at 11:07 a.m., listed the diagnoses as "Panic disorder" and "Alcohol use disorder, in remission." The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify these diagnoses according to the DSM-5 or ICD-10 criteria for panic disorder or alcohol use disorder.

7. The Psychiatric Evaluation for Patient 12, dated 6/7/17 at 12:02 p.m., listed the diagnoses as "Adjustment disorder with disturbance of emotions and conduct" and "Alcohol use disorder." The Psychiatric Evaluation did not document sufficient information in the psychiatric history and mental status examination to justify these diagnoses according to the DSM-5 or ICD-10 criteria for adjustment disorder or alcohol use disorder.

B. Interview

During an interview with the Medical Director on 6/14/16 at 11:30 a.m., the Medical Director acknowledged that the psychiatric evaluations for the sampled patients (2, 4, 7, 9, 10, 11, and 12) failed to contain sufficient information to justify diagnoses and planned treatment.

Based on record review and interview, the facility failed to ensure that the psychiatric evaluations of four (4) of eight (8) active sample patients (2, 4, 7, and 12) included an inventory of descriptive patient assets that could be used in treatment planning. Failure to identify patient assets impairs the ability of the treatment team to develop interventions, utilizing the individual strengths of each patient.

A. Record Review

1. The psychiatric evaluations (dates in parentheses) for the following patients did not contain specific patient assets:

a. For Patient 2 (6/8/17), Patient 9 (6/5/17), and Patient 11 (6/1/17), no patient assets were documented on the psychiatric evaluations.

b. For Patient 4 (6/5/17) and Patient 6 (6/5/17), the only, non-specific patient assets were "[S/he] is in good health and wants help."

c. For Patient 7 (5/12/17), the only, non-specific patient asset was "Average Intelligence."

d. For Patient 12 (6/7/17), the only, non-specific patient asset was "[S/he] is in good health."

B. Staff Interview

During an interview on 6/14/17 at 11:30 a.m., the Medical Director acknowledged that the psychiatric evaluations for the sampled patients (2, 4, 6, 7, 9, 10, 11 and 12) did not document specific patient assets that could be utilized for treatment planning.

Based on interview and record review it was determined that the facility failed to:
I. Develop and document comprehensive treatment plans based on the individual needs of eight (8) of eight (8) sample patients (2, 4, 6, 7, 9, 10, 11 and 12). The treatment plans were based on a computerized program with a menu of set of problems with goals and interventions from which to choose. The treatment plans did not include a substantiated diagnosis (Refer to B120). Many of the documented goals in the treatment plans were non-measurable or were based on compliance with treatment rather than on the patient's specific problem. (Refer to B121). The majority of staff interventions were role functions without patient individualization. In addition, interventions for care of patients' safety problems (e.g. violence to self and others) were insufficient (Refer to B122). These practices result in repetition from one plan to another and in absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings.
II. Review and revise treatment plans for four (4) of eight (8) active sample patients (2, 7, 9 and 10) based on patient needs and changing behaviors. This failure jeopardizes a timely, coordinated, responsive treatment process.

Findings include:

A. Record Review

1. Patient 2

a. According to the psychiatric evaluation (6/8/17) Patient 2 was admitted due to "an overdose on [his/her] Depakote in a suicide attempt. [S/he] has been getting thoughts that people are out to get [him/her] and [s/he] has been having auditory hallucinations and also using marijuana."

b. Review of "Group Flow Charting" for Patient 2 provided by administration revealed that between 6/7/17 and 6/12/17 Patient 2 attended only six (6) of 23 groups offered. No alternative treatments were documented when Patient 2 failed to attend offered groups.

c. Even though this patient was not attending scheduled groups, Patient 2 was paranoid, experiencing auditory hallucinations and unable to tolerate high levels of stimuli, review of Patient 2's treatment plan revealed that as of 6/12/17, Patient 2's treatment plan had not been revised based on his/her current needs.

2. Patient 7

a. According to the psychiatric evaluation (5/12/17) Patient 7 was admitted due to threatening others and presented with "psychosis, mood fluctuations, and mood irritability...[S/he] has been having delusions of persecution."

b. During interview on 6/13/17 at 10:00 a.m. and on 6/14/17 about 1:30 p.m. Patient 7 presented problems in relating. S/he mumbled and gestured and was unable to respond to questions. On 6/12/17 at about 10:30 a.m. and on 6/13/17 at 9:30 a.m., Patient 7 was observed "throwing [him/herself] on the floor, wailing and thrashing about. At these times, Patient 7 did not respond to redirection by the staff." No alternative treatments were documented when Patient 7 failed to attend offered groups.

c. Review of "Group Flow Charting" for Patient 7 provided by administration revealed that between 5/30/17 and 6/12/17 Patient 7 attended only 27 of 67 groups offered.

d. Even though this patient was too acutely ill to attend groups as scheduled and interrupted the treatment of other patients when attending the groups, review of Patient 7's treatment plan (6/7/17 listed as a plan update) included an intervention stated as "Will provide [Patient] w/ (with) groups or alternative therapies, that assist [him/her] with effectively engaging in necessary and desired occupational roles." As of 6/12/17, Patient 7's treatment plan had not been revised based on his/her current needs and no alternative interventions to group therapy was documented in the treatment plan for Patient 7.

3. Patient 9

a. During an interview with Patient 9 on 6/11/17 at 10:40 a.m., Patient 9 expressed poorly organized paranoid delusions that harm would come to him/her.

b. The Psychiatric Evaluation for Patient 9 dated 6/3/17 stated that Patient 9 was admitted 6/2/17 because of "refusing medications and threatening [his/her] case manager. Patient 9 was described as "argumentative, angry, agitated and paranoid . . . marginally cooperative, accusatory. . . very paranoid."

c. The Master Treatment Plan for Patient 9 dated 6/8/17, last updated 6/12/17, included the Problem of "Non-adherence to medication or treatment related to poor insight and mental illness as evidenced by statements made by case manager and threats to case manager by client." The identified interventions included "COTA staff will provide [Patient 9] with groups or alternative therapies that assist client with prompting the importance of health, wellness and positive coping strategies to utilize as a positive symptom management tool" and "SW [social work] will meet with [Patient 9] individually and/or with treatment team in staffing, to assess for a decrease in altered thought process symptoms, as evidenced by self-reports, scaling questions and observation."

d. A review of the "Group Flow Charting" notes from 6/2/17 to 6/12/17 documented that Patient 9 refused to attend 30 out of 55 groups during this period. Patient 9 only partially attended 11 other groups, generally leaving the group after about 15 minutes. Patient 9 attended 14 groups, mostly leisure activity groups outside of the unit. No alternative treatments were documented when Patient 9 failed to attend offered groups.

e. Even though this patient was not attending scheduled groups, review of Patient 9's treatment plan revealed that as of 6/12/17, his/her treatment plan had not been revised based on his/her current needs and no alternative interventions to group therapy was documented in the treatment plan for Patient 9.

4. Patient 10

a. During an interview with Patient 10 on 6/11/17 at 10:50 a.m., Answers to questions were not related to the questions.

b. The Psychiatric Evaluation for Patient 10 dated 5/3/17 stated that Patient 10 was admitted 5/2/17 because of psychosis, "responding to internal stimuli," and "quite paranoid and guarded." Patient 10 was described as "responding to internal stimuli, talking and mumbling to [him/herself]," "at times yelling," and "not fully cooperative."

c. The Master Treatment Plan for Patient 10 dated 6/7/17 included the Problem of "Alteration in thought process related to psychosis as evidenced by client appears to be responding to internal stimuli." The identified interventions included "COTA staff will provide [Patient 10] [with] groups or alternative therapies that assist [with] cognitive skills, socialization skills, life skills and groups that allow [him/her] to explore/engage in leisure/hobbies to utilize as a symptom management tool" and "SW [social work] will encourage [Patient 10] to attend all groups on the Unit when thought process clears (10, 12:30, 2:15), alternative activities will be provided if client is unable to attend group."

d. A review of the "Group Flow Charting" notes from 5/30/17 to 6/12/17 documented that Patient 10 refused to attend 33 out of 77 groups during this period. Patient 10 was generally documented as not actively participating in the groups that were attended. No alternative treatments were documented when Patient 10 failed to attend or participate in offered groups.

e. During interview on 6/13/17 at 2:20 p.m. RN 1 reported that Patient 10 had attended a few groups. She stated that Patient 10 was "intrusive to other patients in the groups and has a negative attitude in the groups." RN 1 did not refute that groups may not be the appropriate treatment for Patient 10 at the current time.

f. Even though this patient was not attending scheduled groups, was psychotic
and unable to tolerate high levels of stimuli, review of Patient 10's treatment plan revealed that as of 6/12/17, his/her treatment plan had not been revised based on his/her current needs and no alternative interventions to group therapy was documented in the treatment plan for Patient 2.

B. Interview:

When asked in treatment team meeting on 6/13/17 at 9:00 a.m. if the treatment plan for any current patients had been revised, the Clinical Director indicated that the treatment plans for Patient 2, Patient 7, Patient 9 and Patient 10 had not been revised.

Based on record review and staff interview, the facility failed to develop Master Treatment Plans that included a substantiated diagnosis for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 9, 11, 12, and 13). The absence of a substantiated diagnosis (or diagnoses) on the treatment plan compromises the ability of the treatment team to deliver clinically focused treatment.

Findings include:

A. Record Review

No substantiated psychiatric or medical diagnoses were identified in the treatment plans for the following patients (dates of plans are in brackets): Patient 2 (6/7/17, updated (6/9/17), Patient 4 (6/10/17), Patient 6 (6/8/17, updated 6/12/17), Patient 7 (6/7/17), Patient 9 (6/8/17, updated 6/12/17), Patient 10 (6/7/17), Patient 11 (6/8/17), and Patient 12 (6/8/17, updated 6/12/17).

B. Staff Interview

During an interview with the Medical Director on 6/14/17 at 11:30 a.m., the Medical Director acknowledged that the treatment plans did not include documentation of substantiated diagnoses to be utilized in treatment planning.

Based on interview and record review the facility failed to ensure that goals in the treatment plans were based on individual patient findings for eight (8) of eight (8) sample patients ( 2,4,6,7,9,10,11,12). Some goals were stated in non-measurable terms or as treatment compliance or attendance at groups/activities. This failure hinders the treatment team's ability to individualize treatment and to measure change in the patient consequent to treatment and implement changes to the treatment plan.

Findings include:

A. Record Review

1. Patient 2 (plan 6/7/17 with update of 6/9/17)

The problem was listed as, "Alteration in thought process related to hx (history) of schizophrenia as evidence by overdose on Depakote and believes [s/he] is being watched by police." The short term goals were "[Patient 2] will contract for safety with staff at least once per shift" and "Will take prescribed medications each shift." This was a treatment compliance statement rather than a patient outcome goal.

A non-measurable goal was stated as "[Patient 2] will demonstrate [sic] clearer thought process by improvement in affect/increased trust in others/relating."

2. Patient 4 (plan 6/10/17),

The problem was listed as "Ineffective coping related to mental health issue as evidenced by suicidal thoughts," Treatment compliance stated as a short-term goal was: "[Patient 4] will contract for safety with staff at least once per shift."

3. Patient 6 (plan 6/8/17 with update of 6/12/17)
The problem was listed as "Ineffective coping related to loss of companion dog on 4/20/17 as evidenced by making statement 'I want to [f ...ing] die,'" Treatment compliance stated as a short-term goal was "[Patient 6] will contract for safety with staff at least once per shift."

4. Patient 7 (plan 6/7/17)

a. The problem was listed as "Alteration in thought process related to ...depression and psychosis as evidenced by disrobing, aggression towards others and homicidal statements." A treatment compliance statement is "[Patient 7] will take prescribed medications each shift."

A non-measurable goal was listed as "[Patient 7] will demonstrate a more stabilized mood level by displaying improvement in affect & not being able to modify behavior as appropriate for situation [sic]."

b. For the problem, "Risk for injury related to seclusion," a goal was "Client will be released from seclusion and will comply with unit rules." This goal indicated that the staff expect that the patient will present behaviors for which seclusion will be utilized. Also the goal suggests that the patient was/is to be secluded for non-compliance with unit rules which is not an emergency situation.

5. Patient 9 (plan 6/8/17 with update of 6/12/17)

For the problem, "Non-adherence to medication or treatment related to poor insight and mental illness as evidenced by statement made by case manager and threats to case manager by client," treatment compliance was listed as a patient goal: "[Patient 9] will take prescribed medications each shift."

A non-measurable goal was listed as "[Patient 9] will demenstate [sic] stabilized mood, improvement in judgement [sic] & more goal directed behaviors."

6. Patient 10 (plan 6/7/17)

a. The problem was listed as "Non-adherence to medication or treatment related to mental health commitment with medication order as evidenced by client has not beencompliant with MD ordered medications." Treatment compliance listed as a patient goal was: "[Patient 10] will take prescribed medications each shift."

B. For the problem, "Alteration in thought process related to psychosis as evidenced by client appears to be responding to internal stimuli," a non-measurable goal was "[Patient 10] will be able to identify and differentiate between delusional thoughts false beliefs, and reality."

Another non-measurable goal was: "[Patient 10] will demonstrate more stabilized mood level by displaying improvement in affect & interacting in ways that are socially appropriate."

7. Patient 11 (plan 6/8/17)

a. The problem listed was, "Ineffective coping related to client's statement that [s/he] has difficulty coping with [his/her] divorce ...as evidenced by [s/he] put a knife up to [his/her] throat ...has been having anxiety attacks ...." Treatment compliance stated as a goal was "[Patient 11] will participate in at least three groups/activities per day."

8. Patient 12 (plan 6/7/17 with update of 6/12/17)

For the problem, "Risk for suicide related to alcohol dependence as evidenced by making suicidal statements to kill self to crisis staff and police officer," a short-term goal was "[Patient 12] will contract for safety with staff at least once per shift." This was a treatment compliance statement rather than a patient outcome goal.

A non-measurable goal was stated as "[Patient 12] will stabilize both physically/mentally & establish a supportive recovery plan."

B. Interview

1. During an interview and review of treatment plans for Patient 2 and Patient 7, on 6/13/17 at 1:50 p.m., with the Acting Director of Nursing (ADON) and RN1, the ADON stated that goals and objectives should have been measurable.

2. During an interview and review of the treatment goals in Patient 10's treatment plan, on 6/14/17 at 9:05 a.m., the Director of Social Work verified that the goals were non-measurable.

Based on record review and interview, the facility failed to develop treatment plans that clearly delineated interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (dates of plans in parentheses) as follows: Patient 2 (6/7/17 with update of 6/9/17), Patient 4 (6/10/17), Patient 6 (6/8/17 with update of 6/12/17), Patient 7 (6/7/17), Patient 9 (6/8/17 with update of 6/12/17), Patient 10 (6/7/17), Patient 11 (6/8/17), and Patient 12 (6/7/17 with update of 6/12/17). Instead, treatment plans included interventions that were routine, generic discipline functions. In addition, there was failure to include interventions to guide personnel in the care of patients presenting safety issues in the clinical areas. This resulted in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient 2

For the problem, "Alteration in thought process related to hx (history) of schizophrenia as evidence by overdose on Depakote and believes [s/he] is being watched by police," generic nursing interventions were listed as "Registered Nurse (RN) will encourage attendance for all visits with the psychiatrist," "RN will reinforce Medical Director (MD) teaching and educate [Patient 2] on medication uses and potential side effects" and "RN will encourage [Patient 2] to take medications as prescribed on a daily basis."

A generic physician intervention was stated as "The psychiatrist will monitor effectiveness of medications, monitor for side effects and make necessary adjustments."

A social work intervention was "Social Worker (SW) will encourage [Patient 2] to attend all groups while on the Unit ...alternative activities will be provided if [Patient 2] is unable to attend group." The first part of this statement is generic. The last part of the statement does not specify the alternative activities based on this patient's needs.

A social work intervention was listed as "SW will meet individually and/or with treatment team in staffing, to assess [Patient 2] for a decrease depression symptoms (sic) as evidenced by self-reports, scaling questions and staff observation." This statement is an expected assessment, rather than action to be taken based on assessment.

Even though this patient was admitted after a suicidal attempt and was still talking about being "hopeless" and hearing voices, there were no nursing safety interventions based on his/her specific findings.

2. Patient 4

For the problem, "Ineffective coping related to mental health issue as evidenced by suicidal thoughts," generic nursing interventions were "Nursing staff will encourage [Patient 4] to take medications as prescribed on a daily basis" and "Nursing staff will encourage attendance for all visits with the psychiatrist."

There were no identified physician interventions in Patient 4's treatment plan.

A generic social work intervention states "SW will encourage [Patient 4] to attend all groups on the Unit when thought process clears, alternative activities will be provided if client is unable to attend groups." Specific alternative activities based on patient's needs were not stated.

A social work intervention was listed as "SW will meet with [Patient 4] individually and/or with treatment team in staffing, to assess [Patient 4] for a decrease in altered thought process symptoms as evidenced by self-reports, scaling questions and staff observation." This statement is an expected assessment, rather than action to be taken based on assessment.

A generic social work intervention was stated as "SW will collaborate with {Patient 4's] collaterals to ensure effective treatment, and successful discharge."

Even though this patient was admitted after a suicidal attempt and was still talking about being "hopeless" and hearing voices, there were no nursing safety interventions based on his/her specific findings.

3. Patient 6

For the problem, "Ineffective coping related to loss of companion dog on 4/20/17 as evidenced by making statement 'I want to [f ...ing] die,'" a nursing intervention was stated as "Nursing staff will encourage [Patient 6] to admit and accept personal responsibility for own actions/behavior." It was not clear how this action related to the stated problem.

There were no identified physician interventions in Patient 4's treatment plan.

Generic nursing interventions were "RN will encourage attendance for all visits with psychiatrists," and "RN will encourage [Patient 6] to take medications as prescribed on a daily basis."

4. Patient7

a. For the problem, "Alteration in thought process related to ...depression and psychosis as evidenced by disrobing, aggression towards others and homicidal statements," generic nursing interventions were "RN will encourage attendance for all visits with psychiatrists," and "RN will encourage [Patient 7] to take medications as prescribed on a daily basis."

A generic physician intervention was stated as "The psychiatrist will monitor effectiveness of medications, monitor for side effects and make necessary adjustments."

An occupational therapy statement was "Will provide [Patient 7] with groups or alternative therapies that assist [him/her] w/ (with) social skills, stress management skills, & provide [him/her] with effectively engaging in necessary and desired occupational roles." This is an unrealistic intervention for this patient as s/he is too acutely ill and also greatly disrupts the groups for other patients who are attending. In addition, the alternative therapies for this patient were not specified.

A generic physician intervention was stated as "The psychiatrist will monitor effectiveness of medications, monitor for side effects and make necessary adjustments."

A generic social work intervention states "SW will encourage [Patient 7] to attend all groups on the Unit when thought process clears, alternative activities will be provided if client is unable to attend groups." Specific alternative activities based on patient's needs are not stated.

A social work intervention was listed as "SW will meet with [Patient 7] individually and/or with treatment team in staffing, to assess [Patient 7] for a decrease in altered thought process symptoms as evidenced by self-reports, scaling questions and staff observation." This statement is an expected assessment, rather than action to be taken based on assessment.

A generic social work intervention was stated as "SW will collaborate with [Patient 7's] collaterals to ensure effective treatment, and successful discharge."

A nursing intervention was documented as "[Patient 7] to be secluded for agitation resulting in physically assaulting a staff [sic] by throwing an orange at staff." This intervention indicates that seclusion was to be used in non-emergency situations.

b. For the problem, "Risk for injury related to seclusion," generic nursing interventions were "Modify environment as indicated to enhance safety" and "All staff to monitor for unsafe situations and provide education to the client as needed."

5. Patient 9

For the problem, "Non-adherence to medication or treatment related to poor insight and mental illness as evidenced by statement made by case manager and threats to case manager by client," a generic nursing intervention was "Nursing will encourage attendance for all visits with the psychiatrist."

A generic physician intervention was "The psychiatrist will monitor effectiveness of medications, monitor for side effects and make necessary adjustments."

An occupational therapist intervention was "Certified Occupational Therapy Assistant (COTA) staff will provide [Patient 9] with groups or alternative therapies that assist client with promoting the importance of health, wellness and positive coping strategies to utilized (sic) as a positive symptom management tool." The specific alternative strategies to meet his/her needs were not identified.

A social work intervention was "SW will encourage [Patient 9] to attend two groups on the Unit, alternative activities will be provided if client is unable to attend group."

The specific alternative strategies to meet his/her needs are not identified.

A social work intervention was listed as "SW will meet with [Patient 9] individually and/or with treatment team in staffing, to assess [Patient 9] for a decrease in altered thought process symptoms as evidenced by self-reports, scaling questions and staff observation." This statement is an expected assessment, rather than action to be taken based on assessment.

A generic social work intervention was stated as "SW will collaborate with [Patient 9's] collaterals to ensure effective treatment, and successful discharge."

6. Patient 10

a. For the problem, "Non-adherence to medication or treatment related to mental health commitment with medication order as evidenced by client has not been compliant with MD ordered medications," generic role functions were stated as nursing interventions: "Nursing staff will encourage [Patient 10] to take medications as prescribed on a daily basis" and "RN will reinforce MD teaching and educate [Patient 10] on medications uses and potential side effects."

A generic physician intervention was "The psychiatrist will monitor effectiveness of medications, monitor for side effects and make necessary adjustments."

b. For the problem, "Alteration in thought process related to psychosis as evidenced by client appears to be responding to internal stimuli," a social work intervention was "SW will encourage [Patient 10] to attend all groups on the Unit when thought process clears, alternative activities will be provided if client is unable to attend group." The specific alternative strategies to meet his/her needs are not identified.

A social work intervention was listed as "SW will meet with [Patient 10] individually and/or with treatment team in staffing, to assess [Patient 10] for a decrease in altered thought process symptoms as evidenced by self-reports, scaling questions and observation." This statement is an expected assessment, rather than action to be taken based on assessment.

A generic social work intervention was stated as "SW will collaborate with [Patient 10's] collaterals to ensure effective treatment, and successful discharge."

An occupational therapy intervention was "COTA staff will provide [Patient 10] w/ (with) groups or alternative therapies that assist w/ (with) cognitive skills socialization skills, life skills & groups that allow [him/her] to explore/engage in leisure/hobbies to utilized as a symptom management tool." The specific alternative strategies to meet his/her needs were not identified.

A social work generic role function was listed as "SW will provide [Patient 10] with a list of community resources including but not limited to shelter, food, clothing, employment, support groups, etc."

7. Patient 11

For the problem, "Ineffective coping related to client's statement that [s/he] has difficulty coping with [his/her] divorce ...as evidenced by [s/he] put a knife up to [his/her] throat ...has been having anxiety attacks ...," a social work intervention was listed as "SW will meet with [Patient 11] individually and/or with treatment team in staffing, to assess [Patient 11] for a decrease in anxious symptoms as evidenced by self-reports, scaling questions and staff observation." This statement is an expected assessment, rather than action to be taken based on assessment.

There were no identified physician interventions in Patient 11's treatment plan.

A generic social work intervention was stated as "SW will collaborate with [Patient 11's] collaterals to ensure effective treatment, and successful discharge."

A social work generic role function was listed as "SW will provide [Patient 11] with a list of community resources including but not limited to shelter, food, clothing, employment, support groups, etc."

8. Patient 12

For the problem, "Risk for suicide related to alcohol dependence as evidenced by making suicidal statements to kill self to crisis staff and police officer," a nursing intervention was stated as "Nursing staff will encourage [Patient 12] to admit and accept personal responsibility for own actions/behavior." It was not clear how this action related to the stated problem.

A generic intervention was stated as "All staff will encourage [Patient 12] to go to the 10:30, 12:30 and 14:00 groups, Alternative interventions will be offered for groups missed." Focus of groups based on this patient's needs was not identified.

There were no specific safety interventions to direct nursing personnel in the care of this patient.

B. Interview

1. During an interview and review of treatment plans for Patient 2 and Patient 7, on 6/13/17 at 1:50 p.m. the Acting DON and RN1 verified the findings for these patients, adding, "Group assigments must be realistic for the patient."

2. During an interview and review of the treatment plans for patients 2, 4 ,6 ,7 ,9 ,10 , 11, and 12 with the Director of Social Work on 6/14/17 at 9:00 a.m., the Director of Social Work acknowledged that the interventions on the treatment plans for these patients were generic social worker functions and not specific to patient needs.

3. During telephone interview, with discussion about nursing interventions for patients 2, 4 ,6 ,7 ,9 ,10 , 11, and 12, on 6/14/17 at 10:00 a.m., the Director of Nursing agreed that many of the nursing interventions were generic role functions.

4. During interview, with review of physician interventions on treatment plans for patients 2, 4 ,6 ,7 ,9 ,10 , 11, and 12, on 6/14/17 at 11:30 a.m., the Clinical Director acknowledged that physician interventions were generic role functions. He also verified that the treatment plans for Patients 4, 6 and 11 did not include physician interventions.

Based on observation, interview, and record review, the facility failed to ensure that active treatment measures, such as group and individual treatment and therapeutic activities, were provided for four (4) of eight (8) active sample patients (2, 7, 9 and 10) who were unable, unwilling or not motivated to attend or participate in assigned active treatment groups on each patient's individual activity schedule. Although Master Treatment Plans included multiple group therapies, the patients regularly and repeatedly did not attend or participate in assigned groups. Treatment plans for these patients failed to include alternative interventions for these patients. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement.

Findings include:

A. Patient Review

1. Patient 2 was admitted on 6/7/17.

a. Patient Observation and interview

During interview on 6/13/17 at 10:45 a.m. Patient 2 reported two recent suicide attempts, difficult relationships with significant others and talked at length about having auditory hallucinations and persecutory thoughts. Patient 2 was very verbal, and was not reluctant to talk about his/her issues. Prior to this interview Patient 2 was lying in bed with door closed. S/he readily accepted a request for an interview.

b. Record Review

1) According to the psychiatric evaluation (6/8/17) this patient was admitted due to "an overdose on [his/her] Depakote in a suicide attempt. [S/he] has been getting thoughts that people are out to get [him/her] and [s/he] has been having auditory hallucinations and also using marijuana."

2) As documented in the psychiatric evaluation (6/8/17) Patient 2 was paranoid, and experiencing auditory hallucinations Review of Patient 2's treatment plan (6/7/17 with update as of 6/9/17) included an occupational intervention stated as "Will provide [Patient] w/ (with) groups or alternative therapies, that assist [him/her] w/cognitive skills, social skills & life skills." As of 6/12/17, Patient 2's treatment plan had not been revised based on his/her current needs. This plan failed to include structured alternative interventions to the scheduled groups to include sessions with a professional (physician, social worker, nursing) with focus of assisting this patient to deal with his/her issues. The only related intervention was stated as "SW [Social Worker] will assist client in identify [sic] two coping skills which will lessen symptoms of depression." The focus of this intervention did not clearly identify the issues (relationships, finances, dealing with current symptoms of voices and paranoid thoughts) Patient 2 continually talked about in interview on 6/13/17.

3) Review of "Group Flow Charting" for Patient 2 provided by administration revealed that between 6/7/17 and 6/12/17 Patient 2 attended only six (6) of 23 groups offered. Review of these notes revealed the following documentation: The occupational therapist note (6/8/17) stated "Client refused group request by verbalizing refusal reason was because [s/he] was tired." The mental health technician note (6/9/17) stated, "Client remained in bed willing to skip group activities this morning." The occupational therapist notes (6/9/17) stated "[Patient] declined group stating [s/he] wasn't feeling well" and "Client declined group today." The occupational therapist notes for 2 groups on 6/10/17 stated "Client refused group request by verbalizing refusal reason was that [s/he] doesn't want to." The occupational therapist note (6/11/17) stated, "Writer was unable to approach client for group or offer an alternative, as [s/he] was on the phone out in the day room ..." The Social Worker note (6/11/17) documented "Client refused group stating, 'Police officers are coming to take me away' ..."

4) Review of progress notes revealed the following statements: A registered nurse note (6/8/17 at 12:21 p.m.) documented "Refused breakfast and has been isolative to [his/her] room and sleeping much of the shift." A registered nurse note (6/9/17 at 1:26 p.m.) documented "Appears tired and slept much of the morning and refused most groups offered today." A registered nurse note (6/10/17 at 1:27 p.m.) stated "'Pt [Patient] spent much of the morning in [his/her] room reading and resting. [S/he] was up to use the phone twice ..."

c. Staff Interview

During interview on 6/13/17 at 1:50 p.m., RN 1 reported that Patient 2 was still very paranoid, heard voices and spent most of the time in his/her room.

2. Patient 7 was admitted on 5/11/17.

a. Observation and Interview

During interview with surveyor on 6/13/17 at 10:00 a.m. and on 6/14/17 about 1:30 p.m. Patient 7 presented problems in relating. S/he mumbled and gestured and was unable to respond to questions. On 6/12/17 at about 10:30 a.m. and on 6/13/17 at 9:30 a.m., Patient 7 was observed by the surveyor "throwing [him/herself] on the floor, wailing and thrashing about. At these times, Patient 7 did not respond to redirection by the staff."

b. Record Review

1) According to the psychiatric evaluation (5/12/17) Patient 7 was admitted due to threatening others and presented with "psychosis, mood fluctuations, and mood irritability...[S/he] has been having delusions of persecution."

2) Review of Patient 7's treatment plan revealed that even though s/he was too acutely ill to attend groups as scheduled and interrupted the treatment of other patients when attending the groups, the treatment plan (6/7/17 listed as a plan update) included an occupational intervention stated as "Will provide [Patient] w/ (with) groups or alternative therapies, that assist [him/her] with effectively engaging in necessary and desired occupational roles." As of 6/12/17, Patient 7s treatment plan had not been revised based on his/her current needs.

For a short-term treatment goal stated as, "Client to refrain from laying [sic] on floor in dayroom and refrain from assaulting staff," a nursing intervention stated "[Patient] to be secluded for agitation resulting in physically assaulting a staff by throwing an orange at staff. There was failure to include structured interventions to be implemented by staff members to assist this patient to reduce/resolve these behaviors.

3) Review of "Group Flow Charting" for Patient 7 provided by administration revealed that between 5/30/17 and 6/12/17 Patient 7 attended only 27 of 67 groups offered. Review of these notes revealed the following documentation: An occupational note (5/31/17) stated, "Verbalized bizarre comments about [his/her husband/wife] wanting to kill [him/her] ...was fixated on talking to the Green Bay polices [sic] as writer was unable to redirect [him/her] to a different topic." An occupational note (5/31/17) documented "Verbalized nonsensical bizarre statements while in group ...Attempted to direct client's focus on group activities, but client demonstrated difficulties w/ (with) focusing attention of group & engaging. Client left group abruptly appearing irritable & verbalizing irritable comments towards group members ..." An occupational therapist note (6/7/17) documented "During group client needed a high amount of redirection to not talk, while others were talking & to stay on topic ...needed redirection from writer not to touch other patients 2-3 x's during group. Client was asked to leave after [s/he] started lying on the floor." An occupational therapist note (6/11/17) stated, "Client needed a high amount of redirection from CNA (certified nursing assistant) & writer, due to disruptive & inappropriate behaviors. Some examples included disrobing, verbalizing loud comments, lying on the floor or intrusive behaviors w/ (with) peers."

4) Review of a physician's order (6/4/17) and observations on the Unit (6/12/17 and 6/13/17) revealed that Patient 7 had been reassigned to a bedroom with a camera that is viewed in the nursing station. As a result of this Patient 7 could be viewed by all staff when [s/he] disrobed in his/her bedroom. In addition, physician orders indicated that one of the reasons for use of seclusion for Patient 7 was for disrobing behavior. The use of these interventions for disrobing behavior failed to provide privacy for this behavior.

d. Staff interview

During interview on 6/13/17 at 1:50 p.m., RN 1 reported that Patient 7 continued to be very intrusive to other patients, continues to disrobe and is a safety risk on the unit.

3. Patient 9

a. Observation

During the time of the scheduled "Self-Awareness Group" on 6/11/17 at 10:30 a.m., Patient 9 was observed sitting alone in the dining area of the unit.

b. Patient Interview

During an interview with Patient 9 on 6/11/17 at 10:40 a.m., Answers to questions were disorganized and not related to the questions. Patient 9 expressed poorly organized paranoid delusions that harm would come to him/her. Patient 9 was unable to provide coherent responses to questions about care and treatment received.

c. Record Review

1) The Psychiatric Evaluation for Patient 9 dated 6/3/17 stated that Patient 9 was admitted 6/2/17 because of "refusing medications and threatening [his/her] case manager." Patient 9 was described as "argumentative, angry, agitated and paranoid . . . marginally cooperative, accusatory. . . very paranoid." Diagnoses at the time of admission included "schizoaffective disorder with acute psychotic symptoms."

2) The Master Treatment Plan for Patient 9 dated 6/8/17, last updated 6/12/17, included, for the Problem of "Non-adherence to medication or treatment related to poor insight and mental illness as evidenced by statements made by case manager and threats to case manager by client," the identified interventions included "Certified Occupational Therapy Assistant (COTA) staff will provide [Patient 9] with groups or alternative therapies that assist client with prompting the importance of health, wellness and positive coping strategies to utilize as a positive symptom management tool" and "SW [social work] will meet with [Patient 9] individually and/or with treatment team in staffing, to assess for a decrease in altered thought process symptoms, as evidenced by self-reports, scaling questions and observation."

3) A review of the "Group Flow Charting" notes from 6/2/17 to 6/12/17 documented that Patient 9 refused to attend 30 out of 55 groups during this period. Patient 9 only partially attended 11 other groups, generally leaving the group after about 15 minutes. Patient 9 attended 14 groups, mostly leisure activity groups outside of the unit.

d. Interview

During interview on 6/13/17 at 2:20 p.m. RN 1 when asked if Patient 9 attended unit groups, she stated "[S/he] likes to go outside. Sometimes [s/he] follows another patient into the group, but sits and responds to internal stimuli."

4. Patient 10

a. Observation

During the time of the scheduled "Self-Awareness Group" on 6/11/17 at 10:30 a.m., Patient 10 was observed sitting in the dayroom with another patient.

b. Patient Interview

During an interview with Patient 10 on 6/11/17 at 10:50 a.m., Patient 10 appeared paranoid and psychotic. Answers to questions were not related to the questions. Patient 10 was unable to provide coherent responses to questions about care and treatment received.

c. Record Review

1) The Psychiatric Evaluation for Patient 10 dated 5/3/17 stated that Patient 10 was admitted 5/2/17 because of psychosis, "responding to internal stimuli," and "quite paranoid and guarded." Patient 10 was described as "responding to internal stimuli, talking and mumbling to [himself/herself]," "at times yelling," and "not fully cooperative."

2) The Master Treatment Plan for Patient 10 dated 6/7/17 included, for the Problem of "Alteration in thought process related to psychosis as evidenced by client appears to be responding to internal stimuli," the identified interventions "COTA staff will provide [Patient 10] [with] groups or alternative therapies that assist [with] cognitive skills, socialization skills, life skills and groups that allow [him/her] to explore/engage in leisure/hobbies to utilize as a symptom management tool" and "SW [social work] will encourage [Patient 10] to attend all groups on the Unit when thought process clears (10, 12:30, 2:15), alternative activities will be provided if client is unable to attend group."

3) A review of the "Group Flow Charting" notes from 5/30/17 to 6/12/17 documented that Patient 10 refused to attend 33 out of 77 groups during this period. Patient 10 was generally documented as not actively participating in the groups that were attended.

d) Interview

During interview on 6/13/17 at 2:20 p.m. RN 1 reported that Patient 10 has attended a few groups. She stated that Patient 10 is "intrusive to other patients in the groups and has a negative attitude in the groups." RN 1 did not refute that groups may not be the appropriate treatment for Patient 10 at the current time.

B. Interviews

1. During an interview with the Recreational Therapy Services Director on 6/14/17 at 11:00 a.m., she stated that COTA staff did not engage patients in one-to-one therapies. She stated that patients who refused to attend COTA groups were offered worksheets. She stated that other one-to-one contacts were not directed or structured.

2. During an interview with SW 1 on 6/13/17 at 9:10 a.m., she stated that social workers were the only staff providing individual therapy to patients in the facility. She stated that she excluded patients who were psychotic or uncooperative. She stated that she was not providing individual therapy for Patient 4, Patient 7, Patient 9, or Patient 10 who had not responded to other interventions including group therapy.

3. During an interview with the DON on 6/14/17 at 10:00 a.m., she stated that registered nurses did not provide individual therapy, alternative treatments, or one-to-one interventions with patients in the facility.

4. During an interview with the Medical Director on 6/14/16 at 11:30 a.m., the Medical Director acknowledged that Patient 4, Patient 7, Patient 9, and Patient 10 had received no treatments other than medications and received no alternative treatments when they failed to attend or respond to the prescribed group therapies.

Based on record review and interview, the facility failed to provide physician progress notes that contained information to specifically address patient progress and response to treatment as related to goals in the treatment plan for eight (8) of eight (8) active sample patients (2, 4, 6, 7, 9, 10, 11 and 12). Failure to record the psychiatric progress of patients prevents the treatment teams from monitoring progress or deterioration in the psychiatric condition of patients.

Findings include:

A. Record Review

1. Patient 2 was admitted on 6/8/17. Based on review of the medical record on 6/12/17, the only progress notes documented by the responsible physician were as follows:

a. The physician progress note dated 6/8/17 at 9:32 a.m. stated "Initial eval [evaluation] dictated. Schizophrenia."

b. The physician progress note dated 6/9/17 at 9:29 a.m. stated "Patient has been denying having any problems now and says voices are less, admits to not taking meds [medications] at times, denies SI [suicidal ideation]. Plan continue meds."

c. The physician progress note dated 6/6/17 at 10:45 a.m. stated "patient has been feeling [s/he] is under surveillance. [S/he] is feeling paranoid, denies SI. Plan increase prolixin 10 mg [milligrams] po [by mouth] bid [twice daily]."

d. These notes fail to be related to the goals of the treatment plan and fail to document a chronological picture of Patient 2's progress or lack of progress towards attaining goals of the treatment plan.

2. Patient 4 was admitted on 6/5/17. Based on review of the medical record on 6/12/17, the only progress notes documented by the responsible physician were as follows:

a. The physician progress note dated 6/5/17 at 9:54 a.m. stated "pt [patient] seen. dx [diagnosis] major depression, psychotic disorder nos [not otherwise specified], obsessive compulsive disorder, Polysubstance use disorder. assessment dictated."

b. The physician progress note dated 6/6/17 at 9:47 a.m. stated "Patient has been abusing drugs, snorting wellbutrins, says [s/he] is hearing voices, [s/he] is switched to Anafranil, and also started on resperdal and cont [continue] Prozac, [S/he] is here voluntary but will be going to jail for PO [probation officer] hold. Plan continue current meds."

c. The physician progress note dated 6/7/17 at 9:43 a.m. stated "Patient has been feeling same, says [s/he] is having visual hallucinations, depressed. [His/her] meds are adjusted, [s/he] is denying SIHI [suicidal ideation homicidal ideation]. Plan continue current meds."

d. The physician progress note dated 6/8/17 at 9:30 a.m. stated "patient reports feeling the same but has been sleeping well, appetite is fine, No SI. Plan discharge next week, continue current meds."

e. The physician progress note dated 6/9/17 at 9:43 a.m. stated "Patient has been doing well, sleep and appetite is fine, no SI, no psychoposis [sic]. Plan discharge Monday. continue current meds."

f. The physician progress note dated 6/12/17 at 11:17 a.m. stated "Patient has been doing well, sleep and appetite is fine, denies SIHI. no psychosis. Plan discharge today. [S/he] is going to be picked up by police."

g. These notes fail to be related to the goals of the treatment plan and fail to document a chronological picture of Patient 2's progress or lack of progress towards attaining goals of the treatment plan.

3. Patient 6 was admitted on 6/5/17. Based on review of the medical record on 6/12/17, the only progress notes documented by the responsible physician were as follows:

a. The physician progress note dated 6/5/17 at 11:20 a.m. stated "pt seen. major depression with psychotic features, ptsd [posttraumatic stress disorder] chronic delayed. assessment dictated."

b. The physician progress note dated 6/6/17 at 10:04 a.m. stated "pt seen. prior dx [diagnosis]. not sleeping well, continues to greive [sic], and had sig [significant] delusions. signed hold open. Dc[ discontinue] vraylar and start Seroquel 150 mg hs and inc [increase] effexor xr to 225 mg qd [daily]."

c. The physician progress note dated 6/7/17 at 9:48 a.m. stated "pt seen. prior dx. slept well, eating ok, a bit tired, but calmer and less worrisome, less preoccupied. encouraged particiipation [sic]."

d. The physician progress note dated 6/8/17 at 9:39 a.m. stated "pt seen. prior dx. still delusional butr [sic] less bothered and less anxious, more positive, some truncal movements noted."

e. The physician progress note dated 6/12/17 at 11:17 a.m. stated "pt seen. prior dx. continues to improve, tolerating meds, some tiredness. much calmer, much less preoccupied. cpm [unknown abbreviation], dc [discharge] early next week."

f. The physician progress note dated 6/12/17 at 9:55 a.m. stated "Patient has been feeling a bit tired, denies SI. [S/he] denies auditory hallucinations but says [s/he] sees spirits. Plan continue current meds."

g. These notes fail to be related to the goals of the treatment plan and fail to document a chronological picture of Patient 6's progress or lack of progress towards attaining goals of the treatment plan.

4. Patient 7 was admitted on 5/12/17. Based on review of the medical record on 6/12/17, the only progress notes documented by the responsible physician were as follows:

a. The physician progress note dated 6/2/17 at 9:26 a.m. stated "Patient has been having labile mood and irritability, paranoid. Plan start Aristada 662 mg IM [intramuscular] q [every] 4 weeks."

b. The physician progress note dated 6/6/17 at 10:12 a.m. stated "Patient has been very psychotic, manic, not responding well to various med changes, [s/he] has no insight. Very irritable. Plan discontinue Abilify, aristada, start prolixin 10 mg po tid [three times a day]."

c. The physician progress note dated 6/9/17 at 9:27 a.m. stated "[Patient 7] remains quite psychotic despite quite a bit of med changes, [s/he] is mumbling, has been in seclusion room, no insight. Plan change Seroquel to 200 mg po qam [every morning] and 400 mg po qhs [every night] to help sleep better."

d. These notes fail to be related to the goals of the treatment plan and fail to document a chronological picture of Patient 7's progress or lack of progress towards attaining goals of the treatment plan.

5. Patient 9 was admitted on 6/2/17. Based on review of the medical record on 6/12/17, the only progress notes documented by the responsible physician were as follows:

a. The physician progress note dated 6/6/17 at 9:32 a.m. stated "Patient has been non compliant [sic] in taking meds, [s/he] has been un willing [sic] to take meds, [s/he] was threatening to hit me in the face. Encourage [him/her] to continue meds.

b. The physician progress note dated 6/7/17 at 9:52 a.m. stated "patient remains irritable, paranoid, [s/he] is reluctant to take meds. No SI. Plan to continue current meds."

c. The physician progress note dated 6/12/17 at 11:35 a.m. stated "Patient has been refusing [his/her] meds and says [s/he] is only going to take Navane at night. Cont [continues] to be paranoid, no SI. Plan to change Navane to 20 mg [milligrams] po [by mouth] qhs [at bedtime]."

d. These notes fail to be related to the goals of the treatment plan and fail to document a chronological picture of Patient 9's progress or lack of progress towards attaining goals of the treatment plan.

6. Patient 10 was admitted on 5/2/17. Based on review of the medical record on 6/12/17, the only progress notes documented by the responsible physician were as follows:

a. The physician progress note dated 6/2/17 at 9:24 a.m. stated "Patient has been agitated, mumbling, swearing. grinding he [sic] teeth. no insight. Plan increase clozaril 50 mg po qam and 75 mg po qhs."

b. The physician progress note dated 6/6/17 at 10:14 a.m. stated "Patient has been responding some to clozaril however remains psychotic. Plan increase Fazaclo 50 mg po bid."

c. The physician progress note dated 6/7/17 at 9:33 a.m. stated "patient has refused [his/her] meds yesterday, [s/he] is currently sleeping well, denies SI. Plan continue current meds."

d. These notes fail to be related to the goals of the treatment plan and fail to document a chronological picture of Patient 10's progress or lack of progress towards attaining goals of the treatment plan.

7. Patient 11 was admitted on 6/1/17. Based on review of the medical record on 6/12/17, the only progress notes documented by the responsible physician were as follows:

a. The physician progress note dated 6/1/17 at 9:33 a.m. stated "Initial eval [evaluation] dictated. Anxiety disorder NOS. alcohol use disorder in remission."

b. The physician progress note dated 6/2/17 at 10:03 a.m. stated "Patient has been irritable and angry, per family [s/he] has been having mood swings and irritability, [s/he] will be started o [sic] depakote and have a probable cause hearing. [S/he] has been refusing treatment. Dx Bipolar disorder."

c. The physician progress note dated 6/5/17 at 10:32 a.m. stated "pt seen. prior dx. record reviewed. pt appears to be minimizing the situation based on the ed [emergency department] report. [S/he] is very conversant and somewhat convincing but has pc [probable cause] today and family will testigy [sic]. [H/she] is commplying [sic] with meds 'to go along with the flow' denies si."

d. The physician progress note dated 6/6/17 at 9:37 a.m. stated "Patient has been doing better and says [s/he] is not able to swallow pills so [s/he] is scwiched [sic] t [sic] sprinkles, Denies SI, no psychosis. Plan cont meds, [s/he] is on med order and has final hearing."

e. The physician progress note dated 6/7/17 at 9:36 a.m. stated "doing well, says meds are not doing anything, [s/he] is however calm, no SI, no aggression. Plan continue meds, discharge after final hearing."

f. The physician progress note dated 6/8/17 at 9:26 a.m. stated "Patient has been awaiting court hearing, denies SIHI [suicidal ideation homicidal ideation]. No psychosis. Plan discharge after court."

g. These notes fail to be related to the goals of the treatment plan and fail to document a chronological picture of Patient 11's progress or lack of progress towards attaining goals of the treatment plan.

8. Patient 12 was admitted on 6/7/17. Based on review of the medical record on 6/12/17, the only progress notes documented by the responsible physician were as follows:

a. The physician progress note dated 6/7/17 at 10:28 a.m. stated "pt seen. dx adjustment disorder with disturbance of emotions and conduct, alcohol use disorder. assessment dictated."

b. The physician progress note dated 6/8/17 at 9:52 a.m. stated "pt seen. new diagnosis, bipolar didordeer [sic], depressed. pt has hx [history] of sig paranoia and delusions, mood changes, and appears to have been self medicating with alcohol. father has bipolar. pt agreeable to tx [treatment] and will sign a hold open. start abilify 1omg [sic] hs. consider antidepressant pending more collateral."

c. The physician progress note dated 6/9/17 at 9:44 a.m. stated "pt seen. prior dx. tolerating meds. family tx suggests invega [sic] and will dc [discontinue] abilify and go with invega 3 mg hs [nighttime] and start wellbutrin sr 150 mg am."

d. The physician progress note dated 6/12/17 at 9:36 a.m. stated "Patient has been doing well, slept well, mood is stable. Denies SIHI. No psychosis."

e. These notes fail to be related to the goals of the treatment plan and fail to document a chronological picture of Patient 12's progress or lack of progress towards attaining goals of the treatment plan.

B. Interview

During an interview with the Medical Director on 6/14/16 at 11:30 a.m., the Medical Director acknowledged that the physician progress notes for the sample patients failed to contain information to specifically address patient progress and response to treatment as related to goals in the treatment plan.

Based on observation, interview and document review, the facility failed to assure that the Medical Director, the Director of Nursing and the Director of Social Work adequately monitored active treatment and took corrective action when patient care required reassessment. Specifically,

The Medical Director failed to ensure that 1) patients received a psychiatric evaluation containing sufficient information to justify diagnoses and planned treatment; 2) psychiatric evaluations included an inventory of descriptive patient assets that could be used in treatment planning; 3) development, documentation and revision of comprehensive treatment plans to include substantiated diagnosis, measureable outcome goals and physician interventions based on the patients' needs; 4) active treatment measures, such as group and individual treatment and therapeutic activities, were provided for patients who were unable, unwilling or not motivated to attend or participate in assigned active treatment groups and the provision of physician progress notes that contained information to specifically address patient progress and response to treatment as related to goals in the treatment plan. (Refer to B144)

II. The Director of Nursing failed to assure that: 1) nursing staff provided appropriate safety monitoring and supervision for patients while in the unit and 2) Master Treatment Plans included nursing interventions individualized for patients. (Refer to B148)

III. The Director of Social Work failed to ensure that 1) social work assessments were provided that included a social evaluation of strength/deficits, high risk psychosocial issues, conclusions, and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in discharge planning and, 2) development of treatment plans that clearly delineated interventions for social workers to address the specific treatment needs of patients.

These failures prevent patients from receiving appropriate care and treatment in a safe environment, enabling them to achieve an optimal level of functioning and discharge in a timely manner.

Based on observations, interview and record review, it was determined that monitoring and evaluation by the Medical Director did not include sufficient review and corrective measures to assure compliance with necessary practices, treatment of patients, and documentation of treatment in the facility. The Medical Director failed to:

I. Ensure that six (6) of seven (7) active sample patients (2, 4, 6, 7, 11, and 12) who had physical examinations completed received an examination containing a descriptive neurological examination indicating what tests were performed to assess neurological functioning. This failure to document current neurological status precludes accurate diagnosis and future comparative reexamination to measure any change in baseline function. (Refer to B109)

II. Ensure that seven (7) of eight (8) active sample patients (2, 4, 7, 9, 10, 11, and 12) received a psychiatric evaluation containing sufficient information to justify diagnoses and planned treatment. This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate master treatment plan. (Refer to B110)

III. Ensure that the psychiatric evaluations of eight (8) of eight (8) active sample patients (2, 4, 6, 7, 9, 10, 11, and 12) included an inventory of descriptive patient assets that could be used in treatment planning. Failure to identify patient assets impairs the ability of the treatment team to develop interventions, utilizing the individual strengths of each patient. (Refer to B117)

IV. Ensure the development and documentation of comprehensive treatment plans based on the individual needs of eight (8) of eight (8) sample patients (2, 4, 6, 7, 9, 10, 11 and 12). The treatment plans were based on a computerized program with a menu of set of problems with goals and interventions from which to choose. Many of the documented goals in the treatment plans were non-measurable or were based on compliance with treatment rather than on the patient's specific problem. The majority of staff interventions were role functions without patient individualization. In addition, interventions for care of patients' safety problems (e.g. violence to self and others) were insufficient. This practice results in repetition from one plan to another and in absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118 Part I)

V. Ensure that treatment plans were reviewed and revised for four (4) of eight (8) active sample patients (2, 7, 9 and 10) based on patient needs and changing behaviors. This failure jeopardizes a timely, coordinated, responsive treatment process. (Refer to B118 Part II)

VI. Ensure the development Master Treatment Plans that included a substantiated diagnosis for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 9, 11, 12, and 13). The absence of a substantiated diagnosis (or diagnoses) on the treatment plan compromises the ability of the treatment team to deliver clinically focused treatment. (Refer to B120)

VII. Ensure that goals in the treatment plans were based on individual patient findings for eight (8) of eight (8) sample patients (2, 4, 6, 7, 9, 10, 11 and 12). Some goals were stated in non-measurable terms or as treatment compliance or attendance at groups/activities. This failure hinders the treatment team's ability to individualize treatment and to measure change in the patient consequent to treatment and implement changes to the treatment plan. (Refer to B121)

VIII. Ensure the development of treatment plans that clearly delineated interventions for physicians to address the specific treatment needs of eight (8) of eight (8) active sample patients (2, 4, 6, 7, 9, 10, 11 and 12). Instead, treatment plans included interventions that were routine, generic physician functions, or were missing interventions to be performed by the physician. This resulted in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to multidisciplinary treatment. (Refer to B122)

IX. Ensure that active treatment measures, such as group and individual treatment and therapeutic activities, were provided for four (4) of eight (8) active sample patients (2, 7, 9 and 10) who were unable, unwilling or not motivated to attend or participate in assigned active treatment groups on each patient's individual activity schedule. Although Master Treatment Plans included multiple group therapies, the patients regularly and repeatedly did not attend or participate in assigned groups. Treatment plans for these patients failed to include alternative interventions for these patients. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement. (Refer to B125)

X. Ensure the provision of physician progress notes that contained information to specifically address patient progress and response to treatment as related to goals in the treatment plan. Failure to record the psychiatric progress of patients prevents the treatment teams from monitoring progress or deterioration in the psychiatric condition of patients. (Refer to B126)

Interview

During interview on 6/14/17 at 11:30 a.m., the Medical Director was unable to provide evidence of monitoring of clinical services including the quality and appropriateness of services and treatment provided by the medical staff.

Based on interview and document review, the Director of Nursing (DON) failed to meet the educational or on-going consultation and/or training requirements necessary for her administrative position as Executive Nurse within this facility. This hindered direction for the nursing department and the level of care provided by nursing personnel.

Findings include:

A. Review of the DON's resume revealed that she has a Bachelor's of Science in Nursing with 4.5 years of experience as a nurse in the field of psychiatry.

B. Review of training programs revealed 20 hours of continuing education programs since 9/12/16.

C. During a telephone interview on 6/14/17 at 10:00 a.m., the Director of Nursing verified that even though a letter has been sent to a person with a masters in psychiatric nursing requesting consultation, documented consultation with this nurse is not currently on-going.

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

I. Ensure that treatment plans for seven (7) of eight (8) active sample patients (2, 4, 6, 7, 9, 10 and 12). Instead, treatment plans included interventions that were routine, generic nursing functions. In addition, there was failure to include interventions to guide personnel in the care of patients presenting safety issues in the clinical areas. This resulted in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient 2 (plan dated 6/7/17 with update of 6/9/17)

For the problem, "Alteration in thought process related to hx (history) of schizophrenia as evidenced by overdose on Depakote and believes [s/he] is being watched by police," generic nursing interventions were listed as "Registered Nurse (RN) will encourage attendance for all visits with the psychiatrist," "RN will reinforce Medical Doctor (MD) teaching and educate [Patient] on medication uses and potential side effects" and "RN will encourage [Patient] to take medications as prescribed on a daily basis."

Even though this patient was admitted after a suicidal attempt and was still talking about being "hopeless" and hearing voices, there were no nursing safety interventions based on his/her specific findings.

2. Patient 4 (plan dated 6/10/17)

For the problem, "Ineffective coping related to mental health issue as evidenced by suicidal thoughts," generic nursing interventions were "Nursing staff will encourage [Patient] to take medications as prescribed on a daily basis" and "Nursing staff will encourage attendance for all visits with the psychiatrist."

Even though this patient was admitted after a suicidal attempt and was still talking about being "hopeless" and hearing voices, there were no nursing safety interventions based on his/her specific findings.

3. Patient 6 (plan dated 6/8/17 with update of 6/12/17)

For the problem, "Ineffective coping related to loss of companion dog on 4/20/17 as evidenced by making statement 'I want to [f ...ing] die,'" a nursing intervention was stated as "Nursing staff will encourage [Patient] to admit and accept personal responsibility for own actions/behavior." It was not clear how this action related to the stated problem.

Generic nursing interventions were "RN will encourage attendance for all visits with psychiatrists," and "RN will encourage [Patient] to take medications as prescribed on a daily basis."

4. Patient7 (plan dated 6/7/17)

a. For the problem, "Alteration in thought process related to ...depression and psychosis as evidenced by disrobing, aggression towards others and homicidal statements," generic nursing interventions were "RN will encourage attendance for all visits with psychiatrists," and "RN will encourage [Patient] to take medications as prescribed on a daily basis."

Another nursing intervention was documented as "[Patient] to be secluded for agitation resulting in physically assaulting a staff [sic] by throwing an orange at staff." This intervention indicates that seclusion was to be used in a non-emergency situation.

b. For the problem, "Risk for injury related to seclusion," generic nursing interventions were "Modify environment as indicated to enhance safety" and "All staff to monitor for unsafe situations and provide education to the client as needed."

5. Patient 9 (plan dated 6/8/17 with update of 6/12/17)

For the problem, "Non-adherence to medication or treatment related to poor insight and mental illness as evidenced by .... threats to case manager by client," a generic nursing intervention was "Nursing will encourage attendance for all visits with the psychiatrist."

6. Patient 10 (plan dated 6/7/17)

For the problem, "Non-adherence to medication or treatment related to mental health commitment with medication order as evidenced by client has not been compliant with MD ordered medications," generic role functions were stated as nursing interventions: "Nursing staff will encourage [Patient] to take medications as prescribed on a daily basis" and "RN will reinforce MD teaching and educate [Patient] on medications uses and potential side effects."

7. Patient 12 (plan dated 6/7/17 with update of 6/12/17)

For the problem, "Risk for suicide related to alcohol dependence as evidenced by making suicidal statements to kill self to crisis staff and police officer," a nursing intervention was stated as "Nursing staff will encourage [Patient] to admit and accept personal responsibility for own actions/behavior." It was not clear how this action related to the stated problem.

A generic intervention was stated as "All staff will encourage [Patient] to go to the 10:30, 12:30 and 14:00 groups. Alternative interventions will be offered for groups missed." Focus of interventions based on this patient's needs was not identified.

There were no specific safety interventions to direct nursing personnel in the care of this patient.

B. Interview

1. During interview, with review of treatment plans for Patients 2 and 7, on 6/13/17 at 1:50 p.m. the Acting DON and RN1 verified the findings for these patients adding, "groups (attendance) must be realistic for the patient."

2. During telephone interview, with discussion about nursing interventions, on 6/14/17 at 10:00 a.m., the Director of Nursing agreed that many of the nursing interventions were generic role functions.

II. Ensure adequate monitoring of patients in the patient care unit. As documented in an incident report, 2 patients were found in the same bed together. This failure resulted in a safety risk for all patients on the unit.

Findings include:

A. Ward Description:

The unit is a 16-bed co-ed unit for acute adult patients. The unit has two patient hallways with a nursing station at the juncture of these hallways. Males and females are assigned rooms on both hallways, sometimes next to each other or across the hallway.

The usual monitoring checks of patients are completed every hour unless the patient is on 1:1, 15-minute or 30-minute monitoring for specific behaviors/needs.

B. Review of incident:

Review of incident forms revealed that on 3/17/17 at 7:55 p.m., Patient 30 was found in the bed with Patient 31 in Patient 31's assigned bedroom. The description of the event was documented as "[Patient 30] 'was found laying [sic] in bed with another client [Patient 31] and was stroking this client's [Patient 31] hair."

C. Review of patient progress notes revealed that both Patient 30 and 31 were on 15-minute safety checks at the time of the incident.

D. Interviews

1. During interview on 6/12/17 at 2:20 p.m. RN 1 and RN 2 reported that on the day shift when the mental health technicians are not conducting patient or unit safety checks, they are on the unit with the patients. RN 1 and RN 2 reported that the technicians watch the patients for falls, reactions to medications, suicidal statements, patients who are agitated, etc.

2. During interview on 6/12/17 at 3:20 p.m. RN3, RN4 and RN 5, reported the following information :

a. RN 5 reported that three technicians are on duty on the unit on day and evening shifts of duty. One technician is assigned to each of the patient hallways and the third technician is assigned the monitoring checks for all patients on both hallways. At the beginning of the evening shift of duty, one (1) of the three (3) technicians always makes out the dietary slips for patients. Sometimes one of the technicians may be out in the courtyard with one of the patients.

b. RN 5 reported that two technicians are on duty on the unit on the night shift of duty. Each of the technicians is assigned to one of the two hallways to include the required monitoring checks for the patients on their assigned hallway.

c. RN 5 reported that due to assignments there may be one technician assigned to complete the monitoring checks for all patients while the other technician(s) may be doing something else. "The technician completes the safety checks on one hallway and feels they are all safe and then goes to the other hallway. Something could occur (referring to one patient going into another patient's assigned room) while the technician is on the other hallway completing the safety checks for the patients on that side."

d. During telephone interview on 6/14/17 at 10:00 a.m. the DON reported that she had Patient 30 moved to the camera room but had not completed a follow-up investigation on the incident and had made no changes to policies/ procedures related to patient monitoring for safety.

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

I. Ensure that social work assessments were provided that included a social evaluation of strength/deficits, high risk psychosocial issues, conclusions, and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in discharge planning for eight (8) of eight (8) sample patients (2, 4, 6, 7, 9, 10, 11 and 12). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Refer to B108)

II. Ensure the development of treatment plans that clearly delineated interventions for social workers to address the specific treatment needs of eight (8) of eight (8) active sample patients (2, 4, 6, 7, 9, 10, 11 and 12). Instead, treatment plans included interventions that were routine, generic discipline functions or missing interventions to be performed by the social worker. This resulted in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient 2

For the problem, "Alteration in thought process related to hx (history) of schizophrenia as evidence by overdose on Depakote and believes [s/he] is being watched by police," a social work intervention was "SW will encourage [Patient 2] to attend all groups while on the Unit ...alternative activities will be provided if [Patient is unable to attend group." The first part of this statement is generic. The last part of the statement does not specify the alternative activities based on this patient's needs. Another social work intervention was listed as "SW ill meet individually and/or with treatment team in staffing, to assess [Patient 2] for a decrease of depression symptoms as evidenced by self-reports, scaling questions and staff observation." This statement is an expected assessment, rather than action to be taken based on assessment.

2. Patient 4

For the problem, "Ineffective coping related to mental health issues as evidenced by suicidal thoughts," a generic social work intervention states "SW will encourage [Patient 4] to attend all groups on the Unit when thought process clears, alternative activities will be provided if client is unable to attend groups." Specific alternative activities based on patient's needs are not stated. Another social work intervention was listed as "SW will meet with [Patient 4] individually and/or with treatment team in staffing, to assess [Patient 4] for a decrease in altered thought process symptoms as evidenced by self-reports, scaling questions and staff observation." This statement is an expected assessment, rather than action to be taken based on assessment. Another generic social work intervention was stated as "SW will collaborate with [Patient 4's] collaterals to ensure effective treatment, and successful discharge."

3. Patient 6

For the problem, "Ineffective coping related to loss of companion dog on 4/20/17 as evidenced by making statement 'I want to [f ...ing] die,'" no social work interventions were documented.

4. Patient7

a. For the problem, "Alteration in thought process related to ...depression and psychosis as evidenced by disrobing, aggression towards others and homicidal statements," a generic social work intervention was "SW will encourage [Patient 7] to attend all groups on the Unit when thought process clears, alternative activities will be provided if client is unable to attend groups." Specific alternative activities based on patient's needs were not stated. Another social work intervention was listed as "SW will meet with [Patient 7] individually and/or with treatment team in staffing, to assess [Patient 7] for a decrease in altered thought process symptoms as evidenced by self-reports, scaling questions and staff observation." This statement is an expected assessment, rather than action to be taken based on assessment. Another generic social work intervention was stated as "SW will collaborate with [Patient 7's] collaterals to ensure effective treatment, and successful discharge."

5. Patient 9

For the problem, "Non-adherence to medication or treatment related to poor insight and mental illness as evidenced by statement made by case manager and threats to case manager by client," a social work intervention was "SW will encourage [Patient 9] to attend two groups on the Unit, alternative activities will be provided if client is unable to attend group." The specific alternative strategies to meet his/her needs are not identified.
Another social work intervention was listed as "SW will meet with [Patient 9] individually and/or with treatment team in staffing, to assess [Patient 9] for a decrease in altered thought process symptoms as evidenced by self-reports, scaling questions and staff observation." This statement is an expected assessment, rather than action to be taken based on assessment. Another generic social work intervention was stated as "SW will collaborate with [Patient 9's] collaterals to ensure effective treatment, and successful discharge."

6. Patient 10

a. For the problem, "Non-adherence to medication or treatment related to mental health commitment with medication order as evidenced by client has not been compliant with MD ordered medications," no social work interventions were documented.

b. For the problem, "Alteration in thought process related to psychosis as evidenced by client appears to be responding to internal stimuli," a social work intervention was "SW will encourage [Patient 10] to attend all groups on the Unit when thought process clears, alternative activities will be provided if client is unable to attend group." The specific alternative strategies to meet his/her needs are not identified. A social work intervention was listed as "SW will meet with [Patient 10] individually and/or with treatment team in staffing, to assess [Patient 10] for a decrease in altered thought process symptoms as evidenced by self-reports, scaling questions and observation." This statement is an expected assessment, rather than action to be taken based on assessment. A generic social work intervention was stated as "SW will collaborate with [Patient 10's] collaterals to ensure effective treatment, and successful discharge." A social work generic role function was listed as "SW will provide [Patient 10] with a list of community resources including but not limited to shelter, food, clothing, employment, support groups, etc."

7. Patient 11

For the problem, "Ineffective coping related to client's statement that [s/he] has difficulty coping with [his/her] divorce ...as evidenced by [s/he] put a knife up to [his/her] throat ...has been having anxiety attacks ...," a social work intervention was listed as "SW will meet with [Patient 11] individually and/or with treatment team in staffing, to assess [Patient 11] for a decrease in anxious symptoms as evidenced by self-reports, scaling questions and staff observation." This statement is an expected assessment, rather than action to be taken based on assessment. A generic social work intervention was stated as "SW will collaborate with [Patient 11's] collaterals to ensure effective treatment, and successful discharge." A social work generic role function was listed as "SW will provide [Patient 11] with a list of community resources including but not limited to shelter, food, clothing, employment, support groups, etc."

8. Patient 12

For the problem, "Risk for suicide related to alcohol dependence as evidenced by making suicidal statements to kill self to crisis staff and police officer," A generic intervention was stated as "All staff will encourage [Patient 12] to go to the 10:30, 12:30 and 14:00 groups. Alternative interventions will be offered for groups missed." Focus of interventions based on this patient's needs was not identified.

B. Interview

During an interview and review of these treatment plans with the Director of Social Work on 6/14/17 at 9:00 a.m., the Director of Social Work acknowledged that the interventions on the treatment plans for these patients were generic social worker functions and not specific to patient needs.