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Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that identified patient-centered short-term goals stated in behavioral terms for eight (8) of eight (8) active patients (A1, A2, A3, A4, A5, A6, A7and A8). Lack of measureable, patient specific goals hampers the treatment team ' s ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs.

Findings include:

A. Record Review

1. Patient A1 was admitted on 3/9/15. The MTP dated 3/9/15 identified the problem, "Mania". The short-term goal listed was "Pt (patient) does not manipulate others for gratification of own needs before D/C (discharge)." For the problem "Hallucinations", the short-term goal listed was "Pt will verbalize content of hallucinations before D/C."

2. Patient A2 was admitted on 3/8/15. The MTP dated 3/8/15 identified the problem, "Risk for Suicide". The short-term goal listed was "Patient will demonstrate increased insight regarding suicidal ideations, intentions, and attempts as evidenced by verbally recognizing one (1) time [sic], prior to discharge, that when the level of control over their own behavior/actions decreases it increases patient's risk for harm to self or others."

3. Patient A3 was admitted on 3/9/15. The MTP dated 3/9/15 identified the problem, "Paranoid and/or Delusional Thoughts/Behaviors". The short-term goal listed was "Pt's speech will reflect reality-based thinking."

4. Patient A4 was admitted on 3/14/15. The MTP dated 3/14/15 identified the problem, "Potential for Violence". The short-term goal listed was "Pt will be able to demonstrate learned coping skills and refrain from violent behavior before DC (discharge)."

5. Patient A5 was admitted on 3/09/15. The MTP dated 3/09/15 identified the problem, "Hallucinations". The short-term goal listed was "Pt will be able to discuss content of hallucinations with staff as needed before DC (Discharge)."

6. Patient A6 was admitted on 3/11/15. The MTP dated 3/11/15 identified the problem, "Hallucinations". The short-term goal listed was "Pt will come to staff when internal stimuli increases and prior to DC."

7. Patient A7 was admitted on 3/11/15. The MTP dated 3/11/15 identified the problem, "Depression." The short-term goal listed was "Patient will demonstrate in increase in insight relating to their depression as evidenced by identifying ____triggers/stressors that precipitate their feeling of depression __times during hospitalization."

8. Patient A8 was admitted on 3/12/15. The MTP dated 3/12/15 identified the problem, "Risk for Suicide." The short-term goal listed was "Pt will seek out staff when feeling urge to harm self as need [sic] before DC."

B. Interviews

1. During interview on 3/17/15 at 10:00 AM, RN2 and the Assistant Vice-President of Clinical Operations agreed that the short-term goals were not patient specific or stated in measureable terms.

2. During interview on 3/17/19 at 11:50 AM, the Medical Director concurred that the short-term goals lacked patient specificity and were not stated in behavioral terms.

Based on record review and interview, the facility failed to identify in the MTP specific nursing treatment modalities to address the identified patient problems for six (6) of eight (8) active patients (A1, A2, A4, A6, A7 and A8). The nursing interventions were stated in vague terms and were generic discipline functions rather than directed at specific interventions. This deficiency results in failure to guide nursing staff regarding the specific treatment purpose of each intervention designed to achieve measureable, behavioral outcomes for patients.

Findings include:

A. Record Review

1. Patient A1 was admitted 3/9/15. The MTP dated 3/9/15 identified the problem, "Hallucinations". The nursing interventions to address the problem included, "Staff will assess for severity of impairment in daily functioning every shift."

2. Patient A2 was admitted 3/8/15. The MTP dated 3/8/15 identified the problem, "Depression". The nursing interventions to address the problem included, "Staff will monitor and document hours of sleep and food and fluid intake every shift."

3. Patient A4 was admitted 3/14/15. The MTP dated 3/8/15 identified the problem, "Potential for Violence". The nursing interventions to address the problem included, "Staff will maintain and convey a calm attitude toward pt."

4. Patient A6 was admitted on 3/11/15. The MTP dated 3/11/15 identified the problem, "Hallucinations". The nursing intervention to address the problem included, "Staff will assess for severity of impairment in daily functioning every shift."

5. Patient A7 was admitted on 3/11/15. The MTP dated 3/11/15 identified the problem, "Depression". The nursing intervention to address the problem included, "Staff will assess mood and depressive symptoms every shift or more frequently as needed."

6. Patient A8 was admitted on 3/12/15. The MTP dated 3/12/15 identified the problem, "Risk for Suicide". The nursing intervention to address the problem included, "Staff will prevent anxiety/agitation from increasing within the environment by monitoring a calm and safe environment for the patient for ___ days."

B. Interviews

During interview on 3/17/15 at 10:00 AM, RN2 and the Assistant Vice-President of Clinical Operations agreed that the nursing interventions were generic discipline functions rather than specific interventions to meet the identified patient needs.

Based on record review and interview, the medical director failed to ensure:

1. The development of Master Treatment Plans (MTPs) that identified patient-centered short-term goals stated in behavioral terms for eight (8) active patients (A1, A2, A3, A4, A5, A6, A7and A8). Lack of measureable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs. (See B121).

During interview on 3/17/19 at 11:50 AM, the Medical Director concurred that the short-term goals lacked patient specificity and were not stated in behavioral terms.

Based on record review and interview, the Director of Nursing failed to ensure that the nursing staff identified specific, patient centered interventions on the MTPs. The nursing treatment interventions were stated in vague terms and were generic discipline functions rather than directed at specific interventions. This deficiency results in failure to guide nursing staff regarding the specific treatment purpose of each designed to achieve measurable behavioral outcomes for patients.

Findings include:

A. Record Review

1. Patient A1 was admitted 3/9/15. The MTP dated 3/9/15 identified the problem, "Hallucinations". The nursing interventions to address the problem included, "Staff will assess for severity of impairment in daily functioning every shift."

2. Patient A2 was admitted 3/8/15. The MTP dated 3/8/15 identified the problem, "Depression". The nursing interventions to address the problem included, "Staff will monitor and document hours of sleep and food and fluid intake every shift."

3. Patient A4 was admitted 3/14/15. The MTP dated 3/8/15 identified the problem, "Potential for Violence". The nursing interventions to address the problem included, "Staff will maintain and convey a calm attitude toward pt."

4. Patient A6 was admitted on 3/11/15. The MTP dated 3/11/15 identified the problem, "Hallucinations". The nursing intervention to address the problem included, "Staff will assess for severity of impairment in daily functioning every shift."

5. Patient A7 was admitted on 3/11/15. The MTP dated 3/11/15 identified the problem, "Depression". The nursing intervention to address the problem included, "Staff will assess mood and depressive symptoms every shift or more frequently as needed."

6. Patient A8 was admitted on 3/12/15. The MTP dated 3/12/15 identified the problem, "Risk for Suicide". The nursing intervention to address the problem included, "Staff will prevent anxiety/agitation from increasing within the environment by monitoring a clam and safe environment for the patient for ___ days."

B. Interviews

During interview on 3/17/15 at 10:00 AM, RN2 and the Assistant Vice-President of Clinical Operations agreed that the nursing interventions were generic discipline functions rather than specific interventions to meet the identified patient needs.