HospitalInspections.org

Based on document review and interview, the hospital failed to maintain a list of all contracted services, including the scope and nature of services provided, for 12 services (CS1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12).

Findings:

1. On 4-13-15 at 1010 hours, the chief executive officer A1 was requested to provide a list of all contracted service providers for the hospital and none was provided prior to exit.

2. Review of contracted service agreements and/or documentation of services provided by a contractor indicated the following: biohazardous waste disposal by CS1, biomedical engineering by CS2, dietitian services by CS3, fire detection and suppression by CS4, laboratory services by CS5, laundry services by CS6, medical transcription by CS7, pest control service by CS8, pharmacy services by CS9, physical, occupational, and speech therapy services by CS10, radiology services by CS11, and waste disposal by CS12.

3. On 4-13-15 at 1150 hours, the chief executive officer A1 confirmed that the facility failed to maintain a list of contracted services including the 12 providers indicated above.

Based on policy and procedure review, personnel record review, and staff interview, the facility failed to ensure staff training with demonstration of competency related to restraint and/or seclusion for 2 of 2 (A17 and A18, Registered Nurses [RNs]) agency personnel and 1 of 5 (A24, Radiology Tech) contracted personnel records reviewed.

Findings:
1. Policy titled, "Staff Orientation and Training for Restraint and Seclusion" revised/reapproved 2/2015, indicated on pg. 1, under Procedure section, bulleted points, "During hospital orientation, the initial restraint and seclusion competency is completed, prior to participating in restraint use and then revisited...During the first 180 days of employment, direct care staff are assigned to attend crisis prevention (CPI) intervention training."

2. Review of personnel records at 2:00 PM on 4/15/15, indicated personnel:
A. A17 (Agency RN):
a. was hired on 4/2014 and provides direct patient care.
b. lacked documentation of restraint and seclusion training with demonstration of competency.
c. lacked documentation of CPI training.
B. A18 (Agency RN):
a. was hired on 11/2014 and provides direct patient care.
b. lacked documentation of restraint and seclusion training with demonstration of competency.
c. lacked documentation of CPI training.
C. A24 (Radiology Tech):
a. contract was renewed 11/2014 and provides direct patient care.
b. lacked documentation of restraint and seclusion training with demonstration of competency.
c. lacked documentation of CPI training.

3. Personnel A2, Director of Nursing, was interviewed on 4/15/15 at 2:15 PM, and confirmed personnel A17, A18, and A24 provide direct patient care and lacked documentation of restraint and seclusion training with demonstration of competency on orientation and documentation of CPI training as required by facility policy and procedure. No restraint or seclusion episodes had occurred in 2014 or 2015, but staff are still required to have the training.

Based on document review and interview, the hospital failed to follow its policy/procedures and ensure an adverse patient event was investigated and reviewed for 1 patient event (patient 26) reviewed.

Findings:

1. The policy/procedure Sentinel Events (revised 11-14) indicated the following: "Process to conduct a root cause analysis: Creation of a detailed work plan [with] target dates [and] key activities in the process ...Defining the event and identifying the proximate and underlying causes: describe what happened as accurately as possible, create a more detailed definition of the event (when, where, how, why), [and] ask what processed and issues were involved and how these were part of the cause and if there was a common factor ...implementing interim changes: who is responsible ...when to implement actions ...how the effectiveness of the actions will be evaluated?"

2. On 4-13-15 at 1330 hours, the vice president of quality and risk A6 was requested to provide documentation indicating a review of adverse patient events at the facility for use with completing a quality assessment tool.

3. On 4-14-15 at 1535 hours, the director of quality A4 indicated that the staff (A4) was requested to conduct a root cause analysis (RCA) for patient 26 in response to a report of a fall with injury. The RCA documentation provided for review failed to indicate an analysis of all potential underlying causes and/or factors associated with a patient fall and/or with a wrong site xray was performed and failed to indicate a comprehensive account of the fall event including interview statements from any staff responding to the patient fall or with the attending physician responsible for ordering a right hand xray. The RCA documentation failed to indicate that a root cause for the patient fall and/or the wrong site xray was determined and failed to indicate how improvement actions to be implemented by a responsible person or persons would be evaluated for effectiveness.

4. During an interview on 4-15-15 at 1430 hours, the director of quality A4 and the vice president of quality and risk A6 confirmed that the facility failed to follow its policy/procedure for conducting a root cause analysis and confirmed that the documentation failed to indicate a root cause(s) was determined or how improvement interventions would be evaluated for effectiveness.

Based on document review and interview, the governing body failed to ensure that all departments and services, including contracted services, were assessed and reviewed through its quality assessment and performance improvement (QAPI) program for 3 services (environmental services, medical transcription, and radiology services).

Findings:

1. The policy/procedure Organizational Performance Improvement Plan (approved 1-15) indicated the following: "...departments will have quality improvement measures. These quality improvement measures will be coordinated by the Director of Quality thru the facility's Quality Council...the Quality Council ...has the responsibility for monitoring every aspect of safety and patient care ...[the] Quality Council quarterly report will include, but is not limited to the following ...contracted services: quality indicators will be reviewed by the Quality Council."

2. Review of 2014 and 2015 Quality Council minutes and 2014 and 2015 Governing Board minutes failed to indicate that the hospital department/services for environmental services, medical transcription services, or radiology services were evaluated and reviewed through the program.

3. During an interview on 4-15-15 at 1630 hours, the director of quality A4 and the vice president of quality A6 confirmed that the facility lacked documentation indicating its environmental services, medical transcription services, and radiology services were evaluated and reviewed by the Quality Council and confirmed that no other documentation was available.

Based on record review and staff interview, the nursing services failed to follow physician orders for glucometer testing for one (#L1) of four patient records reviewed, failed to follow up with the patient's practitioner for abnormal glucometer test results for three (#L1, #L2, #L3) of four patient records reviewed and failed to supervise and evaluate the nursing care for each patient related to indwelling Foley catheter care for 1 of 1 (Patient #N1) open patient medical records reviewed of patients with an indwelling Foley catheter.

Findings include:
1. Review of patient medical records indicated the following:
A. Patient #L1 was admitted on 3-30-15. The "Admission Orders" noted the patient had Type II Diabetes and contained an order for "accuchecks BID - 0600 and 1600." Glucometer testing was not performed on 4-1-15 at 1600, as ordered. There was no notation in the nursing documentation to indicate the patient refused glucometer testing.

Date Time Result (mg/dL)
__________________
4-2-15 0600 194
4-3-15 1600 172
4-4-15 0600 175
4-5-15 1600 176
4-6-15 1600 196
4-8-15 1600 204
4-9-15 1600 186
4-10-15 1600 203
4-12-15 1600 196
4-13-15 0600 163

The patient's glucometer test results were greater than 150 milligrams per deciliter (150 mg/dL) with no documentation of contacting the physician concerning the glucometer results greater than 150 mg/dL.

B. Patient #L2 was admitted on 3-20-15. The "Admission Orders" noted the patient had Type II Diabetes. A practitioner's order for "BID accuchecks dx diabetes" was documented on "4-8-15" and "1730 PM."

Date Time Result (mg/dL)
_________________________
4-9-15 1630 330
4-10-15 1630 264
4-11-15 1630 237
4-12-15 1130 170
4-12-15 1630 335

The patient's glucometer test results were greater than 150 milligrams per deciliter (150 mg/dL) with no documentation of contacting the physician concerning the glucometer results greater than 150 mg/dL.

C. Patient #L3 was admitted on 3-24-15. The "Admission Orders" noted the patient had Type II Diabetes. The patient had a "Sliding Scale Insulin Protocol" ordered by the physician on "3/25/15" at "1644." The "Sliding Scale Insulin Protocol" included orders for glucometer testing at "6:30 AM, 11:30 AM, 4:30 PM, and 9:30 PM." Glucometer testing was not performed on 3-27-15 at 0630.

2. In interview on 4-15-15 at 1:28 PM, Staff Member #A2 acknowledged the above missing glucometer test results and lack of nursing follow-up for glucometer test results above 150 mg/dL.


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3. Review of open patient medical records on 4/13/15 at approximately 1206 hours, confirmed patient #N1 had an indwelling Foley catheter in place and lacked daily Foley catheter care on each shift on 4/7/15 through 4/11/15; Foley catheter care was done only one time in a 24 hour period, except for 4/8/15 when it was done twice in the same shift.

4. Staff #A26 (Registered Nurse) was interviewed on 4/13/15 at approximately 1350 hours and indicated the Foley catheter policy did not address how often care was to be provided and confirmed standard of care deemed indwelling Foley catheters should be done at least two times in a 24 hour period; one time each shift. This was not done for patient #N1.

Based on record review and staff interview, the medical record failed to include practitioner's orders for glucometer testing for one (Patient #2) of four patient records reviewed.

Findings include:

1. Record review indicated the following:
A. A policy / procedure titled: "Noting Physician Orders," policy number "II-C.52," issued "12/2001," last revised "2/2015" read: "There shall be Physician's Orders (sic) for medical and functional management written for each patient specific to their own needs."
B. The medical record for Patient #2 indicated the patient was admitted on 3-20-2015. The admission orders signed by the admitting physician and dated "3/23/15," indicated the patient had Type II Diabetes, but there was not an order for glucometer testing. There was a practitioner's order for "BID accuchecks dx diabetes" placed on "4/8/15" at "1730 PM." Glucometer testing was performed as follows:

Date Time Result (mg/dL)
________________________
3-20-15 0630 164
2100 371
3-21-15 0630 169
1130 267
1630 154
2100 252
3-22-15 0630 87
1130 136
2100 208
3-23-15 0630 110
1130 173
1630 240
2100 255
3-24-15 0630 118
1130 134
1630 289
2100 179
3-25-15 0630 125
1130 189
1630 143
2100 308
3-26-15 0630 96
1130 138
1630 249
2100 264
3-27-15 1130 237
1630 196
2100 274
3-28-15 0630 125
1100 274
1130 247
1630 291
2100 366
3-29-15 0630 104
1130 291
1630 220
2100 312
3-30-15 0630 104
1130 102
1630 289
2100 303
3-31-15 0630 122
1130 145
1630 192
2100 109
4-1-15 0630 116
1130 172
1630 247
2100 325
4-2-15 0630 86
1130 171
1630 263
2000 181
2100 150
4-3-15 0630 112
1130 205
1630 257
2100 309
4-4-15 0630 100
1130 104
1630 208
2100 222
4-5-15 0630 118
1130 296
1630 178
1900 286
2100 291
4-6-15 0630 95
1130 246
1630 178
1900 291
2100 291
4-7-15 0630 110
1130 191
1630 286
2100 263
4-8-15 1130 165
1630 205

Date - date of glucometer testing; Time - time of glucometer testing; Result - glucometer test result in millingrams per deciliter (mg/dL)

2. In interview on 4-14-15 at 2:48 PM, Staff Member #A2, CNO (Chief Nursing Officer) acknowledged there were no practitioner's orders for glucometer testing for Patient #L2 between 3-20-15 and 4-8-15 when glucometer testing was performed. Staff Member #A2 indicated the practitioner's orders were missing from Patient #L2's medical record.

Based on document review and interview, the facility failed to follow its policy/procedure and ensure that radiation exposure badges were processed quarterly with evidence indicating that the results of exposure monitoring were reviewed by a radiation safety officer or radiologist appointed to supervise its radiology services.

Findings:

1. The policy/procedure Imaging/Radiology Department Safety (revised 11-13) indicated the following: "Radiation exposure badges shall be worn by all department employees. Badges will be processed and recorded quarterly."

2. The policy/procedure Radiation Monitoring Badge (revised 11-13) indicated the following: "The radiation safety officer will review the records quarterly, and provide all employees a copy of their report."

3. On 4-15-15 at 1300 hours, the 2014 annual radiation exposure monitoring report dated 3-24-15 failed to indicate that quarterly monitoring was performed for the 5 personnel indicated on the report and failed to indicate that the results of exposure monitoring were reviewed by a radiation safety officer or supervising radiologist in accordance with facility policy.

4. On 4-15-15 at 1320 hours, the chief executive officer A1 confirmed the radiation exposure monitoring report failed to indicate that quarterly radiation exposure monitoring was performed or indicate that a review of the radiation exposure documentation was performed by a radiation safety officer or supervising radiologist.

Based on Life Safety Code (LSC) survey, Doctors Neuropsychiatric Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety From Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 18, New Health Care Occupancies. The facility has elected to utilize a Categorical Waiver pertaining to the size of a suite of rooms and is in compliance.

The 100 unit building was a one story facility with a partial basement determined to be of Type II (000) construction. The 200 unit building was a two story building with a partial basement determined to be of type II (111) construction and was fully sprinklered with the exception of the elevator equipment room and a clean supply room. The facility has a fire alarm system with smoke detection in the corridors, in patient rooms and in spaces open to the corridor. The facility has a capacity of 37 beds and had a census of 26 at the time of this survey.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to meet the building construction type and height requirement for 1 of 2 buildings (see K 012), failed to ensure 1 of 3 stairway doors with a one and one half hour rating, closed and latched into the door frame and failed to ensure 3 of 4 stairway enclosures maintained a fire resistance rating of at least one hour (see K 020), failed to ensure 1 of 1 ceiling smoke barriers and 2 of 4 smoke barrier walls were maintained to provide a one hour fire resistance rating (see K 025), failed to ensure the corridor doors entering 1 of 1 kitchen and 1 of 1 dry foods storage room, used to store combustibles and measuring over 50 square feet in size, were provided with a self closing device and positive latching hardware (see K 29), failed to document testing of emergency lighting for 3 of 3 battery operated emergency lights in the facility (see K 046), failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 completed quarters (see K 050), failed to ensure 1 of 2 fire alarm panels located in an area that were not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire (see K 052), failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms and 1 of 1 basement clean supply rooms (see K 056), failed to replace the corroded sprinkler head in 1 of 1 emergency ration storage rooms and failed to provide a complete supply of spare sprinklers for the automatic sprinkler system (see K 062), failed to ensure 1 of 2 fire extinguishers in the 100 unit was readily accessible at all times (see K 064), failed to enforce 1 of 1 smoking policies for the facility (see K 066), failed to ensure 1 of 1 exterior oxygen supply storage locations was protected from the weather (see K 076), failed to ensure the penetration in 1 of 1 basement fire barrier walls was maintained to ensure the fire resistance of the barrier and failed to ensure the water heaters in 1 of 2 basement boiler/water heater rooms had a current inspection certificate to ensure the water heaters were in safe operating condition (see K 130), failed to maintain 1 of 1 master alarm panels in the 100 unit (see K 140), failed to ensure the alternate source of power from the 1 of 2 emergency generators was capable of automatically connecting to the load within 10 seconds in the event of failure of normal power (see K 144) and failed to ensure 8 of 8 flexible cords such as extension cord power strips, 2 of 2 multiplug adapters and 1 of 1 extension cords were not used as a substitute for fixed wiring (see K 147).

The cumulative effect of these systemic problems resulted in the hospital ' s inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation, record review and interview, the facility failed to meet the building construction type and height requirement for 1 of 2 buildings, failed to ensure 1 of 3 stairway doors with a one and one half hour rating, closed and latched into the door frame, failed to ensure 3 of 4 stairway enclosures maintained a fire resistance rating of at least one hour, failed to ensure 1 of 1 ceiling smoke barriers and 2 of 4 smoke barrier walls were maintained to provide a one hour fire resistance rating, failed to ensure the corridor doors entering 1 of 1 kitchen and 1 of 1 dry foods storage room, used to store combustibles and measuring over 50 square feet in size, were provided with a self closing device and positive latching hardware, failed to document testing of emergency lighting for 3 of 3 battery operated emergency lights in the facility, failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 completed quarters, failed to ensure 1 of 2 fire alarm panels located in an area that were not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire, failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms and 1 of 1 basement clean supply rooms, failed to replace the corroded sprinkler head in 1 of 1 emergency ration storage rooms and failed to provide a complete supply of spare sprinklers for the automatic sprinkler system, failed to ensure 1 of 2 fire extinguishers in the 100 unit was readily accessible at all times, failed to enforce 1 of 1 smoking policies for the facility, failed to ensure 1 of 1 exterior oxygen supply storage locations was protected from the weather, failed to ensure the penetration in 1 of 1 basement fire barrier walls was maintained to ensure the fire resistance of the barrier and failed to ensure the water heaters in 1 of 2 basement boiler/water heater rooms had a current inspection certificate to ensure the water heaters were in safe operating condition, failed to maintain 1 of 1 master alarm panels in the 100 unit, failed to ensure the alternate source of power from the 1 of 2 emergency generators was capable of automatically connecting to the load within 10 seconds in the event of failure of normal power and failed to ensure 8 of 8 flexible cords such as extension cord power strips, 2 of 2 multiplug adapters and 1 of 1 extension cords were not used as a substitute for fixed wiring.

Findings:

1. Observation with Maintenance Director (#1), Maintenance Director (#2) and the Compliance Specialist (#3) on 04/15/15 indicated a two foot section of the steel beam above the ceiling tile in patient room 202 was not treated with a fire rated material.

2. In interview with #3 at the time of observation, it was indicated the remainder of the building was treated with a fire rated material and this section must have been missed.

3. Observation with the Chief Operating Officer #4, Maintenance Director #1 and Maintenance Director #2 on 04/15/15 at 1:45 p.m., it was noted the west stairway door failed to latch into the door frame after ten (10) attempts.

4. At the time of observation, the CEO #4 acknowledged the west stairway door failed to latch into the door frame.

5. Observation with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 from 3:40 p.m. to 4:35 p.m. noted the following unsealed penetrations above the ceiling tile:
a) both second floor stairway enclosures had unsealed penetrations measuring in size from one and one quarter inch to three quarters of an inch
b) at the first floor west stairway enclosure, there was an unsealed penetration measuring one and one half inch

6. In observation with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 from 2:13 p.m. to 4:25 p.m., the following unsealed penetrations were noted:
a) the basement mechanical room where the transfer switch for the Onan generator is located had fiberglass insulation stuffed into a ceiling penetration.
b) in the one hour smoke barrier wall that continues along the 200 unit the following
penetrations were found above the ceiling tile; a three inch penetration across from the EEG room and a twelve inch by six inch penetration above the doors entering the 200 unit.
c) at the second floor one hour smoke barrier floor above the ceiling tile there was an unsealed penetration measuring 12 inches by 12 inches around an HVAC duct.

7. All unsealed penetrations were acknowledged by Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist #3 at the time of observations.

8. Observation with Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist #3 on 04/15/15 at 1:08 p.m. to 1:18 p.m. indicated the two corridor doors entering the kitchen lacked a self closing device and positive latching hardware and the two corridor doors entering the dry food storage area lacked positive latching hardware.

9. Observation was acknowledged by the Compliance Specialist #3 on 04/15/15 at 1:08 p.m. to 1:18 p.m.

10. In interview on 04/15/15 at 10:56 a.m., Maintenance Director#1 and Maintenance Director #2 acknowledged an annual 90 minute test had not been conducted on the three battery operated emergency light since January 2014.

11. Review of the "Fire Drill Observer Evacuation" forms with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 at 11:37 a.m. revealed there was no record of a second shift fire drill for the first quarter of 2015.

12. Interview with the Maintenance Director #2 at the time of record review indicated a second shift fire drill had not been conducted in the first quarter of 2015.

13. Observation with Maintenance Director #1 on 04/15/15 at 12:05 p.m., indicated the 100 unit building main fire alarm panel located in the IT (information technology) room adjacent to the break room was not electrically supervised by a smoke detector or in an area continuously occupied.

14. At the time of observation, Maintenance Director #1 acknowledged the IT room was provided with only a heat detector.

15. Observation on 04/15/15 from 11:20 a.m. to 1:53 p.m. with Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist #3 noted the elevator equipment room and the basement clean supply room lacked sprinkler coverage.

16. In interview on 04/15/15 from 11:20 a.m. to 1:53 p.m., Maintenance Director # 1, Maintenance Director #2 and the Compliance Specialist #3 acknowledged the elevator equipment room and the basement clean supply room lacked sprinkler coverage.

17. Observation on 04/15/15 at 1:25 p.m. with Maintenance Director #1 indicated one of two sprinkler heads in the emergency ration storage room was corroded with a green substance.

18. In interview on 04/15/15 at 1:25 p.m., Maintenance Director #1 acknowledged one of two sprinkler heads in the emergency ration storage room was corroded with a green substance and there were no green glass bulb sprinkler heads in the spare sprinkler cabinet.

19. Observation with the CEO #4, Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15 from 12:05 p.m. to 12:10 p.m. indicated the fire extinguishers in the 100 unit were in locked wall mounted cabinets.

20. In interview with Maintenance Director #2 at the time of observation, #2 stated all staff members were supposed to be provided with the key.

21. In interview at 12:10 p.m., Registered Nurse #1 stated he/she did not have a key to the fire extinguisher cabinets.

22. Observation with Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist #3 on 04/15/15 from 12:35 p.m. to 12:36 p.m. noted the grassy area around both emergency generators was littered with cigarette butts.

23. In interview with Maintenance Director #1 at the time of observation, #1 stated the entire campus is designated smoke free.

24. Observation with Maintenance Director #1 on 04/15/15 at 2:40 p.m. indicated two large liquid oxygen containers, approximately 5 feet tall, were located in a chain link enclosure near the Caterpillar emergency generator. The chain link enclosure did not offer protection from sun, snow, or rain.

25. Maintenance Director #1 agreed at the time of observation, the liquid oxygen containers were exposed to all types of weather conditions.

26. Observation with Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist #3 on 04/15/15 at 4:35 p.m. indicated at the basement two hour fire barrier doors above the ceiling tile, there was an unsealed penetration measuring one inch around a conduit and a one and one half inch unsealed penetration around a sprinkler line.

27. The Compliance Specialist confirmed the wall was a two hour fire barrier wall at the time of observation.

28. Observation with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 at 5:30 p.m. noted the basement water heater with the state registration number 318523 lacked a Certificate of Inspection.

29. In interview with Maintenance Director #1 and Maintenance Director #2 at the time of observation, it was confirmed they were unable to provide documentation to confirm the aforementioned water heater had been inspected and had a Certificate of Inspection.

30. Observation with CEO #4, Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist #3 on 04/15/15 at 12:20 p.m. indicated the master alarm panel in the 100 unit was not operational.

31. In interview with Maintenance Director #2 at the time of observation, it was stated the facility is waiting for a service company from another city to make the necessary repairs.

32. Observation with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 from 12:40 p.m. to 12:50 p.m. noted the Onan emergency generator failed to start with the transfer switch after two (2) attempts.

33. In interview with Maintenance Director #1 at the time of observation, he was able to manually start the generator and then start the generator with the transfer switch. He stated a relay could have been stuck.

34. Observation on 04/15/15 from 1:49 p.m. to 3:17 p.m. with Maintenance Director #1 and Maintenance Director #2 noted the following:
a) three extension cord power strips were plugged together and providing power to computer equipment and a copier in the Pharmacy
b) an extension cord was plugged in and continued up through the ceiling in the basement IT room
c) a multiplug adaptor was plugged in and providing power to an extension cord power strip which was plugged in and providing power another extension cord power strip which was providing power to IT equipment in the basement IT room
d) a multiplug adaptor was plugged in and providing power to an extension cord power strip which was providing power to an electric air freshener in the Discharge Planning office
e) an extension cord power strip was plugged in and providing power to another extension cord power strip which was providing power to telephone equipment in the telephone equipment closet on the second floor.

35. In interview on 04/15/15 from 1:49 p.m. to 3:17 p.m., Maintenance Director #1 and Maintenance Director #2 acknowledged the following:
a) three extension cord power strips were plugged together and providing power to computer equipment and a copier in the Pharmacy
b) an extension cord was plugged in and continued up through the ceiling in the basement IT room
c) a multiplug adaptor was plugged in and providing power to an extension cord power strip which was plugged in and providing power another extension cord power strip which was providing power to IT equipment in the basement IT room
d) a multiplug adaptor was plugged in and providing power to an extension cord power strip which was providing power to an electric air freshener in the Discharge Planning office
e) an extension cord power strip was plugged in and providing power to another extension cord power strip which was providing power to telephone equipment in the telephone equipment closet on the second floor.

Based on policy and procedure review, personnel record review, and staff interview, the infection control officer failed to ensure job-specific training on hospital infection control practices, policies, and procedures upon hire and at regular intervals for 1 of 2 (A18, Registered Nurse [RN]) agengy personnel and 1 of 5 (A24, Radiology Tech) contracted personnel records reviewed; and failed to ensure training on blood borne pathogens upon hire, at regular intervals, and as needed for for 1 of 2 (A18, RN) agengy personnel and 1 of 5 (A24, Radiology Tech) contracted personnel records reviewed; and failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel by not ensuring respiratory fit testing as required by facility policy and procedure for 1 of 2 (A17, RN) agengy personnel and 1 of 5 (A24, Radiology Tech) contracted personnel records reviewed; and documentation of communicable disease history or immunity to hepatitis B and/or evidence that annual influenza vaccination was offered for 2 of 8 (A12, RN and A16, Certified Nursing Assistant [CNA]) personnel and 2 of 2 (A17 and A18, RNs) agengy personnel and 2 of 5 (A23, Physical Therapist and A24, Radiology Tech) contracted personnel records reviewed.

Findings:
1. Policy titled, "Transmission-Based Precautions (Isolation)" revised/reapproved 1/2015, indicated on pg. 7, under Airborne Precautions section, bulleted point, "Staff Restrictions: All employees will be trained in the use of PAPRs (Purified Air Personal Respirator) upon New Hire and updated annually on PAPRs usage."

2. Policy titled, "Immunization Requirements for all Persons Working in a Healthcare Setting" revised/reapproved 12/2014, indicated on pg. 1, under Policy section, "[facility] will follow all immunization recommendations set forth by the Centers for Disease Control & Prevention and the Indiana State Department of Health for Rubeola (Measles), Mumps, Rubella, Varicella, Tdap, Diphtheria, Influenza, and Hepatitis B virus. As a condition of employment, medical staff credentialing, or other affiliation with [facility] all persons, (employees, Medical Staff, associates/volunteers, traveling/agency staff and students) will be required to provide proof of immunity or be screend for: 1. Rubeola, Mumps, Rubella; 2. Varicella; 3. Tdap (those who are expected to have direct patient contact with patients 12 months of age or younger); 4. Influenza; 5. Hepatitis B (those who are expected to have occupational risk for blood/body fluid exposure)."

3. Review of personnel records at 2:00 PM on 4/15/15, indicated personnel:
A. A12 (RN):
a. was hired on 12/2013, provides direct patient care, and is expected to have occupational risk for blood/body fluid exposure.
b. lacked documentation of communicable disease history or immunity to hepatitis B.
B. A16 (CNA):
a. was hired on 11/2013, provides direct patient care, and is expected to have occupational risk for blood/body fluid exposure.
b. lacked documentation of communicable disease history or immunity to hepatitis B.
C. A17 (Agency RN):
a. was hired on 4/2014, provides direct patient care, and is expected to have occupational risk for blood/body fluid exposure.
b. lacked documentation of respiratory fit testing for PAPR on hire and annually.
c. lacked evidence that annual influenza vaccination was offered.
D. A18(Agency RN):
a. was hired on 11/2014, provides direct patient care, and is expected to have occupational risk for blood/body fluid exposure.
b. lacked documentation of job-specific training on hospital infection control practices, policies, and procedures and training on blood borne pathogens upon hire, at regular intervals, and as needed.
c. lacked evidence that annual influenza vaccination was offered.
E. A23 (Physical Therapist):
a. contract was renewed 11/2014 and provides direct patient care.
b. lacked evidence that annual influenza vaccination was offered.
F. A24 (Radiology Tech):
a. contract was renewed 11/2014 and provides direct patient care.
b. lacked documentation of job-specific training on hospital infection control practices, policies, and procedures and training on blood borne pathogens upon hire, at regular intervals, and as needed.
c. lacked documentation of respiratory fit testing for PAPR on hire and annually.
d. lacked evidence that annual influenza vaccination was offered.
e. lacked documentation of communicable disease history or immunity to hepatitis B.

4. Personnel A6, Infection Control Officer, was interviewed on 4/15/15 at 2:15 PM, and confirmed personnel A17 and A24 provide direct patient care and lacked documentation of job-specific training on hospital infection control practices, policies, and procedures and training on blood borne pathogens upon hire, at regular intervals, and as needed; and respiratory fit testing for PAPR on hire and annually as required by facility policy and procedure; and documentation of communicable disease history or immunity to hepatitis B and/or evidence that annual influenza vaccination was offered. A policy related to infection control training and blood borne pathogens training was requested, but not provided prior to exit.

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

I. Provide and document individualized and measurable short term goals on the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A6, A7, A8, A9, B10, B11, B12 and B13). Specifically, the MTPs listed similarly worded short termed goals for patients that were not measurable outcome behaviors. These failures result in treatment plans that do not identify individualized expected patient outcomes in a manner that can be utilized by the treatment team to measure effectiveness of treatment and/or progress towards discharge. (Refer B121)

II. Consistently develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A6, A7, A8, A9, B10, B11, B12 and B13). Specifically, interventions were stated as routine, generic discipline functions that lacked focus and frequency of treatment. There was no social work interventions listed on any of the plans. In addition, none of the plans listed any specific group modalities related to any patient's specific needs; patients were encouraged to attend all groups offered on the program schedule and without focus. These deficiencies result in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and purpose for each. These failures hamper staff's ability to provide individualized treatment that is purposeful and goal directed. (Refer to B122)

III. Ensure that the MTPs included each responsible person's name and discipline for seven (7) of eight (8) active sample patients (A6, A7, A9, B10, B11, B12 and B13). The MTPs identified the staff person discipline as the responsible person for interventions. This practice results in the facility's inability to monitor staff accountability for specific treatment interventions. (Refer B123)

The written plan must include long-term and short-range goals.

Based on record review and interview, the facility failed to develop individualized, observable and measurable short-term goals on the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A6, A7, A8, A9, B10, B11, B12 and B13). Specifically, the MTPs listed similarly worded short termed goals for patients that were not measurable outcome behaviors. This resulted in a document that failed to identify individualized expected patient outcomes in a manner that could be utilized by the treatment team to observe or measure effectiveness of treatment progress/lack of progress towards discharge.

Findings include

A. Record review

1. Active sample patient A6 MTP dated 4/3/15; the short-term goals were listed as "Patient will exhibit less than 2 incidences of medication non-compliance for 48 consecutive hours." "Patient will exhibit no incidences of non-compliance for 48 consecutive hours." " Patient will have less than 2 delusional statements for 48 consecutive hours." "Patient will be free from delusional statement for 48 consecutive hours." These goals were ambiguous in that there was no direction when the 48 hours began and ended.

2. Active sample patient A7 MTP dated 4/8/15; the short-term goals were listed as "Patient will have less two incidences of anxiety per day for 48 hours." "Patient will have not incidences of anxiety for 48 consecutive hours" "Patient will exhibit less than 2 incidences of verbal aggression for 48 consecutive hours." Patient will exhibit no incidences of verbal aggression for 48 consecutive hours." These goals were ambiguous in that there was no direction when the 48 hours began and ended.

3. Active sample patient A8 MTP dated 3/27/15; the short-term goals were listed as "Patient will have less than two (2) incidences of intrusive behaviors per day for 48 consecutive hours." Patient will have no incidences of intrusive behavior 48 consecutive hours." Patient will have less than two (2) incidences of auditory hallucinations per day for three (3) consecutive days." "Patient will have no incidence of auditory hallucinations for three (3) consecutive days." These goals were ambiguous in that there was no direction when the 48 hours began and ended.

4. Active sample patient A9 MTP dated 3/23/15; the short-term goals were listed as "Patient will less than two (2) incidences of aggression per day for 48 consecutive hours." Patient will have not incidences of aggression for 48 consecutive hours." "Patient will exhibit less than two (2) incidences of medication non-compliance for 48 consecutive hours." "Patient will have no incidences of medication non-compliance for 48 consecutive hours." These goals were ambiguous in that there was no direction when the 48 hours began and ended.

5. Active sample patient B10 MTP dated 4/10/15; the short-term goals were listed as "Patient will attend individual therapy with psychologist 75% of the time for the length of hospital stay." This is an intervention written as patient's short-term goal. "Patient's geriatric depression score will range within mild or normal by end of hospital stay." This goal is not written in patient behavioral terms. "Patient will exhibit less than two (2) incidences of verbal aggression for 48 consecutive hours." "Patient will exhibit no incidences of verbal aggression for 48 consecutive hours. These goals were ambiguous in that there was no direction when the 48 hours began and ended.

6. Active sample patient B11 MTP dated 4/9/15; the short-term goals were listed as "Patient will be free of feeling and statements to harm others within five (5) days of stay." "Patient will verbalize feelings of wanting to harm others 100% of the time when having malicious thoughts." "Patient will have less than two (2) delusional statements for 48 consecutive hours." "Patient will be free from delusional statements for 48 consecutive hours." These goals were ambiguous in that there was no direction when the 48 hours began and ended. These goals were ambiguous in that there was no direction when the 48 hours began and ended.

7. Active sample patient B12 MTP dated 4/1/15; the short-term goals were listed as "Patient will exhibit less than two (2) incidences of physical aggression for 48 consecutive hours." "Patient will exhibit no incidences of physical aggression for 48 consecutive hours." "Patient will be easily re-directable without verbal or physical aggression during activities of daily living 75% of the time throughout hospitalization." These goals were ambiguous in that there was no direction when the 48 hours began and ended.

8. Active sample patient B13 MTP dated 4/3/15; the short-term goals were listed as "Patient will exhibit less than three (3) incidences of physical aggression for 48 consecutive hours." "Patient will exhibit no incidences of physical aggression for 48 consecutive hours." These goals were ambiguous in that there was no direction when the 48 hours began and ended.

B. Policy review

1. Facility policy No I.C. 32 titled "Plan of Care" Issued 12/2011 and revised 2/2015: States " The plan of care, treatment and services includes, but may not be limited to: Measurable goals and objectives based on the assessed needs, strengths and patient limitations." This is not reflective in the patient's MTPs.

C. Interview

1. In an interview on 4/14/15 at 1:30 p.m. with the Director of Nursing, the short-term goals were discussed and her response was "Yes I see."

2. In an interview on 4/14/15 at 3:05 p.m. with the Chief of Psychiatry, he stated that the treatment plan was a working document and yes the goals should be written in measurable terms.

Based on record review and interview the facility failed to consistently develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A6, A7, A8, A9, B10, B11, B12 and B13). Specifically, interventions were stated as generic monitoring and discipline functions written as treatment interventions to be performed by clinical staff. MTPs also failed to state the frequency of contact, specific focus for interventions, and whether interventions would be delivered in groups or individual sessions. These deficiencies result in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and purpose for each. These failures also potentially result in inconsistent and/or ineffective treatment.

Findings include:

A. Policy review

The Facility policy No II-C.26 titled "Standard of Patient Care" Issued 12/2011 and revised 3/2014: under "Standard of Care II- Master Treatment Plan c. Active Problems; States interventions- appropriate disciplines are identified for each problem. The interventions include the specific action or activity, the frequency of the interventions, and the responsible person." This policy does not provide the staff with sufficient information to guide them in writing treatment intervention statements. Listed below is the generic list of interventions by discipline in regards to the identified problem for eight (8) of eight (8) active sample patient.

B. Record review

1. Active sample patient A6 MTP dated 4/1/15; for problem "Refusal of medications."

Nursing: "Approach patient in calm manner and state your purpose for providing medications." "Re-approach patient at a later time and/or a different staff member to provide medications." "Educate on the purpose of medication and it will be necessary to receive Intramuscular (IM) back up as per physician plan of care." "Provide IM back up as ordered by physician."

Psychiatrist: "Educate on the purpose of medication and it will be necessary to receive Intramuscular (IM) back up as per physician plan of care." "Provide IM back up as ordered by physician."

For the problem "Physical aggression" the written interventions by each discipline are;

Nursing: "Approach patient in calm manner and state your purpose for providing care; Re-approach patient at a later time and/or a different staff member." "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." "Provide protective supervision as needed." "Provide structured environment with schedule routine activities or daily living."

Psychiatrist: "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." " Provide protective supervision as needed."

Psychology: "Provide protective supervision as needed." "Individual therapy with psychology."

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

2. Active sample patient A7 MTP dated 4/8/15; for problem "Anxiety."

Nursing: "Acknowledge awareness of anxiety." "Medications as ordered." "Reassured patient he/she [sic] is safe." "Maintain a calm manner when interacting with the patient."

Psychiatrist: "Medications as ordered."

Psychology: "Acknowledge awareness of anxiety." "Individual therapy with psychologist."

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

For problem "Verbal aggression" the written interventions by each discipline are;

Nursing: "Approach patient in calm manner and state your purpose for providing care; Re-approach patient at a later time and/or a different staff member." "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." "Provide protective supervision as needed." "Provide structured environment with schedule routine activities or daily living."

Psychiatrist: "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." " Provide protective supervision as needed."

Psychology: "Provide protective supervision as needed." "Individual therapy with psychology."

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

3. Active sample patient A8 MTP dated 3/27/15; for problem "Intrusive behavior -violation of boundaries/invading others personal space."

Nursing: "Offer redirection out of the rooms of others; show patient where their room is." "Redirect and engage in activities that are within patient capabilities and tolerance level." "Keep safe from harm."

For problem "Hallucinations (auditory)" the written interventions by each discipline are;

Nursing: "Stress frequent rest periods." "Medications as ordered/medications as needed." "Avoid environmental triggers such as loud noise and bright lights." "Do not argue regarding false belief; validate that you believe their belief and utilize distractions techniques."

Psychiatrist: "Medications as ordered/Review medications as needed." "Do not argue regarding false belief; validate that you believe their belief and utilize distraction techniques."

Psychology: No interventions listed.

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

For problem "Physical aggression" the written interventions by each discipline are;

Nursing: "Approach patient in calm manner and state your purpose for providing care; Re-approach patient at a later time and/or a different staff member." "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." "Provide protective supervision as needed." "Provide structured environment with schedule routine activities or daily living."

Psychiatrist: "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." "Provide protective supervision as needed."

Psychology: "Provide protective supervision as needed." "Individual therapy with psychology."

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

4. Active sample patient A9 MTP dated 3/23/15; for problem "Physical aggression"

Nursing: "Approach patient in calm manner and state your purpose for providing care; Re-approach patient at a later time and/or a different staff member." "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." "Provide protective supervision as needed." "Provide structured environment with schedule routine activities or daily living."

Psychiatrist: "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." "Provide protective supervision as needed."

Psychology: "Provide protective supervision as needed." "Individual therapy with psychology."

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

For problem "Refusal of Medications" the written interventions by each discipline are;

Nursing: "Approach patient in calm manner and state your purpose for providing medications." "Re-approach patient at a later time and/or a different staff member to provide medications." "Educate on the purpose of medication and it will be necessary to receive Intramuscular (IM) back up as per physician plan of care." "Provide IM back up as ordered by physician."

Psychiatrist: "Educate on the purpose of medication and it will be necessary to receive Intramuscular (IM) back up as per physician plan of care." "Provide IM back up as ordered by physician."

5. Active sample patient B10 MTP dated 4/10/15; for problem "Depression"

Nursing: "Assess the patient's awareness of depression." "Explain sign and symptoms for depression." "Medications for depression as ordered." "Encourage patient to participate in normal activities of daily living." "Encourage patient to participate in individual therapy with psychology."

Psychiatrist: "Explain the sign and symptoms of depression." "Medications for depression as ordered."

Psychology: "Explain the sign and symptoms of depression." "Encourage patient to participate in individual therapy with psychology."

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

For problem "Verbal aggression" the written interventions by each discipline are;

Nursing: "Approach patient in calm manner and state your purpose for providing care; Re-approach patient at a later time and/or a different staff member." "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." "Provide protective supervision as needed." "Provide structured environment with schedule routine activities or daily living."

Psychiatrist: "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail."

Psychology: No interventions listed.

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

6. Active sample patient B11 MTP dated 4/9/15; for problem "Homicidal ideation - potential for harming others."

Nursing: "Monitor patient so she is unable to harm others." "Inquire to patient of any thoughts regarding attempting to harm others." "Reassure patient that they are safe here and that they are a valued person." "Medications as ordered."

Psychiatrist: "Medications as ordered."

Psychology: No interventions listed.

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

For problem "Disturbed thought process - delusions - as evidenced by patient's statement/ belief of: She believes her call light is a knife and she is attempting to stab others with it."

Nursing: "Approach patient in a calm manner and maintain a reality based conversation." "Provide a safe and structured environment." "Be concrete in the setting of rules of the unit." "Re-orient patient to present/current situational reality."

Psychiatrist: No interventions listed.

Psychology: "Re-orient patient to present/current situational reality."

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

7. Active sample patient B12 MTP dated 4/1/15; for problem "Physical aggression."

Nursing: "Approach patient in calm manner and state your purpose for providing care; Re-approach patient at a later time and/or a different staff member." "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." "Provide protective supervision as needed." "Provide structured environment with schedule routine activities of daily living."

Psychiatrist: "Patient will take medications as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail."

Psychology: "Provide protective supervision as needed." "Individual therapy with psychology."

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

For problem "Depression" the written interventions by each discipline are;

Nursing: "Assess the patient's awareness of depression." "Explain sign and symptoms for depression." "Medications for depression as ordered." "Encourage patient to participate in normal activities of daily living." "Encourage patient to participate in individual therapy with psychology."

Psychiatrist: "Explain the sign and symptoms of depression." "Medications for depression as ordered."

Psychology: "Explain the sign and symptoms of depression." "Encourage patient to participate in individual therapy with psychology."

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

8. Active sample patient B13 MTP dated 4/3/15; for problem "Physical aggression"

Nursing: "Approach patient in calm manner and state your purpose for providing care; Re-approach patient at a later time and/or a different staff member." "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." "Provide protective supervision as needed." "Provide structured environment with schedule routine activities of daily living."

Psychiatry: "Patient will take medications as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail."

Psychology: "Provide protective supervision as needed." "Individual therapy with psychology."

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

For problem "Anxiety"

Nursing: "Acknowledge awareness of anxiety." "Medications as ordered." "Reassured patient he/she [sic] is safe." "Maintain a calm manner when interacting with the patient."

Psychiatry: "Medications as ordered."

Psychology: "Acknowledge awareness of anxiety." "Individual therapy with psychologist."

Social Service: No interventions listed.

Activity Therapy: No interventions listed.

C. Interview

1. In an interview on 4/14/15 at 1:30 p.m. with the Director of Nursing, the treatment interventions on the Master Treatment Plans were discussed. She acknowledged that the interventions were generic and routine staff functions.

2. In an interview on 4/14/15 at 3:05 p.m. with the Chief of Psychiatry, he acknowledged that the treatment interventions needed to be listed objectively and it was a working document and it would be helpful to see an example as to how to write a proper treatment plan. He further stated that he would purse the internet and dialogue with other psychiatric hospital to develop a realistic and quantitative treatment plan.

3. In an interview on 4/14/15 at 2:30 p.m. with the Social Service Director and license social worker I. The Master Treatment Plan was discussed in regards to the lack of social service representation for providing active treatment care of the patient and interventions. Both acknowledge the absence of social service interventions in the MTP.

4. In an interview on 4/15/15 at 10:05 a.m. with the Psychology supervisor, the treatment team modalities were discussed and he agreed that they were staff duties, "Our roles and job and yes they were identified as interventions."

Based on record review and interview, the facility failed to ensure that the name and discipline of staff person responsible for specific aspects of care where listed on the Master Treatment Plans of eight (8) of eight (8) active sample patients (A6, A7, A8, A9, B10, B11, B12 and B13). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

A. Record review (MTP dates in parenthesis)

1. Active sample patient A6 (4/1/15)
The MTP included no staff names for the listed interventions: "Approach patient in calm manner and state your purpose for providing care; Re-approach patient at a later time and/or a different staff member." "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." "Provide protective supervision as needed." "Provide structured environment with schedule routine activities or daily living."

2. Active sample patient A7 (4/8/15)
The MTP included no staff names for the listed interventions: "Acknowledge awareness of anxiety." "Medications as ordered." "Reassured patient he/she [sic] is safe." "Maintain a calm manner when interacting with the patient." "Approach patient in calm manner and state your purpose for providing care; Re-approach patient at a later time and/or a different staff member." "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." "Provide protective supervision as needed." "Provide structured environment with schedule routine activities or daily living."

3. Active sample patient A9 (3/23/15)
The MTP included no staff names for the listed interventions: "Encourage patient to participate in normal activities of daily living."

4. Active sample patient B10 (4/10/15)
The MTP included no staff names for the listed interventions: "Approach patient in calm manner and state your purpose for providing care; Re-approach patient at a later time and/or a different staff member." "Patient will take medication as prescribed; provide IM back up as ordered by physician if necessary to calm patient if all other interventions fail." "Provide protective supervision as needed." "Provide structured environment with schedule routine activities or daily living."


5. Active sample patient B11 MTP (4/9/15)
The MTP included no staff names for the listed interventions: "Monitor patient so she is unable to harm others." "Inquire to patient of any thoughts regarding attempting to harm others." "Reassure patient that they are safe here and that they are a valued person."

6. Active sample patient B12 MTP (4/1/15)
The MTP included no staff names for the listed interventions: "Encourage patient to participate in normal activities of daily living."

7. Active sample patient B13 MTP (4/3/15)
The MTP included no staff names for the listed interventions: "Acknowledge awareness of anxiety." "Medications as ordered." "Reassured patient he/she [sic] is safe." "Maintain a calm manner when interacting with the patient." "Individual therapy with psychology."

B Interview

1. In an interview on 4/14/15 at 1:30 p.m. with the Director of Nursing, the Master Treatment Plan was shown to her, which did not identify any responsible persons name for the interventions. Her response was, "I see what you are saying."

2. In an interview on 4/15/15 at 10:05 a.m. with the Psychology supervisor, he agreed that the name of the responsible person for the modality was not identified.

Based on record review and interview, the Chief of Psychiatry failed to ensure:

I. The staff developed MTPs that include short term goals stated in observable, measurable behavioral terms for eight (8) of eight (8) active sample patients (A6, A7, A8, A9, B10, B11, B12 and B13). This resulted in a document that failed to identify individualized expected treatment outcomes in a manner that staff could observe or measure. (Refer B 121)

II. The Master Treatment Plans for eight (8) of eight (8) active sample patients (A6, A7, A8, A9, B10, B11, B12, and B13) identifies intervention for the psychiatrist that were individualized. The interventions written in the MTPs were routine, generic, discipline functions. This results in the facility not delineating the role of the physician in the treatment of the patients. (Refer B122)

III. Ensure that the MTPs for seven (7) of eight (8) active sample patients (A6, A7, A9, B10, B11, B12 and B13) have the responsible staff person for each intervention identified by their name and discipline. Instead, each intervention has the clinical department title listed such as nursing, nursing aides, psychiatry and psychology. This failure results in a lack of staff accountability for the interventions and a failure to deliver treatment to meet the patient's identified need. (Refer B123)

Based on record review and interview, the Director of Nursing failed to ensure the MTPs for eight (8) of eight (8) active sample patients (A6, A7, A8, A9, B10, B11, B12 and B13) include nursing goals and interventions that were individualized, had specific frequency that were observable and measurable. The primary responsible person for compliance and accountability were absent on some interventions. These failures can result in fragmented nursing care, non-compliance with planned treatment and lack of accountability putting the patient at risk for adverse treatment outcomes. Specifically, the Director of Nursing failed to ensure:

I. The Master Treatment Plans for eight (8) of eight (8) active sample patients (A6, A7, A8, A9, B10, B11, B12 and B13) identified short-term treatment goals that were observable and measurable addressing the individual patient presenting problems and needs. (Refer B121)

II. The Master Treatment Plans for eight (8) of eight (8) active sample patients (A6, A7, A8, A9, B10, B11, B12 and B13) included treatment interventions/modalities specific to the patient's psychiatric needs with frequency and duration. The Master Treatment Plans listed nursing interventions that were repetitive, routine, generic discipline functions expected to be regularly provided by nursing staff for all patients.
(Refer B122)

III. Ensure that the Master Treatment Plans for 7 of 8 active sample patients (A6, A7, A9, B10, B11, B12, and B13) included the names of responsible staff for listed modalities/interventions. (Refer B123)
B. Interview

1. In an interview on 4/14/15 at 1:30 p.m. with the Director of Nursing, the
interventions on the Master Treatment Plans were discussed. She acknowledged that the short term goals were not measurable and the interventions were generic and routine staff functions. In the same interview the lack of responsible person's name for the interventions were pointed out. Her response was, "I see what you are saying."

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

I. Ensure the development of Master Treatment Plans that identified social service role and responsibility in discharge planning and family interventions for eight (8) of eight (8) active sample patients (A6, A7, A8, A9, B10, B11, B12, and B13). The absence of such treatment modalities on the Master Treatment Plans could results in the patients been hospitalized for longer period of time.

A. Record review

There was an absence of social services interventions in the Master Treatment Plans for eight (8) of eight (8) active sample patients (A6, A7, A8, A9, B10, B11, B12, and B13). (Refer B122)

B. Interview

In an interview on 4/14/15 at 3:30 p.m. with the Social Service Director and Social worker 1, the MTPs were discussed. Both individuals agreed that there were no intervention identified for social service. It was also stated that they do not provide groups or individual therapy.