HospitalInspections.org

Based on observation and interview, the facility 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 and failed to ensure the penetration in 1 of 1 basement fire barrier walls was maintained to ensure the fire resistance of the barrier.

Findings:

1. In observation with Maintenance Man #1 on 07/21/15 from 10:46 a.m. to 10:49 a.m., the following unsealed penetrations were noted:
a) A three inch hole above the ceiling tile on the 2nd floor stairwell near resident room 203 was unsealed.
b) One of nine sprinkler heads was missing an escutcheon near resident room 203.
c) Multiple ceiling penetrations in the Basement Boiler room including a two inch penetration around conduit, four inch, three inch, and a two inch drywall cut unsealed penetrations.

2. In interview at the time of each observation, the Maintenance Man #1 acknowledged each aforementioned condition.

3. In observation with Maintenance Man #1 on 07/21/15 at 11:03 p.m., it was noted that the two corridor doors entering the kitchen contained self closing devices, but only had manual latching hardware into the frame.

4. In interview at the time of observation, the Maintenance Man #1 acknowledged the aforementioned condition.

5. In observation with Maintenance Man #1 on 07/21/15 during the facility tour between 10:11 a.m. and 12:19 p.m., it was noted at the basement two hour fire barrier doors above the ceiling tile, there was an unsealed penetration above the ceiling tile measuring four inches around a hot water line.

6. In interview at the time of observation, the Maintenance Man #1 acknowledged the aforementioned condition.

Based on record review and interview the facility failed to:


1. Provide Master Treatment Plans (MTPS) that identified patient goals in measurable, behavioral terms for eight (8) of eight (8) active sample patients (A4, A6, A9, A14, B1, B2, B8 and B10). In addition, many goals were staff interventions or failed to correlate with the stated problem. This failure results in documented goals that fail to identify individualized expected treatment outcomes in a manner that can be utilized by the treatment team to measure individual progress in care. (Refer to B121)

2. Ensure that interventions on the Master Treatment Plans (MTPs) evidenced sufficient individualized planning for eight (8) of eight (8) active sample patients (A4, A6, A9, A14, B1, B2, B8 and B10). Most of the interventions did not include frequency and/or duration. Many of the psychiatric interventions were the same or similar on all patients regardless of each patient ' s specific problem(s). The nursing interventions and some of the psychology interventions listed routine generic discipline functions, inappropriately written as treatment interventions. In addition, there were no interventions by psychiatrists on any of the MTPs reviewed. These failures result in a lack of guidance to staff in providing individualized patient treatment that is purposeful and goal directed. (Refer to B122)





30489

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)

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPS) that identified patient goals in measurable, behavioral terms for eight (8) of eight (8) active sample patients (A4, A6, A9, A14, B1, B2, B8 and B10). In addition, many goals were staff interventions or failed to correlate with the stated problem. This failure results in documented goals that fail to identify individualized expected treatment outcomes in a manner that can be utilized by the treatment team to measure individual progress in care.

Findings include:

A. Medical Record Review:

1. Patient A4:

a. MTP, dated 7/6/15, had as a problem, "Schizophrenic undifferentiated -observed at (sic) laughing/crying/screaming, non-compliant with medication and care...." a short term goal was stated as "...will comply with physical care with zero refusal." This goal was not correlated with the stated problem.

b. For problem, "Diagnosis of dementia possible (sic) Alzheimer and depression-history of refusing care and medication, crying screaming," short term goals were stated as "(Patient) will complete mini mental status exam (MMSE) within three (3) days" and "(Patient) will participate in art group activities at least three (3) times a week to express (his/her) feelings of hopelessness and helplessness in an appropriate way." These statements were staff interventions.

2. Patient A6:

a. MTP, dated 7/15/15, had as a problem, "Dementia with behaviors," a goal was stated as "(Patient) will engage in care conference to discuss Dementia with power of attorney within ten days." This staff intervention was written as a goal statement.

b. For problem, "Agitation/Anxiety," goals were stated as "Will be redirected without physical or verbal aggression on her part 100% of the time when agitated noted to be developing" and "Will engage and participate in cognitive stimulation group activities one time daily on (sic) three times weekly to improve focus and mood as evidenced by group activity notes." These statements were a combination of a staff interventions and patient goals.

3. Patient A9:

a. MTP, dated 7/14/15, had as a problem, "Dementia Alzheimer/Vascular," goals were stated as "(Patient) will complete mini mental status exam with (sic) three (3) days of admission," "(Patient) will engage in family care conference with (unclear word) to discuss dementia within ten days," and "(Patient) will meet with (unclear word) services to complete (unclear word) to return to nursing home prior to discharge." These statements were staff interventions, rather than patient goals.

b. For problem, "PTSD without dissociated symptoms of anxiety," a patient goal was stated as "(Patient) will complete Geriatric Anxiety Scale within three (3) days of admission." This statement was a staff intervention.

Another goal was stated as "Will develop new coping skills to manage anxiety within two (2) days of admission." This goal was non-measurable.

c. For problem, "Delusional disorder, persecutory type," a patient goal was stated as "Will replace maladaptive beliefs, distressing beliefs with accurate beliefs within seven (7) days of admission." This patient goal was non-measurable.

d. For problem, "Depression," a patients goals were stated as" (Patient) will complete Geriatric Depression Scale within three (3) days of admission" and "will engage in socialization group, activity programs to encourage positive social interaction one time daily and three times weekly as evidenced by group activity note." These statements were staff interventions.

Another goal was stated as "Will replace negative belief with positive beliefs within seven (7) days of admission." This goal was non-measurable.

4. Patient A14:

a. MTP, dated 7/14/15, problem, "Bipolar, Manic," a patient goal was stated as "(Patient) will develop one new coping skill (i.e. refocusing) within seven (7) days of admission to address mania." This goal was non-measurable.

Additional goals for this problem were "(Patient) will meet with (unclear word) services to complete Level 2 prior to discharge" and "Will engage in care conference with guardian to discuss Bipolar disorder within 10 days." These statements were staff interventions, rather than patient goals.

b. For problem, "Depress and Insomnia," a patient goal was stated as "(Patient) will complete Beck Depression Inventory II within three (3) days of admission." This statement was a staff strategy.

Another goal was stated as "(Patient) will replace negative beliefs with positive beliefs within seven (7) days of admission." This goal was non-measurable.

c. For problem, "Anxiety" a patient goal was stated as "(Patient) will complete Beck Anxiety Inventory within three (3) days of admission." This statement was a staff strategy.

Another goal was stated as "(Patient) will develop one new coping skill (i.e. deep breathing) to manage anxiety within seven (7) days of admission." This goal was non-measurable.

5. Patient B1:

a. MTP, dated 7/20/15, had as a problem," Bipolar-long history of episodes," a goal was stated as "(Patient) will accept redirection 100% of the time, when behaviors are in evidence, throughout hospitalization." This goal did not correlate with the stated problem.

b. For problem, "Depression," a goal was stated as "(Patient) will complete Beck Depression Inventory within 3 days of admission." This was a staff intervention.

Another goal for this problem was stated as "(Patient) will replace negative beliefs with a positive belief within seven (7) days of admission." This goal was non-measurable.

c. For problem, "Suicidal ideations," a goal was stated as "(Patient) will discuss suicidal ideation, plan, intent within three (3) days of admission." This goal was not evidence that the patient's problem had been reduced or resolved.

6. Patient B2:

MTP, dated7/10/15, problem, "Diagnosis of depression-refusal of medication and care," a goal was stated as "(Patient) will replace negative thoughts with positive thoughts within seven (7) days of admission." This goal was non-measurable.

Another goal was stated as "(Patient) will complete Geriatric Depression Scale within three (3) days of admission." This statement was a staff intervention.

7. Patient B8:

a. MTP, dated 7/6/15 had as a problem, "Alzheimer dementia with delusion and behaviors," a goal was stated as "(Patient) will complete mini mental status exam within three (3) days of admission." This statement was a staff intervention.

Another patient goal was stated as "(Patient) will interact appropriately with staff and peers during socialization group activities at least three (3) times a week." This goal was non-measurable.

b. For problem, "Depression..." a goal was stated as "(Patient) will complete Geriatric Depression Scale within three (3) days of admissions."

Another goal for this problem was stated as "(Patient) will replace negative belief with a positive belief within two (2) days of admission." This statement was a staff intervention.

8. Patient B10:

MTP, dated, 7/7/15, had as a problem, "Bipolar one (1) disorder, mixed episode," a goal was stated as "(Patient) will complete Geriatric Depression Scale within three (3) days of admission." This statement was a staff intervention.

Another goal was stated as "(Patient) will replace negative beliefs feelings (emptiness) with a more positive belief within seven (7) days of admission." This goal was non-measurable.

B. Interview:

During interview with review of treatment plans on 7/21/15 at 1:10 p.m., SW 1 stated that treatment plans need to be patient specific. RN 1 stated that patient goals should be "measurable and directed at the patient's problem."





30490

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 ensure that interventions on the Master Treatment Plans (MTPs) evidenced sufficient individualized planning for eight (8) of eight (8) active sample patients (A4, A6, A9, A14, B1, B2, B8 and B10). Most of the interventions did not include frequency and/or duration. Many of the psychiatric interventions were the same or similar on all patients regardless of each patient's specific problem(s). The nursing interventions and some of the psychology interventions listed routine generic discipline functions, inappropriately written as treatment interventions. In addition, there were no interventions by psychiatrists on any of the MTPs reviewed.

These failures result in a lack of guidance to staff in providing individualized patient treatment that is purposeful and goal directed.

Findings include:

A Record Review

1. Facility policy, No I.C. 39, titled, "Plan of Care Protocol for the Use of the Multidisciplinary Format", revised 5/2015, states: "The multidisciplinary plan of care format includes: treatment interventions that are specific to the objectives, indicate the frequency of provision and discipline/staff responsibility."---"This plan must include interventions specific to stated objectives that include who, how, when and where."

2. Active sample patient A4
The Master Treatment Plan, dated 7/6/15, listed the following problem/symptoms: "Schizophrenia undifferented - observed at previous facility laughing/crying/screaming, non-compliant with medication and care-at-risk for continued behaviors that will negatively affect care and physical well being."

There were only nursing interventions for the above problem - none by physician or social worker.

Nursing intervention - "Direct observation and reporting of behavioral issues. Instruct [name of patient] on inappropriateness of behaviors and offer diversional activity - television, games, conversation with her."

For the problem/symptom of "Diagnosis of dementia possible Alzheimer and depression - history of refusing care and medication, crying and screaming."

The nursing interventions were "medication per order via G-tube (gastrointestinal), check tube placement prior to each medication instillation."

Psychology intervention: "Daily individual therapy with psychology."

Activity Therapy intervention - "Activities staff will encourage [name of patient] to join art groups such as painting and craft."

The interventions above did not include a focus, frequency or duration.

3. Active sample patient A6
The Master Treatment Plan, dated 7/15/15 listed the following problem/symptom: "Dementia with behaviors."

Nursing interventions were: "Medication per order. Encourage medication compliance. If refuses - attempt up to three (3) times for compliance - if still refuses document in medical records." This intervention was a generic routine discipline function that lacked focus, frequency and duration.

There was no physician intervention listed.

For the problem/symptom: "Diagnosis of Agitation/Anxiety."

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate [name of patient] what medication is for and the advantages to him/her of taking same. These interventions were generic discipline functions without frequency or focus.

There were no interventions by physicians and social workers.

Activity therapy interventions were: "Activities staff will encourage [name of patient] engagement in stress management, wellness, and coping skills group activities. These groups lacked focus, frequency and focus."

For the problem/symptom: "Diagnosis of Depression."

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate [name of patient] at his/her level of understanding what medication is for and the consequence to him/her of not taking it in him/her system." The interventions were generic discipline functions without frequency or focus.

All of the nursing interventions listed above were the same or similar regardless of the different problems/diagnoses listed.

4. Active sample patient A9
The Master Treatment Plan, dated 7/14/15, listed the following problem/symptoms: "Diagnosis of dementia Alzheimer/Vascular."

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate what the medication are [sic] for and the importance of his/her disease management. If refuses medication - attempt up to three (3) separate times at approximately 15 minute intervals - if still refuses document in medical records." These interventions were generic discipline functions which lacked focus, frequency and duration.

Psychology intervention: "Individual therapy with psychology to assess cognitive functioning." This is an assessment not a treatment function. It also lacks frequency and duration.

There were no physician interventions for the problem.

For the problem/symptom: "Diagnosis of PTSD [Post-Traumatic Stress Disorder] without dissociated symptoms and anxiety."

The nursing interventions were: "Medication per order. Encourage compliance. Educate on the importance of these medication [sic] and the consequences of not having them in his/her system." These interventions were generic discipline functions which lacked frequency and duration.

Psychology interventions: "Individual therapy with psychology to monitor assess anxiety. Individual therapy with psychology to develop new coping skills." The first intervention is an assessment, not a treatment. Both interventions lack frequency and duration.

There were no physician interventions for this problem.

For the problem/symptom: "Diagnosis of delusional disorder, persecution type."

The nursing interventions were: "Encourage medication compliance. Medication per order. Educate on the importance of the medication and potential consequences of not having them in his/her system." These were generic discipline functions without frequency or duration. The psychology intervention was: "Individual therapy with psychology to monitor and assess maladaptive distressing beliefs." This intervention lacked frequency and focus.

For the problem/symptom: "Diagnosis of depression"

The nursing interventions were: "Medication per order. Encourage medication compliance. If refuses attempt up to three (3) separate times at approximately 15 minute intervals and if still refuses document in medical records for M.D. [doctor]."

The nursing interventions listed above were the same or similar for all three (3) problems listed above.

Psychology interventions were: "Individual therapy with psychology to monitor/assess depression." These interventions lacked frequency and duration. "Individual therapy with psychology replace negative thoughts with positive." These interventions lacked frequency and duration.

There were no physician interventions for the problem listed above.

5. Active sample patient A14
The Master Treatment Plan, dated 7/14/15 had a problem/symptom: "Diagnosis of Bipolar, Manic."

The nursing interventions were: "Medication per order. Encourage medication compliance. If refuses attempt up to three (3) separate times then document continued refusal in medical record." These were routine, generic discipline functions without focus, frequency or duration.

Psychology intervention: "Psychology will assist [name of patient] in developing new coping skills to address mania." This intervention lacked frequency and duration.

Social work intervention: "Social services will contact guardian to schedule care conference." This intervention lacked frequency and duration.

For the problem/symptom: "Diagnosis of depression and insomnia",

The nursing interventions were: "Medication compliance. Educate on what medication is and the consequences of not having in system." These interventions were routine, generic functions which lacked frequency and duration.

Psychology intervention: "Psychology will conduct therapy with [name of patient]." This intervention lacked focus, frequency and duration.

Psychology intervention: "Psychology will conduct therapy with [name of patient] to assist with replacing negative beliefs with positive ones." These interventions were similar to ones for patient A9 above and lacked frequency and duration.

There were no physician interventions for this problem.

For the problem/symptom: "Diagnosis of Anxiety."
The nursing interventions were: "Medication per order. Encourage medication compliance. Educate [name of patient] on what medication is for and the consequences of not taking same. If refuses attempt up to three (3) times at approximately 15 min. intervals." These interventions were routine, generic functions without frequency or duration for most of them.
Psychology interventions were: "Psychology will conduct therapy with [name of patient]. Psychology will assist [name of patient] in developing new coping skills." The first intervention had no focus. Both interventions were generic discipline functions that lacked frequency and duration.

There were no physician interventions for this problem.

6. Active sample patient B1
The MTP, dated 7/20/15, had problem/symptom: "Admission diagnosis of Bipolar - long history of episodes."

The nursing interventions were: "Medication per order. Encourage medication compliance. If refuses medication attempt up to three (3) separate times at approximately 15 minute interval to get him/her to take, - if still refuses document in medical record." These interventions were routine generic functions that lacked focus and frequency.

There were no interventions by the physician.

For the problem/symptom: "Admitting Diagnosis of Depression",

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate on the importance of taking antidepressant medication on a routine basis and the consequences of not doing so." These were generic routine discipline functions with no frequency or duration.

Psychology interventions: "Individual therapy with psychology to monitor/assess depression. Individual therapy with psychology to replace negative beliefs with a positive belief." These interventions lacked frequency and duration.

There was no physician intervention for this problem.

For the problem/symptom: "Admission Diagnosis of agitation",

The nursing interventions were: "Medication per order. Encourage medication compliance." These were routine generic discipline functions with no focus, frequency or duration.

Psychology intervention was: "Individual therapy with psychology to explore issues with agitation." This intervention lacked frequency and duration.

There were no physician interventions for this problem.

For the problem/symptom: "Suicidal Ideation - admitted through ER [emergency room] after going there to indicate s/he was constantly thinking about hurting him/herself, thoughts of hanging him/herself - has actually made attempts in part - stated only thing that stopped him/her was s/he was unsure how to hang him/herself."

Nursing interventions were: "Suicide precaution per order. Re-assess suicide risk each shift, notify M.D. of score for possible reduction in level of precautions. Ask [name of patient] each shift how s/he is feeling - is s/he thinking of suicide, does s/he have a plan, how likely is s/he to attempt same." These were generic, routine interventions which lacked duration..

Psychology intervention: "Individual therapy with psychology to monitor/assess suicidal ideation plan, intent." This intervention lacked frequency and duration.

There were no physician interventions for this problem.

The nursing interventions were the same or similar for all the problems listed above.

7. Active sample patient B2
The MTP, dated 7/10/15, had the problem/symptoms: "Diagnosis of behaviors - intrusive, taking things from other rooms, wandering into other rooms."

The nursing interventions were: "Medication per schedule. Medication compliance. Educate on the consequences of not taking medication per order. Monitor/observe and document behavioral incidents. Re-direct [name of patient] into an appropriate activity when behaviors needed as stated." These were routine, generic discipline interventions without frequency or duration.

Psychology intervention: "Psychology will conduct therapy with [name of patient] to explore issues of agitation. Psychology will complete Cohen-Mansfield agitation inventory through direct care report." The first intervention lacked frequency and duration. The second intervention was a task for the psychiatrist, not a treatment intervention.

There were no physician interventions.

For the problem/symptom: "Diagnosis of Delusions - referred as - believes s/he can [sic] what s/he wishes whenever s/he wishes, crawls into bed with other patient to touch inappropriately or whisper in ear and strokes [opposite sex patient], when interventions attempted screams. 'S/he wants me here---leave me alone'."

The nursing interventions were: "Medication per schedule. Encourage medication compliance. If refuses attempt up to three (3) separate times to get to take - if still refuses document in medical record for M.D." These generic routine discipline interventions lacked focus and duration.

Psychology intervention was: "Psychology will conduct therapy with [name of patient] to monitor/assess thought and beliefs." This intervention lacked frequency and duration.

Social work intervention was: "Social services will check daily log per behavior weekly." This intervention was a task, not a treatment and lacked a focus.

Activity therapy intervention was: "Activities staff will encourage [name of patient] to engage in socialization and activities such as current events." This generic intervention lacked focus, frequency and duration.

There were no physician interventions.

For the problem/symptom: "Diagnosis of depression - refusal of medication and care",

The nursing interventions were: "Medication per schedule. Encourage medication compliance. Attempt up to three (3) separate times if refuses - if still refuses document in medical record for M.D." These generic routine discipline interventions lacked focus and duration.

Psychology interventions: "Psychology will conduct therapy for [name of patient]. Psychology will conduct therapy with [name of patient] to assist in replacing negative thoughts with positive ones." The first generic intervention lacked focus, frequency and duration. The second intervention lacked frequency and duration.

Social work intervention: "Social services will check on behavior log weekly." This intervention was a task not a treatment and lacked focus.

There were no physician interventions.

For the problem/symptom: "Verbal and Physical aggression - reports of refusing care and medication, throwing stuffed animals, shaking fists and threatening to hit staff."

The nursing interventions were: "Medication per schedule. Encourage medication compliance. If refuses attempt up to three (3) separate times at 15 minutes intervals - if still refuses document refusal in medical record for M.D." These generic routine discipline interventions lacked focus and duration.

The psychology interventions were: "Psychology will conduct therapy with [name of patient]. Psychology will compute Cohen-Mansfield agitation inventory with direct care staff." The first generic intervention lacked focus, frequency and duration. The second intervention was a task for the psychologist to complete, not a direct treatment for the patient.

There was no physician intervention.

8. Active sample patient B8
The MTP, dated 7/6/15, had the problem/symptom: "Alzheimer dementia with delusion and behaviors---reported from long term facility - intrusive, sneaking cigarettes in room and smoking when has a roommate on oxygen - state "I got them from a 13 year old" difficult to re-direct refusing medicine and care---at risk for complication from same."

The nursing interventions were: "Medication per order. Encourage medication compliance. If refuses - attempt up to three (3) times for compliance - if still refuses document in medical records. Educate [name of patient] on the consequences of non-compliance with his/her medication." These generic routine discipline interventions lacked focus.

Psychology intervention was: "Psychology to conduct therapy with [name of patient]." This generic intervention lacked focus, frequency and duration.

For the problem/symptom: "Diagnosis of agitation intrusive behavior, refusing medication and care."

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate [name of patient] on the consequence of non-compliance with his/her medication." These generic, routine discipline interventions lacked duration and frequency.

Psychology interventions: "Psychology will conduct therapy with [name of patient] to explore issue with agitation. Psychology will complete Cohen-Mansfield agitation inventory through direct care staff report." The first intervention lacked a focus, frequency and duration. The second was a discipline task, not a treatment modality.

Activity therapy intervention: "Activities staff will encourage [name of patient] to engage in social group such as reminiscence and current events." This generic intervention lacked focus, frequency and duration.

There were no physician interventions on this problem.

For the problem/symptom: "Diagnosis of depression and has been on Cymbalta- currently refuses medication."

The nursing interventions were: "Medication per order. Encourage medication compliance. If refuses - attempt up to three (3) times for compliance - if still refuses document in medical records." These generic routine discipline interventions lacked focus.

Psychology interventions were: "Psychology will conduct therapy with [name of patient]. Psychology will conduct therapy with [name of patient] to replace negative beliefs with positive ones." The first generic intervention lacked focus, frequency and duration. The second intervention which was similar to others on the MTP for different problems, lacked frequency and duration.

There were no physician interventions for the problem listed.

9. Active sample patient B10
The MTP, dated 7/7/15, had a problem/symptoms: "Diagnosis of bipolar 1[one] disorder, mixed episode."

The nursing interventions were: "Medication per order. Encourage medication compliance. If refuses attempt up to three (3) separate times to get to take. Educate [name of patient] on the importance of these medication [sic]." These were routine, generic discipline interventions which lacked focus and duration.

Psychology interventions were: "Individual therapy with psychology to monitor and assess depression and monitor. Individual therapy to replace negative beliefs and develop 1 [one] new coping skill for mania." These interventions lacked frequency and duration.

There were no physician interventions listed for this problem.

For the problem/symptom: "Severe agitation - history of and fear that' s/he will either harm self or another person."

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate on the importance of these medications in his/her system and the consequences to him/her of not taking them." The first 2 interventions were generic routine discipline interventions which lacked a specific focus, frequency or duration. The third lacked frequency and duration.

Psychology interventions were: "Individual therapy with psychology to explore issues with agitation. Completion of Cohen-Mansfield agitation inventory through direct staff report." The first intervention lacked frequency and duration. The second intervention was a task for psychology, not a treatment modality.

For the problem/symptom: "Suicidal ideation - history of self-harm. Attempt in past and now fearful that s/he will attempt again or harm another."

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate on the importance of medication for his/her system. Suicide precaution per order - starting at line of sight. Suicide risk assessment q [every] shift with report or results to M.D., for reduction of level as appropriate." These generic, routine discipline functions did not include frequency or duration and were similar in the nursing interventions for the other problems listed in this MTP.

Psychology intervention was: "Therapy with psychology to assess suicidal ideation and discuss coping skills." The intervention lacked specific frequency and duration.


B. Interviews

1. In an interview on 7/21/15 at 8:30 a.m., the generic routine discipline interventions, which were either the same or similar to most of the other discipline interventions on the eight (8) active sample patients' MTP despite different problems and needs, was discussed with the CEO [Chief Executive Officer]. She had been responsible for the training of clinical staff on treatment plan develop during her role as Nursing Director, prior to promotion as CEO. She did not dispute the findings. "I understand issue. We are still working on it [meaning improving the quality of the MTPs]."

2. In an interview on 7/21/15at 11:12 a.m., the generic nursing interventions on the MTPs was discussed with RN2. She agreed that the nursing interventions were not individualized.

3. During an interview on review of treatment plans on 7/21/15 at 1:10 p.m., RN 1 stated that patient interventions should be patient specific.

4. In an interview on 7/11/15 at 2:50 p.m., the problems of generic, discipline function interventions on the MTPs and the absence of physician interventions was discussed with the Medical Director. He did not dispute the findings. As for the absence of the physician interventions, he stated, "I know how to solve the problem. During daily rounds on the unit with the nurse practitioner, I'll tell her what the [physician] intervention should be and let her do it [put it on the MTP]."







30489

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

Based on record review and interview, the Medical Director failed to monitor and evaluate the quality of care provided to patients. Specifically, the Medical Director failed to:

I. Provide Master Treatment Plans (MTPS) that identified patient goals in measurable, behavioral terms for eight (8) of eight (8) active sample patients (A4, A6, A9, A14, B1, B2, B8 and B10). In addition, many goals were staff interventions or failed to correlate with the stated problem. This failure results in documented goals that fail to identify individualized expected treatment outcomes in a manner that can be utilized by the treatment team to measure individual progress in care. (Refer to B121)

II. Ensure that interventions on the Master Treatment Plans (MTPs) evidenced sufficient individualized planning for eight (8) of eight (8) active sample patients (A4, A6, A9, A14, B1, B2, B8 and B10). Most of the interventions did not include frequency and/or duration. Many of the psychiatric interventions were the same or similar on all patients regardless of each patient's problem(s). The nursing intervention listed routine generic discipline functions, inappropriately written as treatment interventions. In addition, there were no interventions by psychiatrists on any of the MTPs reviewed. These failures result in a lack of guidance to staff in providing individualized patient treatment that is purposeful and goal directed. (Refer to B122)





30489

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 that nursing interventions on the Master Treatment Plans identified sufficient individualized planning for eight (8) of eight (8) active sample patients (A4, A6, A9, A14, B1, B2, B8 and B10). Most of the nursing psychiatric interventions were the same or similar on all patients regardless of each patient's specific problems. The nursing interventions listed routine, generic discipline functions inappropriately written as treatment interventions. This failure results in a lack of guidance for the staff in providing individualized patient treatment that is purposeful and goal directed.

Findings include:

A. Record review

1. Active sample patient A4
The Master Treatment Plan, dated 7/6/15, listed the following problem/symptoms: "Schizophrenia undifferented - observed at previous facility laughing/crying/screaming, non-compliant with medication and care-at-risk for continued behaviors that will negatively affect care and physical wellbeing."

Nursing intervention - "Direct observation and reporting of behavioral issues. Instruct [name of patient] on inappropriateness of behaviors and offer diversional activity - television, games, conversation with her. This generic intervention did not have frequency or duration."

For the problem/symptom of "Diagnosis of dementia possible Alzheimer and depression - history of refusing care and medication, crying and screaming",
The nursing interventions were: "medication per order via G-tube (gastrointestinal), check tube placement prior to each medication instillation."

The interventions above did not include a focus, frequency or duration.

2. Active sample patient A6
The Master Treatment Plan, dated 7/15/15 listed the following problem/symptom: "Dementia with behaviors."

Nursing interventions were: "Medication per order. Encourage medication compliance. If refuses - attempt up to three (3) times for compliance - if still refuses document in medical records." This intervention was a generic routine discipline function that lacked focus, frequency and duration.

For the problem/symptom: "Diagnosis of Agitation/Anxiety",
The nursing interventions were: "Medication per order. Encourage medication compliance. Educate [name of patient] what medication is for and the advantages to him/her of taking same." These interventions were generic discipline functions without frequency or focus.

For the problem/symptom: "Diagnosis of Depression":

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate [name of patient] at his/her level of understanding what medication is for and the consequence to him/her of not taking it in him/her system." The interventions were generic discipline functions without frequency or focus.
All of the nursing interventions listed above were the same or similar regardless of the different problems/ diagnoses listed.

3. Active sample patient A9
The Master Treatment Plan, dated 7/14/15, listed the following problem/symptoms: "Diagnosis of dementia Alzheimer/Vascular".

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate what the medications are [sic] for and the importance of his/her disease management. If refuses medication - attempt up to three (3) separate times at approximately 15 minute intervals - if still refuses document in medical records." These interventions were generic discipline functions which lacked frequency and duration.

For the problem/symptom: "Diagnosis of PTSD [Post-Traumatic Stress Disorder] without dissociated symptoms and anxiety."

The nursing interventions were: "Medication per order. Encourage compliance. Educate on the importance of these medication [sic] and the consequences of not having them in his/her system." These interventions were generic discipline functions which lacked frequency and duration.

For the problem/symptom: "Diagnosis of delusional disorder, persecution type",

The nursing interventions were: "Encourage medication compliance. Medication per order. Educate on the importance of the medication and potential consequences of not having them in his system." These were generic discipline functions without frequency or duration.

For the problem/symptom: "Diagnosis of depression"

The nursing interventions were: "Medication per order. Encourage medication compliance. If refuses attempt up to three (3) separate times at approximately 15 minute intervals and if still refuses document in medical records for M.D. [doctor]."
This is a generic nursing intervention. Note that the nursing interventions listed above were the same or similar for all three (3) problems listed above.

4. Active sample patient A14
The Master Treatment Plan, dated 7/14/15 had a problem/symptom: "Diagnosis of Bipolar, Manic."

The nursing interventions were: "Medication per order. Encourage medication compliance. If refuses attempt up to three (3) separate times then document continued refusal in medical record." These were routine, generic discipline functions without focus, frequency or duration.

For the problem/symptom: "Diagnosis of depression and insomnia,
The nursing interventions were: Medication compliance. Educate on what medication is and the consequences of not having in system." These interventions were routine, generic functions which lacked frequency and duration.

For the problem/symptom: "Diagnosis of Anxiety."

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate [name of patient] on what medication is for and the consequences of not taking same. If refuses attempt up to three (3) times at approximately 15 min. intervals." These interventions were routine, generic functions without frequency or duration for most of them.

5. Active sample patient B1
The MTP, dated 7/20/15, had problem/symptom: "Admission diagnosis of Bipolar - long history of episodes."

The nursing interventions were: "Medication per order. Encourage medication compliance. If refuses medication attempt up to three (3) separate times at approximately 15 minute interval to get him/her to take, - if still refuses document in medical record." These interventions were routine generic functions that lacked focus and duration..

For the problem/symptom: "Admitting Diagnosis of Depression",

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate on the importance of taking antidepressant medication on a routine basis and the consequences of not doing so." These were generic routine discipline functions with no frequency or duration.

For the problem/symptom: "Admission Diagnosis of Agitation",
The nursing interventions were: "Medication per order. Encourage medication compliance." These were routine generic discipline functions with no focus, frequency or duration.

For the problem/symptom: "Suicidal Ideation - admitted through ER [emergency room] after going there to indicate s/he was constantly thinking about hurting him/herself, thoughts of hanging him/herself - has actually made attempts in part - stated only thing that stopped him/her was s/he was unsure how to hang him/herself."

Nursing interventions were: "Suicide precaution per order. Re-assess suicide risk each shift, notify M.D. of score for possible reduction in level of precautions. Ask [name of patient] each shift how s/he is feeling - is s/he thinking of suicide, does s/he have a plan, how likely is s/he to attempt same." These were generic, routine interventions which lacked duration.

6. Active sample patient B2
The MTP, dated 7/10/15, had the problem/symptoms: "Diagnosis of behaviors - intrusive, taking things from other rooms, wandering into other rooms."

The nursing interventions were: "Medication per schedule. Medication compliance. Educate on the consequences of not taking medication per order. Monitor/observe and document behavioral incidents. Re-direct [name of patient] into an appropriate activity when behaviors needed as stated." These were routine, generic discipline interventions without frequency or duration.

For the problem/symptom: "Diagnosis of Delusions - referred as - believes s/he can [sic] what s/he wishes whenever s/he wishes, craws into bed with other patient to touch inappropriately or whisper in ear and strokes (opposite sex of patient, when interventions attempted screams. 'S/he wants me here --- leave me alone'."

The nursing interventions were: "Medication per schedule. Encourage medication compliance. If refuses attempt up to three (3) separate times to get to take - if still refuses document in medical record for M.D." These generic routine discipline interventions lacked focus and duration.

For the problem/symptom: "Diagnosis of depression - refusal of medication and care",
The nursing interventions were: "Medication per schedule. Encourage medication compliance. If refuses attempt up to three (3) separate times to get to take - if still refuses document in medical record for M.D." These generic routine discipline interventions lacked focus and duration.

For the problem/symptom: "Verbal and physical aggression - reports of refusing care and medication, throwing stuffed animals, shaking fists and threatening to hit staff."

The nursing interventions were: "Medication per schedule. Encourage medication compliance. If refuses attempt up to three (3) separate times to get to take - if still refuses document in medical record for M.D." These generic routine discipline interventions lacked focus and duration.

7. Active sample patient B8
The MTP, dated 7/6/15, had the problem/symptom: "Alzheimer dementia with delusion and behaviors---reported from long term facility - intrusive, sneaking cigarettes in room and smoking when has a roommate on oxygen - state "I got them from a 13 year old" difficult to re-direct refusing medicine and care --- at risk for complication from same."

The nursing interventions were: "Medication per order. Encourage medication compliance. If refuses - attempt up to three (3) times for compliance - if still refuses document in medical records. Educate [name of patient] on the consequences of non-compliance with his/her medication." These generic routine discipline interventions lacked focus.

For the problem/symptom: "Diagnosis of agitation intrusive behavior, refusing medication and care."

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate [name of patient] on the consequence of non-compliance with his/her medication." These generic, routine discipline interventions lacked duration and frequency.

For the problem/symptom: "Diagnosis of depression and has been on Cymbalta and currently refuses medication."

The nursing interventions were: "Medication per order. Encourage medication compliance. If refuses - attempt up to three (3) times for compliance - if still refuses document in medical records." These generic routine discipline interventions lacked focus.

8. Active sample patient B10
The MTP, dated 7/7/15, had a problem/symptoms: "Diagnosis of bipolar 1[one] disorder, mixed episode."

The nursing interventions were: "Medication per order. Encourage medication compliance. If refuses attempt up to three (3) separate times to get to take. Educate [name of patient] on the importance of these medication [sic]." These were routine, generic discipline interventions which lacked focus, frequency and duration.

For the problem/symptom: "Severe agitation - history of and fear that s/he will either harm self or another person."

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate on the importance of these medications in his/her system and the consequences to him/her of not taking them." These generic routine discipline interventions lacked a specific frequency or duration.

For the problem/symptom: "Suicidal ideation - history of self-harm. Attempts in past and now fearful that s/he will attempt again or harm another."

The nursing interventions were: "Medication per order. Encourage medication compliance. Educate on the importance of medication for his/her system. Suicide precaution pre order - starting at line of sight. Suicide risk assessment q [every] shift with report or results to M.D., for reduction of level as appropriate." These generic, routine discipline functions did not include frequency or duration and were similar in the nursing interventions for the other problems listed in this MTP.


B. Interview

1. In an interview on 7/21/15at 11:12 a.m., the generic nursing interventions on the MTPs was discussed with RN2. She agreed that the nursing interventions were not individualized.

2. During an interview on review of treatment plans on 7/21/15 at 1:10 p.m., RN 1 stated that patient interventions should be patient specific.







30490

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."