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Based on document review and interview, it was determined that for 2 of 4 (Pt #1 and Pt #11) clinical records reviewed for psychoactive medications, the Hospital failed to ensure the patients' consents for psychoactive medications were obtained prior to administration per policy.

Findings include:

1. The Hospital's policy entitled "Informed Consent for Medication" (effective 11/2014) was reviewed on 8/15/17 and required, "...Informed consent for the administration of psychoactive medication will be evidenced by a copy of the Consent for Treatment with Psychoactive Medication form executed by the patient...or his legal authorized representative. This signed form will be retained in the medical record...Psychoactive medications may not be administered to a patient admitted under the voluntary or involuntary status without informed consent or court order..."

2. The clinical record for Pt #1 was reviewed on 8/15/17 at approximately 10:40 AM. Pt. #1 was a 45 year old male admitted on 8/6/17 with a diagnosis of schizoaffective disorder, bipolar type. The physicians' orders dated 8/5/17 included the following psychoactive medications: Paxil 40 mg (anti-depressive) PO (by mouth) every morning; Trazadone 100 mg (anti-depressive) PO at bedtime; Seroquel 600 mg (anti-depressive) mg PO at bedtime. The physicians' orders dated 8/6/17 included the following psychoactive medications: Cogentin 1 mg (anti-tremor) PO twice a day and every 4 hours as needed; Ativan 1 mg (anti-anxiety) PO every 4 hours as needed; Haldol 5 mg (anti-psychotic) PO every 4 hours as needed; and Zyprexa 10 mg (anti-psychotic) PO every 6 hours as needed. Pt. #1 had received the psychoactive medications as ordered from 8/5/17 through 8/15/17. However, Pt #1's clinical record lacked consent for treatment with psychoactive medications.

3. The clinical record for Pt. #11 was reviewed on 8/15/17, at approximately 10:45 AM. Pt. #11 was a 36 year old male admitted on 8/5/17 with a diagnosis of schizoaffective disorder. The physician's order dated 8/8/17 included Risperidone 2 mg (anti-psychotic) PO at bedtime. Pt. #11 received the medication on 8/8/17 and 8/9/17 as ordered. However, Pt. #11's clinical record lacked a consent for treatment with psychoactive medication, Risperidone.

4. During an interview with the Assistant Director of Nursing (E #3) on 8/8/17 at approximately 8:50 AM. E #3 stated that the psychoactive medication consent form should have included the Risperidone.

5. During an interview with a Registered Nurse (RN-E #2) on 8/15/17 at approximately 10:45 AM, E #2 stated that the consent for psychoactive medications should have been completed for Pt. #1 and maintained in Pt. #1's clinical record.

Based on document review and interview, it was determined that for 2 of 4 (Pt #7 and 8) clinical records on the 1 North Geriatric Unit and 1 of 3 clincial records reviewed (Pt. #11) in the Transitional Care Unit (TCU), the Hospital failed to ensure the patients were monitored every 15 minutes, as required by policy.

Findings include:

1. The Hospital policy entitled, "Precaution: Suicide," (effective date: November 2014) required, "...B. Unit Staff...5. Documents every 15 minutes on the Observation Sheet the patient's whereabouts and what the patient is doing."

2. The Hospital policy entitled, "Observation Levels," (effective date: November 2014) required, "...II. Procedures...9. Special Precaution Levels and protocol guidelines that may be ordered include...5. A Patient Rounds Sheet,which reflects the patient's location and observed behaviors every 15 minutes, is maintained..."

3. The clinical record of Pt #7 was reviewed on 8/15/17 at approximately 10:30 AM. Pt #7 was a 70 year old male admitted to the 1 North Geriatric Unit on 8/5/17 with a diagnosis of major depressive disorder. Pt #7's clinical record contained a physician's order dated 8/5/17 that required Pt #7 be monitored for close observation, suicide precautions, and fall precautions. Pt #7's safety precautions record dated 8/14/17 failed to include the required 15 minute checks for 11:30 PM and 11:45 PM.

4. The clinical record of Pt #8 was reviewed on 8/15/17 at approximately 10:35 AM. Pt #8 was a 55 year old male admitted to the 1 North Geratric Unit on 8/7/17 with a diagnosis of major depressive disorder. Pt #8's clinical record contained a physician's order dated 8/7/17 that required Pt #8 be monitored for close observation, suicide precautions, and fall precautions. Pt #7's safety precautions record dated 8/14/17 failed to include the required 15 minute checks for 11:30 PM and 11:45 PM.

5. The clinical record for Pt. #11 was reviewed on 8/15/17. Pt. #11 was a 36 year old male admitted to TCU on 8/5/17 with diagnosis of schizoaffective disorder. The admission order dated 8/5/17 included close observation precautions, self-harm and assaultive precaution. The every 15 minute observation documentation dated 8/14/17 lacked documentation of every 15 minute observation for 3:30 PM and 3:45 PM.

6. The above findings were discussed with the Assistant Director of Nursing (E #3), during an interview on 8/15/17, at approximately 10:45 AM. E #3 stated that staff should perform safety precaution rounds and document on the patients every 15 minutes.

7. During an interview on 8/15/17 at approximately 11:00 AM, a Registered Nurse/Supervisor from the TCU (Transitional Care Unit) stated that the patients should have been monitored every 15 minutes.

Based on document review and interview, it was determined that for 1 of 2 (Pt #9) clinical records reviewed for diabetic monitoring, the Hospital failed to ensure the physicians' orders were followed as written.

Findings include:

1. The clinical record of Pt #9 was reviewed on 8/15/17 at approximately 10:40 AM. Pt #9 was a 70 year old female admitted on 8/8/17, with a diagnosis of major depressive disorder. Pt #9's clinical record contained a physician's order dated 8/8/17 that required Accucheck (blood sugar monitoring) before meals and at bed time with a sliding scale insulin and to notify the physician if outside parameters, below 80 or above 300. Pt #9's blood sugar at 8:00 PM was documented as 348. Pt #9's clinical record lacked documentation that the physician was notified as required. On 8/14/17 at 6:20 AM, Pt #9's blood sugar was documented as 290. There was no documentation that Pt #9 received the required 6 units of insulin. At 8:00 PM, Pt #9's blood sugar was 334, and the clinical record lacked documentation that the physician was notified, as required.

2. During an interview on 8/15/17 at approximately 11:00 AM, a Registered Nurse/Supervisor from the TCU (Transitional Care Unit) stated that the record lacked documentation of the insulin being administered and the physician having been notified as required.

Based on interview and document review, it was determined that the Hospital failed to ensure all medical records were completed within 30 days of patient discharge.

Findings include:

1. The Interim Director of Health Information Management (HIM E #3) was interviewed on 8/16/17, at approximately 10:30 AM. E #3 stated that she notifies the physicians of any record that needs completing, and that the number of delinquent records has reduced over the year.

2. The Hospital Medical Staff Bylaws Rules and Regulation (rev 12/1/16) required, "Chapter VI ...Routine Discharge Procedures: The Discharge Summary is to be completed within 15 days of discharge. At 30 days post discharge summary not completed will be considered delinquent."

3. The Director of HIM E #9) provided an attestation letter on 8/16/17 at approximately 1:15 PM, which indicated that as of 8/16/17, there were 13 delinquent medical records.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on August 15 & 16, 2017, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on August 15 & 16, 2017, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated August 16, 2017.

Based on document review and interview, it was determined that the Hospital failed to ensure staff training was conducted regarding organ, tissue and eye procurement, potentially affecting 113 patients on census on 8/16/17.

Findings include:

1. On 8/16/17 at 2:05 PM, the Policy titled "Organ Procurement", effective November 2014, was reviewed. The Organ Procurement Policy failed to include staff education must be provided regarding the role of the organ/ tissue procurement organization, transplantation, and donation issues.

2. On 8/16/17 at 2:10 PM, the "Organ and Tissue Procurement Agreement", dated 3/1/15, was reviewed. The Agreement required, "Responsibilities of Gift of Hope (2.5) Training of Hospital Personnel... [includes] Gift of Hope shall conduct periodic education programs for administrative and professional at Hospital regarding the referral and maintenance of Potential Donors if requested..."

3. On 8/16/17 at 2:15 PM, an interview was conducted with the Chief Nursing Officer (E #6). E #6 stated, "I don't believe we do staff training on organ procurement."

Based on observation, record review, and staff interview, the facility failed to ensure that a physician provided consistent supervision and direction of each patient's treatment. Physicians failed to provide direct oversight of treatment planning, reviews and updates. Without consistent onsite supervision and direction of each patient's treatment, patients' recovery may be compromised, potentially delaying their timely discharge. (Refer to B99)

Based on observation, record review, and staff interview, the facility failed to ensure that the treatment planning, reviews and updates were under the direction and supervision of a psychiatrist. Without consistent onsite supervision and direction of each patient's treatment, patients' recovery may be compromised, potentially delaying their timely discharge.

Findings include:

A. Observation:
Treatment team/planning meetings were held daily, five (5) days a week on all six (6) units. The facility uses sign in sheets for members present at the team meetings. During observations of treatment team meetings on 4N on 8/16/17 at 9:30a.m., on 2W on 8/17/17 at 9:30a.m., and on 3S/N on 8/17/17 at 8:45a.m., it was noted no MD's were present in these 3 meetings. Only social work staff, nursing, utilization management and activity staff were present in these meetings. At the Unit 4N treatment team meeting on 8/16/17, the staff was asked why patient A10's diagnosis of "THC[marijuana] use disorder, the problems (SI [Suicidal Ideation] and Depression) identified in the Psychiatric Evaluation or high risk behaviors identified in the Psychosocial Assessment were not being addressed in the master treatment plan [MTP]. The staff was not able to answer as to the reason for not addressing these issues in the MTP.

B. Record review:

The sign in sheets titled, "Treatment Team Attendance Sheet" used to track staff attendance at the treatment review meetings between 8/3/17 to 8/17/17 showing psychiatrists' attendance was requested. Staff could only provide sign in sheets between 8/14/17 and 8/17/17, and the senior vice president for operations stated "I cannot produce other sign in sheets for MDs." Review of these copies indicated that only in five (5) of the meetings for the whole facility did MDs participate in treatment review meetings (five (5) daily meetings per week in each of the six (6) units). The hospital Medical Staff Rules and Regulations under Chapter VII, Medical Records, #3 stated "The physician attends the weekly treatment plan meetings and signs MTP." The job description for the Director of Clinical Services under Clinical Leadership #2 stated "Ensure interdisciplinary treatment planning is organized with participation of all appropriate clinical disciplines."

Currently, the Director of Social Services was also the Director of Clinical Services.


C. Staff interview:

At the treatment team meeting at 9:45a.m. on 8/17/17 SW1 was asked about the process of MTPs. The staff stated that on the next day of hospitalization, after the morning team meeting, social work staff starts writing the MTP sections for physicians, social work and activity therapy staff and gets their signature later. The writing of the treatment plan occurs after review of the psychosocial and psychiatric evaluations. The SW I also reported that "the nurses write their own MTP additions related to medical problems." When asked if the MDs attend these meetings, the staff stated, "maybe twice a week."

Based on Observation, Record review, policy review and staff interview, the facility failed to:

I. Ensure that treatment planning, reviews and updates were under the direction and supervision of a psychiatrist. Without consistent onsite supervision and direction of each patient's treatment, patients' recovery may be compromised, potentially delaying their timely discharge. (Refer to B99)

II. Ensure that Psychosocial Assessments for 10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10) addressed high risk behaviors requiring early interventions, social work recommendations concerning anticipated necessary steps to be taken for discharge and anticipated social work role in treatment and discharge planning. (Refer to B108)

III. Ensure that psychiatric evaluations included an inventory of patient's personal assets in descriptive, non-interpretative fashion for 6 of 10 active sample patients (A1, A2, A3, A4, A6, and A7). (Refer to B117)

IV. Ensure that Master Treatment Plans (MTPs) were based on an inventory of strengths that reflected each patient's specific assets or personal attributes that could be used to formulate treatment goals and active treatment interventions for 9 of 10 active sample patients (A1, A2, A4, A5, A6, A7, A8, A9, and A10). In addition, there was a failure to include clearly defined and individualized problem statements written in behavioral and descriptive terms for 9 of 10 active sample patients (A1, A2, A3, A4, A6, A7, A8, A9, and A10). (Refer to B119)

V. Ensure that Master Treatment Plans (MTP) identified patient-centered short-term goals stated in observable, measurable, behavioral terms for 10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10). (Refer to B121)

VI. Ensure that Master Treatment Plans (MTPs) delineated active treatment interventions to address the specific treatment needs of 10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, and A10). (Refer to B122)

VII. Ensure that registered nurses and social workers adequately documented active treatment interventions listed on the Master Treatment Plan and unit schedule to show detailed and comprehensive information about treatment for five (5) of 10 active sample patients (A1, A3, A4, A6, and A7).(Refer to B124)

VIII. Ensure that (A) active treatment measures were provided for two (2) of 10 active sample patients (A1 and A4) who were unwilling or not motivated to attend or participate in active treatment groups or that their treatment plans are revised as appropriate. (Refer to B125-I) and (B) Ensure that patients attended the scheduled active treatment groups on the Geriatric and Transitional Unit (2 North and 2 South). Specifically, the facility expected all patients to attend the group treatment program, however, fewer than half the assigned patients attending these groups. (Refer to B125 II)

IX. Ensure that discharge summaries for three (3) (D1, D2 and D5) of 5 sample of discharged patients, the hospital failed to ensure that the discharge summaries recapitulate patients' course of hospitalization in a sufficiently descriptive manner. (Refer to B133)

Based on record review, policy review and staff interview the facility failed to ensure that the Psychosocial Assessment for 10 of 10 active sample patients [A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10] included: 1) an evaluation or necessary recommendations of high risk psychosocial issues requiring early treatment planning and intervention; 2) recommendations concerning anticipated necessary steps to be taken for discharge to occur; and 3) anticipated Social Work roles in treatment and discharge planning. The social work roles or recommendations identified in the psychosocial evaluations were not present, generic and/or not related to presenting problems. As a result, critical patients' psychosocial and discharge information necessary for informed treatment planning decisions was not available to the treatment team.

Findings include:

A. Record Review:

1. Patient A1 was admitted for "HI (homicidal ideation) to parents". Psychosocial Assessment completed on 8/4/17 indicates "Patient unable to return home." Anticipated social work role as noted in the assessment was "Patient's goal for discharge are decrease in homicidal ideation and psychosis and mood stabilization. Patient's treatment needs are individual therapy and medication management." Unclear social work role or focus for treatment or discharge planning for this patient.

2. Patient A2, 86-year-old, was admitted with diagnosis of "major depression with suicidal ideations and alcohol dependence." Psychosocial Assessment completed on 8/13/17 states "Due to several inconsistencies Therapist has concerns with patient's memory especially placement concerns. Pt reports [he/she] hopes to work on medication regulation and finding coping skills to address his/her symptoms." Unclear social work role or focus for treatment or discharge planning.

3. Patient A3 was admitted with a diagnosis of "bipolar one (1) disorder, manic with psychotic features." Psychosocial Assessment completed on 7/31/17 indicates social work role as "Therapist will begin work on treatment plan with pt. Therapist will also work on discharge planning." Unclear social work role or focus for treatment or discharge planning.

4. Patient A4, per Psychosocial Assessment completed on 8/3/17,"admitted due to crashing car near pedestrians. Pt. also eloped from ER and overdosed on pills." Stated social work role was "Therapist will begin to work on aftercare plans. Therapist will also work on treatment plan with pt." Unclear social work role or focus for treatment or discharge planning.

5. Patient A5, per Psychosocial Assessment completed on 8/10/17,"admitted due to increased feelings of depression, suicidal ideations and social anxiety." Stated social work role is "Goals for discharge include mood stabilization and decreased suicidal ideations. Treatment will include individual therapy, group therapy and medication management." Unclear social work role or focus of treatment or discharge planning.

6. Patient A6 admitted with a diagnosis of "Methamphetamine induced Psychosis." Psychosocial Assessment completed on 8/2/17 states "Goals for discharge: Reduce psychosis, and mood stabilization. Treatment needs: Individual and group therapy, medication management". "Patient will continue with outpatient providers when stable for discharge." Unclear social work role or focus for of treatment or discharge planning for this patient.

7. Patient A7, per Psychosocial Assessment completed on 8/1/17 "Pt. was arrested due to public masturbation and stating, "I am suicidal like a mother fucker." "Patient currently homeless." Stated social work role is "Therapist will work on treatment plan with pt. Therapist will also contact thresholds and work on discharge planning." Unclear social work role or focus for treatment or discharge planning.

8. Patient A8, per Psychosocial Assessment completed on 8/9/17 "admitted due to expressing thoughts of overdosing on pills." Stated social work role is "Therapist will begin to work on treatment plan. Therapist will also work on aftercare planning." Unclear social work role or focus for treatment or discharge planning.

9. Patient A9, per Psychosocial Assessment completed on 8/10/17, "Patient admitted to inpatient treatment due to auditory hallucinations, delusions and paranoia, and being verbally aggressive with ED staff and police." Goals for discharge: "Reduce aggression, reduce psychosis, and mood stabilization." Treatment needs: Individual and group therapy, medication management." Unclear social work role or focus for treatment or discharge planning for this patient.

10. Patient A10 admitted with a diagnosis of "MDD (Major Depressive Disorder) Severe, THC (marijuana) use disorder". The Psychosocial Assessment completed on 8/9/17, "admitted for suicidal ideation with plan," "Reports living at home," "I just can't live there," "Patient reported [he/she] sells marijuana to support [her/him] self," "endorsed accepting money, gifts of favor in exchange for sexual acts." "Goals for discharge: Mood stabilization, decrease in suicidal ideation and increase in ability to cope with stressors. Patient will participate in individual therapy, group therapy and medication management." Unclear social work role for this patient in relation to presenting problems, including high risk behaviors and discharge planning.

B. Policy review:

The facility "Psychosocial" policy issued on November 2014, under II Procedure: 1 b states "Substance use.... if positive then a full CD (chemical dependency) Assessment will be completed." The policy makes no mention of needed conclusions and recommendations including social work role related to high risk behaviors and anticipated social work role(s) in treatment and discharge planning.

C. Staff interview:

In a meeting with the Director of Social Services on 8/16/17 at 2:45p.m., and a review of the above deficiencies stated, "I understand."

Based on record review, staff interview and policy review, it was determined that the psychiatric evaluations failed to include an inventory of patient's personal assets in descriptive, non-interpretative fashion for six (6) of 10 active sample patients (A1, A2, A3, A4, A6 and A7). This deficiency results in lack of necessary information to guide staff in developing a plan of treatment for the patient.

Findings include:

A. Record review

1. Psychiatric evaluation of patient A1, dated 8/3/17 listed for strengths: "has some support. No drug use, Good."

2. Psychiatric evaluation of patient A2, dated 8/11/17 listed for strengths: "Access to health care - supportive family."

3. Psychiatric evaluation of patient A3, dated 7/28/17 listed for strengths: "fair physical condition, has access to healthcare, has housing."

4. Psychiatric evaluation of patient A4 dated 8/2/17 listed for strengths: "mobile, reports has housing, has access to health care."

5. Psychiatric evaluation of patient A6, dated 7/31/17 listed for strengths: "[he/she] believes s/he is kind, [he/she] believes that [he/she] is intelligent, [he/she] can love other."

6. Psychiatric evaluation of patient A7, dated 7/31/17 listed for strengths: "Physical health, prior history of function (sic), verbal."

B. Staff interview

In a meeting and a review of a sample of the above psychiatric evaluation deficiencies with the Clinical Director on 8/16/17 at 3:00 p.m., the Clinical Director agreed with the above deficiencies.

C. Policy review

Regarding Psychiatric Evaluation requirements the hospital Medical Staff Rules and Regulations, under Chapter VII, Medical Records, Medical Record Entries: stated "Documentation by physicians shall adhere to the hospital's policies and procedures, standards of the Joint Commission, CMS and State of Illinois."

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) were based on an inventory of strengths that reflected each patient's specific assets or personal attributes that could be used to formulate treatment goals and active treatment interventions for nine (9) of 10 active sample patients (A1, A2, A4, A5, A6, A7, A8, A9, and A10). In addition, there was failure to include clearly defined and individualize problem statements written in behavioral and descriptive terms for nine (9) of 10 active sample patients (A1, A2, A3, A4, A6, A7, A8, A9, and A10). The failure to identify patient strengths and behaviorally descriptive problems can adversely affect clinical decision-making in formulating MTPs and impairs the treatment team's ability to formulate goals and results in treatment plans that are not individualized to patients' unique presenting psychiatric problems.

Findings include:

A. Record review

1. Patient A1's MTP, dated 8/4/17, included the following deficient patient strengths and psychiatric problem statements:

Strengths: "Support system, access to health care, outpatient." These strengths were not descriptions of this patient's personal attributes, skills, or accomplishments that could be used to plan active treatment interventions.

Problem Statement: "Danger to others - As Evidenced by: Patient was admitted to hospital due to homicidal ideation. Patient was stating 'it's your time to go.' Patient has been non-compliant with medications." This problem statement failed to include clear descriptive information about the patient's homicidal ideations and non-compliance with medications including the type of medications. The psychiatric evaluation dated 8/3/17 reported, "... pt. [patient] has been noncompliant w/meds [with/medications] for past years ... [S/he] lives w/ [with] [his/her] parents, has been threatening...threatening to harm them...irritable, restless, [with] poor sleep..."

2. Patient A2's MTP, dated 8/13/17, included the following deficient strength and psychiatric problem statements:

Strength: "Family support." This was the only strength listed. There was no inventory of strengths that would help in treatment planning such as previous helpful experiences during hospitalization, education level, talent, skills, etc. The asset listed was vague and failed to identify how family support would be helpful in treating the patient.

Problem statement: "Danger to self - As Evidenced by: Patient reported that [s/he] wanted to 'wrap [his/her] car around a pole.'" This problem statement failed to include clear descriptive information about this patient's current level and intent of suicide and was not inclusive of assessment information reported in the psychiatric evaluation dated 8/11/17: "Pt's [Patient's] daughter stated that the patient exhibits severe aggression & violence, pt. [patient] threw lamp toward her... abuses alcohol & very dependent, sometimes experiences withdrawal along with depression..."

3. Patient A3's MTP, dated 8/13/17, included the following deficient psychiatric problem statements:

Problem statement: "Danger to self - As Evidenced by: Patient presents with flight of ideas and visual hallucinations. Pt. reported that [s/he] is noncompliant with medication." This problem statement failed to include clear descriptive information about this patient's visual hallucinations that included the content of hallucinations and how they affect the patient. Also, there was no descriptive information about how long the patient had been noncompliant with medications and what medications were involved.

4. Patient A4's MTP, dated 8/13/17, included the following deficient strength and psychiatric problem statements:

Strength: "Access to healthcare." This listed strength was not related to the patient's personal attributes, education level, talent, or skills.

Problem statement: "Danger to self and others - As Evidenced by: "Patient was admitted to due to crashing car near pedestrians. Pt. [Patient] also eloped from ER and overdosed on pills." This problem statement failed to include clear descriptive information about this patient's current level and intent of aggression behavior. Also, there was no descriptive information about the overdose of pills (type, amount, date occurred, etc.).

5. Patient A5's MTP, dated 8/11/17, included the following deficient strength and psychiatric problem statements:

Strength: "Outpt [Outpatient] providers." This listed strength was not a personal attribute, education level, talent, interest or skills that could be used in formulating active treatment interventions for the patient while hospitalized.

6. Patient A6's MTP, dated 7/31/17, included the following deficient strength and psychiatric problem statements:

Strength: "access to healthcare." This was the only strength listed. There was no inventory of strengths that would help in treatment planning such as personal attributes, interests, talent, skills, etc. The asset listed was vague and failed to identify how having access to healthcare would be helpful in providing care during the patient's hospitalization.

Problem statement: "Danger to self and others - As Evidenced by: Paranoia. Command auditory hallucinations, visual hallucinations. Delusional thoughts. Mania, confused, and disorganized." This problem statement failed to include clear descriptive information about this patient's precisely manifested the psychiatric symptoms. There were no descriptive information command auditory and visual hallucinations that included the content of these hallucinations and how they affect the patient. Also, there was no descriptive information about this patient delusional thoughts and mania.

7. Patient A7's MTP, dated 8/1/17, included the following deficient strength and psychiatric problem statements:

Strengths: "access to care, Support network." These listed strengths were not personal attributes, skills, interest or talents of the patient that could help with treatment during the patient's hospital stay. The asset listed was vague and failed to identify how having access to care and support network would be helpful in providing care during the patient's hospitalization.

Problem statement: "Danger to self - As Evidenced by: Patient stated, 'I'm suicidal like a mother fucker." This problem statement failed to include clear descriptive information about this patient's current level and intent of suicide and was not inclusive of assessment information in the psychiatric evaluation dated 7/31/17 reported, " ... admitted due to disruptive and bizarre behavior. [He/she] was taken to ER by police for public masturbation. Pt's mood has been labile. [He/she] can't sleep, has poor focus, poor judgment, impulsivity, poor appetite, wt. loss of 10-15 pounds in 2 months, irritable mood. Clearly agitated."

8. Patient A8's MTP, dated 8/13/17, included the following deficient strength and psychiatric problem statements:

Strengths: "Motivated, Support from friends." These listed strengths were vague and failed to describe what the patient was motivated to do or how support from friends would be helpful in providing psychiatric treatment during the patient's hospital stay.

Problem statement: "Danger to self - As Evidenced by: expressing 'I am going to take all of these pills.' Pt. [Patient] has a plan to overdose on [his/her] medication." This problem statement failed to include clear descriptive information about this patient's current level and intent of suicidal behavior. Also, there was no descriptive information about the overdose of pills (type, amount, when the overdose would occur, etc.).

9. Patient A9's MTP, dated 8/8/17, included the following deficient strength and psychiatric problem statements:

Strengths: "support system, access to healthcare." These were the only strengths listed. There was no inventory of strengths that would help in treatment planning such as personal attributes, interests, talent, skills, etc. The asset listed was vague and failed to identify how having a support system and access to healthcare would be helpful in providing care during the patient's hospitalization.

Problem statement #1: "Danger to others and self - As Evidenced by: Verbal aggressive with ED staff and police ... Delusions and paranoia...disorganized....Flight of ideas." This problem statement failed to include clear descriptive information about how this patient precisely manifested the psychiatric symptoms identified. There was no descriptive information about the extent of the patient's aggression, the content of his/her delusions and paranoia, or how these symptoms affected the patient's behavior.

10. Patient A10's MTP, dated 8/9/17, included the following deficient strength and psychiatric problem statements:

Strengths: "access to healthcare, placement, education." These were the only strengths listed. There was no inventory of strengths that would help in treatment planning such as personal attributes, interests, talent, skills, etc. The asset listed was vague, did not identify the patient's level of education, and failed to describe how access to health care and placement would be helpful in providing care during the patient's hospitalization.

Problem statement #1: "Danger to others and self - As Evidenced by: Patient endorsed suicidal ideation with plan to jump in front of a train. Patient reported financial stressors, poor support system ... peer relationships." This problem statement was vague and failed to include clear descriptive information about this patient's current level of suicide and precisely how s/he manifested the identified problems of financial stressor, poor support system, and peer relationships.

B. Interviews

1. In an interview on 8/16/17 at 12:20 p.m. with the Director of Clinical Services/Social Work and Director of Quality Improvement, the strengths and problem statements on treatment plan were discussed. They did not dispute the findings that strengths did not include personal attributes of the patient and that problem statements were not descriptive of each patient's presenting symptoms.

2. In an interview on 8/16/17 at 3:00 p.m. with the Clinical Director and review of a sample of the above deficiencies, the Director acknowledged the above deficiencies and stated, "Agree with the deficiencies cited."

3. In an interview on 8/16/17 at 2:45 p.m., with the Director of Nursing, the preprinted form with the problems of "Assaultive/Homicidal, SAO [Sexual Acting Out], Elopement, and Arson" that was completed by registered nurses was discussed. He acknowledged that problem statements on the MTP did not have unique descriptors for each patient.

Based on Record review, Policy review and Staff interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered short-term goals stated in observable, measurable, behavioral terms for 10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10). Instead, the goals were either very similar for all patients in spite of different diagnoses and presentations; no goals were identified for some of the problems identified. This lack of patient specific goals hampers the treatment team's ability to assess changes in patient's condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient's needs.

Findings include:

A. Medical Record Review:

1. Patient A1 admitted to the facility on 8/2/17 with a history of homicidal ideations and a diagnosis of Schizophrenia. MTP [Master Treatment Plan]: for the Problem#1: "Danger to others" identified the following Short-Term Goal [STG]: "Patient will utilize adaptive strategies to cope with intense emotions without the presence of homicidal ideation". Problem#2, "Assaultive /Homicidal", had no STG.

2. Patient A2 admitted to the facility on 8/11/17 with a history depression and suicidal ideations and a diagnosis of MDD recurrent and Alcohol dependence. MTP: for the Problem#1: "Danger to self" had the following Short Term Goal [STG]: "Patient will learn adaptive strategies to cope with intense emotions without maladaptive behaviors". Problem #2, "Assaultive /Homicidal", had no STG. Problem #3: "Relapse on Chemical Dependency", STG: "Pt. will recognize relationship between undesirable consequences related to non-compliance with treatment".

3. Patient A3 admitted to the facility on 7/28/17 with a history of flight of ideas, visual hallucinations, paranoid thoughts, poor sleep, and a diagnosis of Bipolar 1 Disorder. MTP: for the Problem#1: "Danger to self" had the following Short Term Goal [STG]: "Patient will learn adaptive strategies to cope with intense emotions without maladaptive behaviors". Problem#2: "Assaultive/Homicidal", had no STG.

4. Patient A4 admitted to the facility on 8/2/17 with a history of "Psychotic decompensation, agitation &suicide attempt" and a diagnosis of Paranoid Schizophrenia. MTP: for the Problem#1: "Danger to self and others" had the following STG: "Patient will learn adaptive strategies to cope with intense emotions, without the maladaptive behaviors". Problem#2: "Elopement," had no STG.

5. Patient A5 admitted to the facility on 8/9/17 with a history of depression, suicidal ideations with plan and a diagnosis of MDD, recurrent. MTP: for the Problem#1: "Danger to self" had the following STG: "Patient will learn adaptive strategies to cope with intense emotions without self destructive behaviors."

6. Patient A6 admitted to the facility on 7/31/17 with a history of "going through a black hole, possessed by the devil" and a diagnosis of Methamphetamine induced psychosis. MTP: for the Problem#1 "Danger to self and others" had the following STG: "Improve coping strategies to minimize the effects of stress on aggressive symptoms." Problem#2: "Assaultive," had no STG. Problem #3 "Substance Related Disorder," had no STG. Problem#4 "Relapse on Chemical dependency" STG: Pt. will recognize relationship between undesirable consequences related to non-compliance with treatment." Problem #5 "Detoxification" STG: "Patient will detoxify in a controlled hospital environment."

7. Patient A7 admitted to the facility on 7/31/17 with a history of "disruptive and bizarre behavior" and a diagnosis of Schizoaffective d/o [disorder]. MTP: for problem#1: "Danger to self" had the following STG: "Patient will learn adaptive strategies to cope with intense emotions without maladaptive behaviors." Problem #2, "SAO [Sexual Acting Out]" had no STG, Problem#3, "Relapse on Chemical dependency," STG: Pt. will recognize relationship between undesirable consequences related to non-compliance with treatment." Problem #4, "Detoxification," STG: Patient will detoxify in a controlled hospital environment."

8. Patient A8 admitted to the facility on 8/8/17 with a history of "I was drunk" and a diagnosis of Bipolar d/o and Intellectual Disability. MTP: for Problem#1: "Danger to self" listed the following STG: "Patient will learn adaptive strategies to cope with intense emotions without self destructive behaviors."

9. Patient A9 admitted to the facility on 8/8/17 with a history of "paranoid ideations" and a diagnosis of Schizophrenia. MTP: for Problem#1: "Danger to self" had the following STG: "Patient will learn adaptive strategies to cope with intense emotions without presence of aggression." Problem #2, "Assaultive/Homicidal" had no STG.

10. Patient A10 admitted to the facility on 8/8/17 with a history of "wanted to kill myself. Don't have much support" and a diagnosis of MDD severe and THC [Marijuana] use disorder. MTP: for the Problem #1: "Danger to self" had the following STG: "Patient will learn adaptive strategies to cope with intense emotions without self-destructive behaviors".

B. Policy review:

Facility Policy titled "Treatment Planning: effective date of November 2014, does not mention required details or the contents of a treatment plan.

C. Staff interview: In a meeting with the Director of Clinical services (currently also Director of Social Work) and the Director of Quality Assurance on 8/16/17 at 11:00 AM, above deficiencies were reviewed and they dispute the identified deficiencies.

Based on record review and interview, the facility failed to develop treatment plans that delineated active treatment interventions to address the specific treatment needs of 10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, and A10). Instead, treatment plans included interventions that were routine, generic discipline functions or were patient goals. Despite each patient presenting with unique psychiatric problems, intervention statements were identical or similarly worded with no method of delivery identified (individual or group sessions). This deficiency results in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to interdisciplinary treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (8/4/17), A2 (8/11/17), A3 (7/31/17), A4 (8/4/17), A5 (8/11/17), A6 (7/31/17), A7 (8/1/17), A8 (8/9/17, A9 (8/8/17), and A10 (8/9/17). This review revealed the following deficient intervention statements assigned to the psychiatrist (MD), registered nurse (RN), social worker (SW), and activity therapist (AT):

1. MD Interventions: The following identically worded deficient intervention statements were identified for patients despite their different presenting psychiatric symptoms and problem:

a. Ten active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10) - "Monitor and educate precautions, risks, benefits and side effects of medications during each visit or discuss possible medication options."

Three active sample patients (A1, A2, and A3) - "Assess for severity of impairment in daily functioning."

Seven active sample patients (A4, A5, A6, A7, A8, A9, and A10) - "Assess/adjust medication efficacy during each visit based on patient's symptom recognition."

These intervention statements were non-specific and did not provide a focus of treatment with descriptors of each patient's unique problem or symptoms. Interventions regarding assessing and monitoring were normal MD functions. The intervention regarding educating the patient failed to identify specific medications that would be taught and did not state whether teaching would be delivered in individual or group sessions with the patient.

2. SW Interventions: The following identically worded deficient intervention statements were identified for patients despite their different presenting psychiatric symptoms and problems:

a. Four active sample patients (A1, A2, A3, and A8) - "Teach coping skills to assist the patient in effectively managing intense emotion and tolerating distress."

b. Three active sample patients (A3, A4, and A7) - "Staff will encourage pt. [patient] to take medication every day at scheduled times."

c. Two active sample patients (A2 and A3) - "Provide psychoeducation on symptoms recognition."

d. Patient A9 and A10 - "Assist the patient in identifying underlying thoughts and emotions related to being a danger to others through CBT model."

These intervention statements were non-specific, did not provide a focus of treatment with unique descriptors of each patient's unique problem or symptoms. They also failed to include whether they would be delivered in individual or group sessions.

3. RN Interventions: The following identically worded deficient intervention statements were identified for problems associated with "Assaultive/Homicidal" and "Elopement. These intervention statements were identical despite each patient's unique presenting psychiatric symptoms and problem:

a. Four active sample patients (A1, A2, A4, and A9) - "Assess cues and warning signals such as behavioral changes, escalating anger, hyperactivity." "Assess for the past violent acts so preventative actions can be taken." "Maintain a therapeutic environment with clear, specific rules and consequences." "Provide individual and/or group counseling." "Teach patient to use coping mechanism appropriately to adapt more effectively with stress and anger." Frequency was listed as "Ongoing" or "As indicated."

Interventions related to assessing cues, assessing past violent acts, and maintaining a therapeutic environment were all routine nursing duties and functions and did not reflect active treatment interventions provided in individual or group sessions to assist him/her to improve presenting psychiatric symptoms. The intervention related to teaching coping mechanism was a non-specific and broad statement and failed to include whether the teaching would occur in individual or group sessions.

4. AT Interventions: All of the active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, and A10) had the following identical or similar worded interventions despite each patient presenting with different psychiatric symptoms: "Engage the patient in therapeutic activities to find alternative forms of expression and increase self-fulfillment." Frequency was "7X/Week."

This intervention statement failed to identify specific therapeutic activities for each patient based on his/her assessed needs and problems. Also, the statement did not include whether therapeutic activities would be delivered in individual or group sessions.

5. The following active sample patients also had the following deficient interventions listed for social workers. They were generic, non-specific, and not based on unique clinical assessment information. No delivery method identified.


a. Patient A1 - "Teach patient psychoeducation about the importance of the compliance with medication."

b. Patient A4 - "Therapist will assist pt. [patient] in identifying 2-3 triggers and/or stressors resulting in being a danger to others."

c. Patient A5 - "Provide psychoeducation on positive reflection and using positive memories to cope with grief/loss of a loved one and negative feelings related to trauma."

d. Patient A6 - "Social worker will work with patient to recognize safe ways to communicate concerns." "Assist patient in recognizing coping strategies available to utilize when feeling overwhelmed and experiencing racing thoughts."

e. Patient A7 - "Teach coping skills to assist the patient in affectively managing feelings of hopelessness." "Therapist will review ways to express emotions to parent and brothers feeling anxious."

f. Patient A8 - "Therapist will review ways to get in communication with staff in group home to access as a support system."

g. Patient A9 - "Teach coping skills to assist the patient in affectively managing intense emotions and tolerating distress and grief."

h. Patient A10 - "Assist patient in finding positive, hopeful things in [his/her] life that contribute to healthy emotional well being."

These intervention statements were non-specific, did not provide a focus of treatment with unique descriptors of each patient's unique problem or symptoms. They also failed to include whether they would be delivered in individual or group sessions.

6. Patient A4's MTP also had the following deficient intervention statements listed for the RN:

RN Interventions: For the problem of "Elopement," the interventions included were, "Monitor patient for inappropriate behaviors such as standing by the door ..." "Reinforce the treatment plan with patient and explain how attempts to elope may affect the length of stay." "Reinforce unit restrictions for the patient if necessary."

7. Patient A8 and A10 had no interventions to address presenting psychiatric symptoms and problems.

B. Interviews

1. In an interview on 8/16/17 at 12:20 p.m. with the Director of Clinical Services/Social Work and Director of Quality Improvement, intervention statements on MTPS were discussed. They did not dispute the findings that many intervention statements were normal job duties of clinical disciplines.


2. During an interview on 8/16/17 at 3:00 p.m., the Clinical Director acknowledged that MD interventions included normal MD duties. He agreed that MD interventions were "not specific to individual patients."

3. In an interview on 8/16/17 at 2:45 p.m., with the Director of Nursing, the preprinted form with the problems of "Assaultive/Homicidal, SAO [Sexual Acting Out], Elopement, and Arson" that was completed by registered nurses was discussed. He acknowledged that problem statements on the MTP did not have unique descriptors for each patient.

Based on record review and interview, the facility failed to ensure that registered nurses and social workers adequately documented active treatment interventions on the Master Treatment Plan and unit schedule to show detailed and comprehensive information about treatment for five (5) of 10 active sample patients (A1, A3, A4, A6, and A7). Specifically, documentation did not consistently include the patients' attendance or non-attendance, specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions.

Findings include:

A. Record Review

The master treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (8/4/17), A2 (8/11/17), A3 (7/31/17), A4 (8/4/17), A5 (8/11/17), A6 (7/31/17), A7 (8/1/17), A8 (8/9/17, A9 (8/8/17), and A10 (8/9/17). This review revealed the following findings regarding assigned treatment interventions to psychiatrists (MD), registered nurses (RN), social workers (SW), and activity therapists (AT).

1. MD Interventions:

a. Four patients (date of admission in parenthesis) A3 (7/28/17), A4 (8/2/17), A6 (7/31/17), and A7 (7/31/17) had the identically or similarly worded MD intervention: "Monitor and educate precautions, risks, benefits and side effects of medications during each visit or discuss possible medication options." The frequency was "Five X [times] per week."

A review of progress notes from 8/7/17 through 8/15/17 were reviewed and revealed that there were no treatment notes reflecting that the MD provided education regarding medications for these patients. There was no documentation about the number and duration of contacts with patients. In addition, there was no documentation to show the patient's response to interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions.

2. Social Worker Interventions

A review of progress notes from 8/7/17 through 8/16/17 revealed that there were no treatment notes reflecting that the SW provided the following interventions assigned on MTPs. There was no documentation about the number of contacts or attempts to provide active treatment interventions identified on MTPS for the interventions below. In addition, there was no documentation to show the patient's response to interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions.

a. Patient A1 and A3 - "Teach coping skills to assist the patient in effectively managing intense emotion and tolerating distress." Patient A7 - "Teach coping skills to assist the patient in affectively [sic] managing feelings of hopelessness."

b. Patient A1 - "Teach patient psychoeducation about importance of the compliance with medication."

c. Patient A3 and A4 - "Therapists will assist pt. [patient] in identifying 2-3 triggers and/or stressors in being (sic) a danger to others."

3. Nursing Interventions: A review of progress notes from 8/7/17 through 8/16/17 revealed that there were no treatment notes reflecting that the RNs provided the following interventions assigned on MTPs. There was no documentation about the number of contacts or attempts to provide active treatment interventions identified on MTPS for the interventions below. In addition, there was no documentation to show the patient's response to interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions.

a. Patient A1, A3, and A6 - "Provide individual and/or group counseling." "Teach patient to use coping mechanism (sic) appropriately to adapt more effectively with stress and anger." Frequency was listed as "Ongoing"

b. Patient A7 - "Teach patient to identify triggers or stressors related to sexually acting out, if experiencing urges." Frequency was "as needed." There was no documented treatment notes and documentation to show that nursing staff determined that the patient needed teaching sessions regarding triggers related to sexually acting out.

4. In addition to lack of documentation of nursing interventions identified on MTPs, there was no documentation of the nursing group titled, "Medication Education ..." identified on unit program schedules for active sample patients A1, A3, A4, A6, and A7.

B. Interview

1. In an interview on 8/15/17 at 11:10 a.m. with RN1, a Medication Education group scheduled on Tuesday, Thursday, and Saturday scheduled from 5:45 - 6:30 p.m. was discussed. RN1 stated that this group was being provided by registered nurses but was unable to locate documented evidence whether active sample patient A5 had attended this group.

2. In an interview on 8/16/17 at 12:20 p.m. with the Director of Clinical Services/Social Work and Director of Quality Improvement, intervention statements on MTPS were discussed. They did not dispute the findings that there was no documented evidence that social work interventions on MTPs were not being provided or not.

3. In an interview on 8/16/17 at 2:45 p.m., the Director of Nursing acknowledged that there was no documented evidence that nursing interventions on MTPs and the medication education group on unit schedules were being conducted by registered nurses.

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

I. Ensure that active treatment measures were provided for two (2) of 10 active sample patients (A1 and A4) who were unwilling or not motivated to attend or participate in active treatment groups. Specifically, there was inadequate frequency and intensity of active treatment to assist with each patient's treatment goal attainment. Also, there was no consistent documentation in the medical record to show attempts to engage these patients in alternative active treatment measures. Despite, inconsistent or lack of regular attendance in groups, Master Treatment Plans (MTP) were not revised to reflect alternative treatment measures to assist patients to achieve treatment goals. Failure to provide active treatment at a sufficient level and intensity results in affected patients being hospitalized without all active treatment interventions for recovery, thereby delaying their improvement.

Findings include:

A. Patient A1

1. Patient A1 was admitted on 8/2/17. The patient's Psychiatric Evaluation, dated 8/3/17, documented a diagnosis of "Schizophrenia - Non-Specified." The Psychiatric Evaluation noted that, "[sic] reports pt. has been noncompliant w/meds [with/medications] for past years... [S/he] lives w/ [with] [his/her] parents, has been threatening ... threatening to harm them... irritable, restless, [with] poor sleep..."

2. During an observation on the Geriatric Unit on 8/15/17 at 10:15 a.m. Patient A1 was in his/her bedroom during the time a group titled, "Positive Imagery" scheduled from 10:00 a.m. to 10:45 a.m. was being held in the dayroom. During a discussion at 10:55 a.m., MHT1 stated that Patient A1 usually does not attend groups. During another observation on 8/16/17 at 1:20 p.m., the group listed on the unit schedule was "Art Therapy" scheduled from 1:15 - 2:00 p.m. A music group was being held but Patient A1 remained in his/her room.

3. Patient A1's MTP, dated 8/4/17, included the following interventions to address presenting psychiatric problems of, "Danger to others - As evidenced by: Patient was admitted to hospital due to homicidal ideation. Patient was stating, 'it's your time to go.' Patient has been non-compliant with medications:"

a. MD Intervention: The MTP listed, "Monitor and educate regarding precautions, risks, benefits and side effects of medications during each visit.

b. Social Work Interventions: The MTP listed, "Teach coping skills to assist the patient in effectively managing intense emotions and tolerating distress." "Teach patient psychoeducation about the importance of the compliance with medication." The frequency was 1x [time] per week.

c. Activity Therapy Intervention: The MTP listed, "Engage the patient in therapeutic activities to find alternative forms of expression and increase self-fulfillment." The frequency was 7x [times] per week.

d. Nursing Intervention: The MTP listed, "Teach patient simple stress-management strategies such as deep-breathing exercises, thought stopping exercises ..." "Teach patient to use coping mechanisms appropriately to adapt more effectively with stress and anger." The frequency was "ongoing."

4. A review of progress and group treatment notes revealed the following findings:

a. MD notes: The review of progress notes by psychiatrists from 8/6/17 through 8/15/17 revealed that the psychiatrist documented attempts to provide education risks, benefits, and side effects of medications. A progress note dated 8/6/17 reported, "Pt. is suspicious, paranoid, and delusional to people ... refused to take [his/her] meds [medications]. [S/he] is very argumentative, doesn't like to attend groups and like to be kept in isolation ..."
b. Social Worker Notes: The review of progress notes by social workers from 8/8/17 through 8/14/17 revealed that of the five notes documented there were no treatment notes regarding the specific teaching of coping skills or psychoeducation on medication compliance provided. All of the notes contained the following identical or similarly worded statement, "Therapist provided emotional support, reflected patient's thoughts and feelings, provided psychoeducation on coping skills, and symptoms ..." There was no information provided regarding what specific coping skills and symptoms were discussed each session and no documentation regarding the patient's response to the psycho- education that reflected the patient's level of participation and understanding, any specific comments or behaviors exhibited during sessions.

The form used to document group treatment, titled "Interdisciplinary Daily Group Note" was reviewed for the period from 8/9/17 through 8/15/17. This review revealed that the patient refused all 6 of the "Process Group" documented by social workers. Alternative active treatment measures were not documented except for on 8/9/17, 8/12/17, and 8/13/17. The section of group note form noted, "Group material offered to complete independently." There was no documentation as of 8/16/17 that showed that the group leader met with the patient to discuss these group materials or documented the patient's response to intervention(s), if provided.

c. Registered Nurse Notes: The review of progress notes by registered nurses from 8/7/17 through 8/15/17 revealed no treatment notes for interventions assigned on the MTP regarding teaching this patient stress-management strategies and coping mechanisms psychiatric problems. In addition, there was no documented evidence that reflected registered nurses attempts to provide the interventions identified on this patient's MTP. An RN progress note dated 8/13/17 reported, " ... still very isolative and not attending groups ..."

d. Activity Therapy Notes: The form used to document group treatment, titled "Interdisciplinary Daily Group Note" was reviewed for the period from 8/7/17 through 8/15/17. This review revealed that the patient refused all 8 of the activity therapy group documented. There were no active treatment measures documented that showed alternatives were offered except for on 8/10/17 and 8/15/17. The section of group note form noted that, "Group material offered to complete independently." However, there was no documentation as of 8/16/17 that showed that the group leader(s) met or attempted to meet with the patient to discuss the group material provided and the patient's response to these interventions.

5. The form used to document the location of patients titled, "Patient Safety Precaution Records" was reviewed for the period from 8/7/17 through 8/15/17. This review revealed the patient was documented as being in his/her bedroom during times groups were held. The patient was, on occasion, documented to be in the hallway or dayroom.

6. Despite this documentation of the patient's lack of involvement in active treatment, the MTP was not revised for Patient A1 to include alternatives to the facility's group treatment program or active treatment measures designed to engage the patient in active treatment. There was limited evidence to show attempts to engage this patient in active treatment.

7. In an interview on 8/16/17 at 11:17 a.m. with SW4, the lack of involvement in active treatment by active sample patient A1 was discussed. SW4 did not dispute the findings. S/he acknowledged that this patient was not participating in active treatment on the unit. When asked about the lack of documentation of social work interventions on the patient's MTP, SW4 stated that the interventions were written by a PRN social worker and admitted that the social work interventions had not been provided.

B. Patient A4

1. Patient A4 was admitted on 8/2/17. The patient's Psychiatric Evaluation, dated 8/2/17, documented a diagnosis of "Paranoid Schizophrenia." The Psychiatric Evaluation noted that, "The patient was admitted, 'after car crash due to driving [sic].' [S/he] attempted to elope from ED and overdosed on pills ... [S/he] was agitated, paranoid, thinks [his/her] neighbor looked into FB [Facebook] account and is after [him/her] and [his/her] son ..."

2. During an observation on the Transitional Unit on 8/15/17 at 12:10 p.m., Patient A4 was located in bed and refused to be interviewed by CMS Surveyor. During a discussion at 12:15 p.m., RN2 stated, "[Patient A4] spends a lot of time in [his/her] room." RN2 also reported that the patient did not attend many groups. During another observation on 8/15/17 at 4:10 p.m., a group titled, "Guided Meditation" was being held. Patient A4 was observed coming in and out of the group and was observed in the hallway at 4:20 p.m.

3. Patient A4's MTP, dated 8/4/17, included the following interventions to address presenting psychiatric problems of, "Danger to self - As evidenced by: Patient was admitted to [sic] due to crashing car near pedestrians. Pt [Patient] also eloped from ER [Emergency Room] and overdosed on pills."

a. MD Intervention: The MTP listed, "Monitor and educate regarding precautions, risks, benefits and side effects of medications during each visit.

b. Social Work Interventions: The MTP listed, "Staff will encourage pt. [patient] to take medication every day at scheduled times." "Therapist will assist pt. in identifying 2-3 triggers and/or stressors resulting in being a danger to others." The frequency was 2x (times).

c. Activity Therapy Intervention: The MTP listed, "Engage the patient in therapeutic activities to find alternative forms of expression and increase self-fulfillment." The frequency was 7x (times) per week.

d. Nursing Intervention: There were no active treatment interventions included on the MTP reflecting nursing staff meeting with the patient in individual or group sessions to address this patient's presenting psychiatric problem. The preprinted form for problems related to "Assaultive/Homicidal, SAO [Sexual Acting out], Elopement, and Arson" showed that elopement had been checked as a problem. The interventions checked were all normal and routine nursing job duties such as, "Monitor patient for inappropriate behavior such as standing by the door in an attempt to run off the unit."

4. A review of progress and group treatment notes revealed the following findings:

a. MD notes: The review of progress notes by psychiatrists from 8/9/17 through 8/15/17 revealed that there were no treatment notes regarding education about risks, benefits, and side effects of medications. There were two notes dated 8/14/15 and 8/15/16 that noted on 8/14/17, "Psychotherapy 16 min focused on discussion of treatment plan and psychoeducation" and on 8/15/17 "Psychotherapy 16 min focused on depressive and anxious ruminations and triggers of worsening mood. There was no documented evidence reflecting patient's response to psychotherapy provided. Also, there was no evidence regarding what psychoeducation was provided, if education identified on the MTP was discussed, or the patient's response to education provided.

b. Social Worker Notes: There was one progress note dated 8/15/17 submitted for the social worker. This note provided no documented evidence that active treatment as assigned on the MTP was provided. The form used to document group treatment, titled "Interdisciplinary Daily Group Note" was reviewed for the period from 8/7/17 through 8/15/17. This review revealed that the patient was documented refusing to attend 7 of 8 groups titled "Process Group" documented by social work. The patient left early when s/he attended the process group on 8/12/17.

c. Registered Nurse Notes: The review of progress notes by registered nurses from 8/7/17 through 8/15/17 revealed no treatment notes regarding psychiatric problems. The addition, there was no documented evidence the patient's attendance in the "Medication Education" group scheduled Saturdays from 2:00 - 2:45 p.m.

d. Activity Therapy Notes: The form used to document group treatment, titled "Interdisciplinary Daily Group Note" was reviewed for the period from 8/7/17 through 8/15/17. This review revealed that the patient refused all 8 activity therapy groups documented. There were no active treatment measures documented that showed alternatives were offered except for on 8/10/17 and 8/15/17. The section of group note form noted: "Group material offered to complete independently." However, there was no documentation as of 8/16/17 that showed that the group leader(s) met or attempted to meet with the patient to discuss the group material provided and the patient's response to these interventions.

5. The form used to document the location of patients titled, "Patient Safety Precaution Records" was reviewed for the period from 8/7/17 through 8/15/17. This review revealed the patient was documented as being in his/her bedroom most of the time. The patient was on occasion documented to be in the hallway or dayroom. The findings included the following information regarding the patient's participation in the facility's group treatment program listed on the unit schedule:

a. On 8/9/17
"Activity Therapy" held from 10:45 - 11:30 a.m. 17 - in his/her bedroom except for 15 minutes in dayroom where the group was held.
"Guided Meditation" held from 12:45 - 1:30 p.m. - in his/her bedroom the entire group period.
"Process Group" held from 2:00 - 2:45 p.m. - in his/her bedroom the entire group period.

b. On 8/12/17
"Medication Education" held from 2:00 - 2:45 p.m. - in his/her bedroom the entire group period.

c. On 8/15/17
"Activity Therapy" held from 10:45 - 11:30 a.m. - in his/her bedroom most of group time.
"Guided Meditation" held from 12:45 - 1:30 p.m. - in his/her bedroom the entire group period.
"Process Group" held from 2:00 - 2:45 p.m. - in his/her bedroom the entire group period.

6. Despite this documented limited involvement in active treatment, Patient A4's MTP was not revised to include alternatives to the facility's group treatment program or to add active treatment measures designed to engage the patient in active treatment such as individual sessions to provide content included in group sessions. There was limited evidence to show attempts to engage this patient in active treatment.

7. In an interview on 8/16/17 at 12:10 p.m. with the Director of Clinical Services/Social Work, who was also responsible for Rehabilitation Therapy, the lack of involvement in active treatment by active sample patients A1 and A4 was discussed. She did not dispute the findings and acknowledged that these patients were not consistently involved in active treatment.

8. Patient A4 agreed to be interviewed by the Surveyor on 8/17/17 at 11:05 a.m. The patient, when asked about attending groups stated, "I am too tired to go." Patient A4 stated that no one had given him/her verbal or written information about medications and reported that s/he only had short contacts with the psychiatrist and stated, "The doctor sticks his head in the door [bedroom door] and ask me about my Seroquel."

II. Ensure that patients attended the scheduled active treatment groups on the Geriatric and Transitional Units (2 North and 2 South). Specifically, the facility expected all patients to attend the group treatment program, however, fewer than half the assigned patients attending these groups. This deficient practice results in fragmented active treatment for patients and potentially delays their recovery and improvement.

Findings include:

A. Observations and Interviews

1. During an observation on the Geriatric Unit on 8/15/17 at 10:15 a.m., the group on the unit schedule was "Positive Imagery" scheduled from 10:00 a.m. to 10:45 a.m. A total of 9 out 16 patients attended this group. No other active treatment measures were scheduled during this period. The patients attending included active sample patients A1 and non-sample patients B3, B4, B7, B8, B11, B12, B13, and B14. Active sample patients A2 and the remaining non-sample patients on the unit were documented to be in their rooms.

2. During an interview at 10:55 a.m. with the group leader (MHT1), the lack of participation of patients in the above group was discussed. MHT1 stated that active sample patient A1 usually does not attend group and reported, "We sometimes give worksheets to the patient and do a 1:1."

3. During an observation on the Transitional Unit on 8/15/17 at 2:13 p.m. the group on the unit schedule was "Process Group" scheduled from 2:00 p.m. to 2:45 a.m. A total of 5 of 19 patients on the unit attended this group. No other active treatment measures were scheduled during this period. The patients attending included active sample patients A3 and non-sample patients C1, C2, C3, and C5. The remaining 14 non-sample patients were documented to be in their rooms or the hallway.

4. During an interview on 8/15/17 at 4:12 p.m. with SW1, patients' lack of involvement in the groups was discussed. SW1 noted that this often occurred and stated that it might be because "a lot of them [patients] receive medications at noon and are sleepy."

5. During an observation on the Transitional Unit on 8/15/17 at 4:13 p.m. the group on the unit schedule was "Guided Meditation" scheduled from 4:00 p.m. to 4:45 p.m. A total of 7 of 15 patients attended this group. The patients attending the entire group included non-sample patients E1, E2, E3, E4, E5, E6, and E7. Active sample patient A4 and two non-sample patients E8 and E9 were in and out of the group. No other active treatment measures were scheduled during this period. The remaining non-sample patients were documented to be in their rooms or the hallway. Active sample patient A4 was observed in the hallway at 4:20 p.m.

Based on record review, staff interview and policy review, for 3 of 5 sample of discharged patients (D1, D2 and D5), the hospital failed to ensure that the discharge summaries recapitulate patients' course of hospitalization in a sufficiently descriptive manner. This deficiency results in a failure to communicate promptly the course of hospital treatment, a summary of relevant physical and lab data and anticipated problems to the outpatient providers of care which may affect outpatient care negatively.

Findings include:

A. Record review:

1. Patient D1was discharged on 6/15/17. The course of treatment in the hospital was documented as "Well through (sic) pharmacotherapy & group therapy. Pt. gradually improved". This brief summary does not recapitulate the course of hospitalization or give a synopsis of the treatment accomplishments while hospitalized.

2. Patient D2 was discharged on 6/28/17. The discharge diagnosis included MDD (Major Depressive Disorder), Alcohol use disorder, severe, and Stimulant use disorder, severe, yet the discharge summary did not reflect if the severe Alcohol and Stimulant use disorders were addressed at all during the course of hospitalization.

3. Patient D5 was discharged on 6/22/17 with Psychiatric Diagnosis of Schizophrenia, paranoid type and medical Diagnosis of Hypertension, Hypothyroidism, Hyperlipidemia and Diabetes Mellitus. Course of treatment in the hospital was documented as follows: "Pt. was admitted to the hospital due to risk of harm to others. Pt. was effectively treated with by team using both pharmacotherapy, psychotherapy. Pt. gradually improved, stabilized, was ok". This brief summary did not recapitulate the course of hospitalization and does not provide a synopsis of the treatment accomplishments while hospitalized. It also did not address the physical status or pertinent laboratory values for the identified multiple medical problems.

B. Policy review:

The hospital Medical Staff Rules and Regulations: Chapter VI, Discharge and Transfer Regulations, does not address the contents of a discharge summary. Chapter VII, Medical records, 1 Medical Record Entries: states "Documentation by physicians shall adhere to the hospital's policies and procedures, standards of the Joint Commission, CMS and state of Illinois."

C. Staff Interview:

In a meeting and review of the above deficiencies with the Clinical Director on 8/16/17 at 3:00 p.m., the director concurred and further stated "agree, not adequate".

Based on observation, record review, and staff interview, the Clinical Director failed to adequately monitor and evaluate the quality of care provided to patients at the facility. This failure may affect patients' treatments and recovery, potentially delaying patient improvements and discharge.

Specifically, the Clinical Director failed to ensure that:

I. The hospitalized patients' active treatment planning, reviews and updates, care and treatment interventions are under the direction of a psychiatrist. As observed, documents reviewed and as required by the hospital policy, the psychiatrists are not present at all of patients' treatment planning meetings, reviews and updates. Without consistent onsite supervision and direction of treatment planning, review and update of each patient's treatment, their recovery may be compromised potentially delaying their timely discharge. (Refer to B99)

II. The Psychiatric Assessments included assessment and documentation of patients' personal assets which describe patients' personal factors on which to base the treatment plan, or are useful in therapy. (Refer to B117)

III. Develop and document MTPs' that were comprehensive, individualized, and behaviorally descriptive with all necessary components for ten 10 of 10 (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10) active sample patients. Specifically, the MTPs did not include the following:

A. Behavioral and descriptive problem statements based on how each patient manifested presenting symptoms. (Refer to B119)

b. Observable, measurable short-term goals written in behavioral terms for 10 of 10 active sample patients (Refer to B121)

C. Individualized, specific active treatment interventions. (Refer to B122)

IV. Ensure that active treatments of adequate intensity and frequency was provided to 2 of 10 active sample patients (A1 and A4) who are unwilling or not motivated to attend group treatments offered, or alternative treatments are provided to these same patients and/or the treatment plans are revised to reflect alternative treatments if any, for unwilling, non-motivated patients. Failure to provide active treatment at a sufficient level and intensity results in affected patients without all active treatment for recovery, thereby delaying their improvement. (Refer to B125-I)

V. Ensure that patients attended the scheduled active treatment groups in the Geriatric and Transitional units (2 North and 2 South). Specifically, the facility expected all patients to attend the group treatment program, however fewer than half the assigned patients were attending the treatment groups. This deficient practice results in fragmented active treatment for patients and potentially delays their recovery and improvement. (Refer to B125-II)

Based on observation, record review, and interview, the facility failed to provide adequate oversight to ensure the quality of nursing services. Specifically, the Director of Nursing failed to monitor to:

I. Ensure that treatment plans delineated nursing interventions to address the specific treatment needs of seven (7) of 10 active sample patients (A1, A2, A3, A4, A6, A7, and A9). Instead, treatment plans included interventions that were routine, generic discipline functions or were patient goals. Despite each patient presenting with unique psychiatric, intervention statements were identical or similarly worded with no method of delivery identified (individual or group sessions). There were no nursing interventions on MTPs for three (3) of 10 active sample patients (A5, A8, and A10) to address presenting psychiatric problems. These deficiencies result in treatment plans that failed to reflect a comprehensive, integrated, and individualized nursing approaches to interdisciplinary treatment. (Refer to B122)

II. Ensure that registered nurses adequately documented active treatment interventions listed on the Master Treatment Plan and unit schedule to show detailed and comprehensive information about treatment for five (5) of 10 active sample patients (A1, A3, A4, A6, and A7). Specifically, there was no documented evidence of treatment notes to reflect patients' attendance or non-attendance in active treatment, specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124)

III. Ensure that active treatment measures were provided for two (2) of 10 active sample patients (A1 and A4) who were unwilling or not motivated to attend or participate in active treatment groups. Specifically, there was an inadequate frequency and intensity of active treatment provided by registered nurses to assist with each patient's treatment goal attainment. Also, there was no documented evidence in the medical record to show attempts by registered nurse to engage these patients in active treatment interventions identified on MTPs or alternative active treatment measures when patients refused to participate. Failure to provide active treatment at a sufficient level and intensity results in affected patients being hospitalized without all active treatment interventions for recovery, thereby delaying their improvement. (Refer to B125-I)

Based on medical record review and staff interview, the Director of Social services failed to ensure that the Psychosocial Assessments for 10 [A1,A2,A3,A4,A5,A6,A7,A8,A9 and A10] out of 10 active sample patients' included: 1) either an evaluation or necessary recommendations of high risk psychosocial issues requiring early treatment planning and intervention; 2) recommendations concerning anticipated necessary steps to be taken for discharge to occur; and 3) anticipated Social Work roles in treatment and discharge planning. The social work roles or recommendations identified in the psychosocial evaluations were generic and/or not related to presenting problems or not identified at all. This resulted in lack of professional social work assessments which can be utilized and necessary for informed treatment and discharge planning decisions. (Refer to B108)

Staff Interview:

In an interview on 8/16/17 at 2:45p.m., above deficient evaluations and the absence of specific roles of social workers in the psychosocial evaluations of the 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10) was discussed with the Director of Social work. The Director acknowledged the above deficiencies and stated, "I understand".