HospitalInspections.org

Based on review of state contract with a contractor for therapy services, review of contract therapists' files and interview, it was determined that the governing body failed to ensure services performed under contract were provided in a safe and effective manner in that no criminal background checks were performed annually for eleven of eleven (#1-#11) therapists in accordance with the contract. By not obtaining criminal background checks, the facility could not assure they fulfilled their obligation to protect patients from registered maltreatment offenders or state or federal criminals. The failed practice had the potential to affect any patient receiving therapy services from the contracted group. Findings follow:

A. Review of the state contract dated 09/01/2012-08/31/13 for therapy services on 09/19/12 at 0930 revealed "The Arkansas State Hospital will be responsible for obtaining a copy of each staff's criminal background check, child and adult maltreatment registry record, TB (Tuberculosis) skin test and seasonal flu vaccination. An employee is required to have both state and federal criminal background checks. Background checks will be performed on an annual basis."

B. Review of contract therapists' files revealed no evidence of background checks performed annually on Therapist #1-#11.

C. Findings were verified through interview on 09/20/12 at 1335 with the Quality Administrator.

Based on review of the facility Master Vendor Contract List and interviews, it was determined that the facility failed to maintain a list of all contracted services including the scope and nature of each of the services for two of two (shredding services and release of information services) Medical Information Services. By not maintaining a current list of contracted services, the facility could not manage the delineated responsibilities between the contractors and the facility. The failed practice had the potential to affect any of the 209 patients in the facility. Findings follow:

A. Review of the 2012 Master Vendor Contract List on 09/19/12 at 0900 revealed two contracted services being utilized in Medical Information Services, shredding services and release of information services, were not listed.

B. Findings were verified through interview on 09/18/12 at 0945 with Quality Administrator.

Based on review of the credential file and interview, the facility failed to provide evidence that the Director of Medical Information Services was credentialed as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) in accordance with the Arkansas Department of Health, Rules and Regulations for Hospitals and Related Institutions. Failure of the Director to be certified as a RHIA or RHIT did not assure patients' health information was maintained or staff was trained according to current standards of practice. The failed practice had the potential to affect the health information for 209 patients in the facility. Findings follow:

A. During an interview on 09/18/12 at 1255, the Director of Medical Information Services verified they were not credentialed.

B. A review of a Credential status paper revealed the Director of Medical Information Services was not credentialed.

Based on observations and interviews, it was determined that one of one (Unit B) room observed designated for Airborne Infection Isolation (AII) did not have negative airflow balance relationship with the corridor, a door closer or a visual device to confirm proper air balance was used in accordance with the Arkansas Department of Health, Rules and Regulations for Hospitals and Related Institutions. Failure to provide for a proper airflow or door controls can affect the health and safety of patients, staff and visitors of the hospital. The failed practice had the potential to affect all patients, staff and visitors. The findings follow:

A. On 09/20/12 between the hours of 0900 and 1100 while on tour with the Interim Director of Maintenance of a room designated for Airborne Infection Isolation (AII) patients on Unit B revealed the room did not have a negative airflow balance relationship with the corridor, self closing doors or a visual device to confirm proper air balance.

B. Interview with the Interim Director of Maintenance at the time of the observation, it was confirmed the room did not have a negative airflow balance. No additional information was offered for review.

Based on observations, review of Infection Control Committee Minutes, Biological Monitoring Log, policies and procedures, and interviews, it was determined that the facility failed to:

a) provide documentation of biological spore test results for one of one steam sterilizer for 4 (06/18/12, 07/03/12, 07/25/12 and 08/13/12) of 17 weeks as identified on the Biological Monitoring Log; monitor results of biological tests;

b) assure biological test results were documented accurately; label sterilized items with lot/control information;

c) and assure airborne isolation rooms were monitored for negative pressure.

The facility could not assure patients, staff, and visitors were protected from potential sources of infection. The failed practice had the potential to affect all staff in the facility. The findings were:

A. The Biological Monitoring Log for Steam Sterilizer #1 was reviewed on 09/21/12 for 07/10/11-09/21/12. Biological Monitoring Log documentation revealed biological indicator lot number, expiration date, and test results were lacking on 06/18/12, 07/03/12, 07/25/12, and 08/13/12. Infection Control Nurse #1 and LPN (Licensed Practical Nurse) #1 were interviewed on 09/21/12 at 1130. LPN #1 stated that biological spore test strips (ProSure) were done with each load and mailed to a contracted company. LPN #1 stated, "The company runs the biological test strip and then sends the results. It usually takes a couple of weeks or so."

1) LPN #1 presented the biological test results received from the contracted company, which is a one page document sent to the facility titled "Sterilizer Test Results". There were no results provided for 05/24/12, 06/18/12, 07/03/12, 07/25/12, and 08/13/12. Surveyor #1 asked LPN #1 for documentation of the results for the missing dates, she stated "they are delayed sometimes in getting the results." Surveyor #1 then requested the missing date results be retrieved if available.

2) On 09/21/12, LPN #1 retrieved and printed "Test Results for the facility total tests = 31." The print out from the company began on 03/06/06. There were no dates listed for test results for 10/26/11, 11/04/11, 12/16/11, 05/24/12, 06/18/12, 07/03/12, 07/25/12 and 08/13/12. This was in conflict with the documentation on the facility Biological Monitoring Log. By interview at the time of observation, LPN #1 confirmed the dates on the printout were processing company biological test strip results and provided no explanation for the conflicting information compared to the Biological Monitoring Log maintained by the facility.

3) On 09/20/12 and 09/21/12, Infection Control Committee Minutes and Quality Assurance and Performance Improvement Minutes were reviewed and revealed the biological indicator results from Sterilizer #1 were not reported or discussed. In an interview with Infection Control Nurse #1 on 09/21/12 at 1140, she stated "we haven't reported the results ".

B. Observation of the sterilized supplies in the clinic area revealed that self-sealing sterilization pouches were used exclusively for single instruments. The pouch was not labeled with lot number, date of sterilization, or initials of individual processing. The items could not be identified and traced in the event of reprocessing or biological test strip failure. The findings were confirmed by LPN #1 on 09/21/12 at 1145.

C. LPN #1 presented the facility binder that included the log book for Biological Monitoring,
2010 ANSI/AAMI (Association for the Advancement of Medical Instrumentation) and ProSure Spore Strips instructions for use, In-service roster, and "Competency-based performance for sterilizer."

1) The ANSI/AAMI Standard, 10.3.1, Lot Control Numbers stated: "Each item or package intended for use as a sterile product should be labeled with a lot control identifier. The lot control identifier should designate the sterilizer identification number or code, the date of sterilization, and the cycle number."

2) Standard 10.3.2, Sterilizer Records stated: "For each sterilization cycle, the following information should be recorded and maintained: The lot number, specific contents of the lot or load, including quantity, department, and a specific description of the items, exposure time and temperature, if not provided on the sterilizer recording chart, name or initials of the water, results of biological testing, if applicable."

3) Standard 10.3.3, Expiration Dating stated: "Each item in a load should be labeled with a control date for stock rotation and the following statement (or its equivalent) "Contents sterile unless package is opened or damaged. Please check before using."

4) The Biological Indicator Sterilization monitoring service instructions for use stated "The use of Biological Indicators is an essential component of an effective infection control program. A technical bulletin (provided) to guide you in determining the frequency of use of your biological indicator (a minimum of once per week). For regulatory compliance, we have also included a biological monitoring log book to allow you to keep a record of your results. When you receive test results form (company), keep them in your log book for third party verification."

5) "Competency-Based Performance for Sterilizer" was signed by LPN#1 on 07/10/11 that stated: "(f) Place a ProSure Biological indicator strip into the autoclave to run through with the load, (h) Documenting the load appropriately in the log book, (i) Place the pro Sure indicator back into the enclosed envelop and mailing it, and (j) When paperwork received back, place the results into the monitoring book."

The findings were confirmed in an interview with LPN #1 on 09/21/12 at 1145.

D. In an interview with Infection Control Nurse #1 on 09/21/12 at 1130, she stated maintenance was responsible for monitoring if the Airborne Isolation Rooms were negative pressure. She stated "I reviewed the policy last week and they are the ones who do that." At the time of the interview, the Infection Control Nurse confirmed she was not aware if the results of the airborne isolation room monitoring were reported through Infection Control Committee.


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Based on observation and interview, it was determined that the facility failed to maintain a clean environment and separate clean items from dirty items. The failed practice did not protect against possible contamination of food and could affect any patient receiving food from the kitchen or nourishment rooms. During a tour of the kitchen and nourishment rooms on 09/17/12 at the following was observed:

A. The following was observed during a tour of the kitchen at 0930 on 09/17/12:

1) The inside of the kitchen microwave contained a quarter sized puddle of brown liquid.

2) Against one wall were two bins containing clean towels, uncovered, directly adjacent to two bins containing dirty towels, also uncovered.

3) Findings were confirmed by the Food service Director at the time of the tour.

B. The following were observed during a tour of three nourishment rooms beginning at 0955 on 09/17/12:

1) Unit B: At 0955 two of two drawers were observed to contain crumbs and a brown sticky substance in the bottom.

2) Unit C: At 0957 a microwave and a refrigerator containing splatters of food residue and build-up were observed. One drawer contained crumbs in the bottom. This drawer housed plastic forks that were not in a sealed container and were lying in direct contact with the dirty drawer surface.

3) Unit D: At 1000 freezer contained a small area of red colored popsicle residue.

4) Findings were confirmed by the Food service Director at the time of the tour.

Based on interview, it was determined that the facility did not have a contract with an organ procurement agency. Failure to have a contract with an organ procurement agency did not allow the facility to address and act when patients were identified as organ donors. The failed practice affected any designated organ donor admitted to the facility. Finding:

During an interview with the Chief Executive Officer and the Chief Medical Director at 0935 on 09/21/12, both stated the facility did not have a current contract with an organ procurement agency at this time.

Based on interview, it was determined that the facility failed to have a contract with an eye and tissue bank. Failure to have a contract with an eye and tissue bank did not allow the facility to address and act when patients were identified as organ donors. The failed practice affected any designated organ donor admitted to the facility. Finding:

During an interview with the Chief Executive Officer and the Chief Medical Director at 0935 on 09/21/12, both stated the facility did not have a current contract with an eye and tissue bank at this time.

Based on review of Contracted Therapists' files, review of therapy weekly schedule, and interview, it was determined that the facility failed to provide evidence a therapist was qualified to provide services in that one (#11) of eleven (#1-11) therapists did not have current proof of licensure. By not ensuring the therapist was licensed, the facility could not assure services provided were provided by qualified individual. The failed practice had the potential to affect all patients who participated in therapy provided by Therapist #11. Findings:

A. Review of Contracted Therapists' files on 09/19/12 revealed Therapist #11 did not have proof of current licensure. Proof of Therapist #11's licensure was requested on 09/19/12 and again on 09/20/12, of which no evidence was provided.

B. Review of an Occupational Therapy schedule revealed Therapist #11 had nine evening sessions regularly scheduled (5:30 - 6:15 Monday and Thursday on Unit B, 6:15 - 7:00 Monday and Thursday on Unit C, 7:00-7:45 Monday and Thursday on Unit A, 5:30-6:15 Tuesday on Unit A, 6:15-7:00 Tuesday on Unit B; and 7:00-7:45 Tuesday on Unit C).

C. Findings were verified through interview on 9/20/12 at 1530 by the Quality Administrator.

Based on a review of treatment plans and interviews, it was determined that the facility failed to clearly state problems/issues presented by 8 of 16 sample patients (B9, B25, D4, E5, E7, G19, G24 and H12).

The problems listed on the treatment plans included diagnoses, lists of symptoms and generalized, confusing statements rather than specific problem behaviors which had to be reduced/resolved for the patient to live in a less restrictive environment. This failure resulted in fragmented treatment plans and lack of specific focus for treatment planning.

Findings include:

A. Record review:

1. Patient B9. On the Master Treatment Plan dated 8/30/12, the identified problem was stated as "Noncompliance with Conditions of Act 911 as manifested by the patient reportedly refused medication at the nursing home; cursed nursing home staff; threw a food tray on the floor; and climbed the fence."

2. Patient B25. On the Master Treatment Plan dated 9/6/12 the problem was identified as "Non-compliance issues with threatening behavior as manifested by...problems accepting limitations and to try to make [his/her] own discharge plans. When told that [s/he] would be going to an RCF upon discharge, [pt.] said that [s/he] would fight and that [s/he] would kill someone when [s/he] got there. [Pt] continues to make statements about using internet for huge profits/inventions/financial wealth/investments."

3. Patient D4. On the Master Treatment Plan dated 8/24/12 the problem was identified as "Aggression related to psychosis as manifested by [Patient's name] report of hallucinations & [patient] reacting aggressively."

4. Patient E5. Master Treatment Plan dated 9/4/12 identified the problem as "Sexually Abusive Behavior."

5. Patient E7. On the Master Treatment Plan dated 8/22/12, Problem was stated as "Sexually Abusive Behavior."
Problem 2 was stated as "It's all about me".

6. Patient G19. On the Master Treatment Plan dated 8/23/12, the identified problem was "Lacks Fitness to Proceed as manifested by [patient name] diagnosed with Moderate Mental Retardation based upon testing completed in a forensic evaluation.... Based upon [his/her] IQ, the evaluator opined that [pt.] lacked fitness to proceed due to mental defect. [Patient Name] demonstrates a significantly limited understanding of current legal situation. For example, [pt.] was unable to relate legal charges and did not know the roles of various courtroom participants."

7. Patient G24. On the Master Treatment Plan dated 8/14/12, the identified problem was "Alcohol Dependence as manifested by alcohol abuse that led to three DUS's and suspension of [pt.] driver's license; conflict....while intoxicated that resulted in a restraining order being filed on [pt.]; ... is alleged to have been intoxicated at the time these crimes were committed."

8. Patient H12. Master Treatment Plan dated 9/4/12 identified the problem as "No Insight to Appropriate Interpersonal Boundaries as manifested by [pt. Name] insist [sic] that [pt.] diagnosis can be changed and that pedophilia is not an accurate diagnosis. constantly asks for special treatment and rules. Pt externalizes issues, failing to take responsibility for actions."

B. Interviews:

1. In an interview 9/19/12 at 2:00 p.m., in review of sample treatment plans, the Clinical Director agreed the problems are not clearly stated.

2.In an interview 9/19/12, at 3:40 p.m, the Medical Director stated "....yes, we noticed some (treatment plans) do not fit the patients ...We just implemented the format, it's a new process....we planned a more intensive implementation process and know we have a lot of training to improve them (plans)..."

Based on record review and interview, the facility failed to develop and document treatment goals in the comprehensive plans based on individual patient findings for 8 of 16 active sample patients (B25, C7, C21, E5, E7, G19, G24 and H12). Goals were stated in non-measurable terms or absent for some problems. These deficiencies in goal statements hinder the ability of the team to individualize treatment and to measure change in the patient consequent to treatment interventions.

Findings include:

A. Record Review: (Treatment plan dates in parentheses)

1. Patient B25 in master treatment plan (9/6/12), for problem, "Non-compliance issues with threatening behavior," a short-term goal was stated as "Patient will be develop [sic] coping mechanisms to deal with accepting limitations without becoming threatening." This goal was not measurable.

2. Patient C7 in master treatment plan (7/16/12), for problem, "Unsuccessful attempt at completion of Act 911 requirements as manifested by ...threatening and violent behaviors", listed a long term goal of "Successful completion of 911 program requirements on the unit that allow discharge" and short-term goal of "verbalize Act 911 program requirements and individual conditions of release with clear, coherent speech on three occasions per month." Goals were not measurable and did not target identified behaviors.

3. Patient C21 in master treatment plan (7/16/12), for problem, "Mania with Violence" , the long-term goal was stated as "Stable phase schizoaffective without aggression [sic];" a short-term goal was stated as "cooperate with nursing assessments and medication administration." Goals were non-measurable.

4. Patient E5 in master treatment plan (9/4/12), for problem, "Sexually Abusive Behavior," a non-measurable long term goal was stated as "Will respectfully and calmly engage in treatment while demonstrating empathy for others."

For problem, "Aggressive and Disruptive Behavior," a non-measurable long term goal was stated as "Will learn to express his/her feelings and thoughts in a calm and safe manner."

5. Patient E7 in master treatment plan (8/21/12), for problem, "It's all about me," a non-measurable goal was stated as "Will consistently take responsibility for his behavior and demonstrate role model behavior."

6. Patient G19 in master treatment plan (8/23/12) for problem, "Lacks fitness to proceed ...due to mental defect ....," a non-measurable goal was stated as "Will possess sufficient legal knowledge to undergo his forensic re-evaluation."

7. Patient G24 in master treatment plan (9/11/12), for problem, "Hypertension and visual impairment-blindness," there was no goal related to blindness.

8. Patient H12 in master treatment plan (9/4/12), for problem "No insight to appropriate interpersonal boundaries," non-measurable long-term goal was stated as "voice understanding of his diagnosis and related responsibilities according to the Act 911 requirements with this hospitalization."

B. During review of treatment plans on 9/19/20 at 2:15 p.m., the Clinical Director viewed and verified that the cited treatment plans were non-measurable.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for 14 of 16 active sample patients (A15, A16, B9, B25, C7, C21, D4, D8, E5, E7, H12, H19, I13, and I19) which included interventions that were specific treatment modalities with a specific focus or purpose, based on each patient's individual problems and goals. Instead, the MTPs included routine discipline functions and/or vague, generic and global statements written as treatment interventions. This failure results in lack of guidance to clinical staff in providing consistent and effective treatment related to patients' presenting problems and goals identified on the Master Treatment Plans.
Findings include:

A. Record Review

1. Patient A15 was admitted 10/7/10 with a diagnosis of "Schizoaffective Disorder, Bipolar type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 2/7/12 noted the following routine staff functions and vague, generic and global statements written as interventions for the following psychiatric problem.

Problem 1 - "Delusional, disorganized and agitated behavior..."

Physician - "1:1 to evaluate thinking and assess the need for any changes in treatment by use of scheduled medication."

Registered Nurse (RN) - "1:1 with Nursing [Staff's name] to stress reality and help organize [his/her] day to day activities."

Social Worker - "1:1 with Social Worker [Staff's name] to encourage reality based thinking in conversation."

2. Patient A16 was admitted 9/4/12 with a diagnosis of "Psychotic Disorder, NOS [Not Otherwise Specified]" identified on the patient's Master Treatment Plan (MTP). The
patient's MTP dated 9/7/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following psychiatric problem.

Problem 1 - "Psychotic thought process with violence/threats..."

Physician - "1:1 to monitor symptoms and side effects and adjust medications as indicated."

Registered Nurse - "...to monitor pt's [patient's] level of paranoia, promote trust, meet [his/her] needs, administer medication."
Social Worker - "... 1:1 to encourage reality based thinking."

3. Patient B9 was admitted 3/13/12 with diagnoses of " Vascular Dementia and Mood Disorder NOS [Not Otherwise Specified] " identified on the Psychiatric Evaluations dated 3/13/12 and 3/15/12. The patient ' s Master Treatment Plan dated 8/2/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following problems:

Problem 1 - "Noncompliance with Conditions of Act 911..."

Physician - "1:1 with Physician, [MD's name] or designee. 1x weekly to assess the effectiveness of his/her medication."

Registered Nurse - "Nsg [Nursing] to administer medication and assess for result." "Medical/Mental Health Group... 2x Weekly to encourage group attendance in order for [him/her] to learn the importance of compliance with medical treatment." [This statement was not a specific intervention which described what the staff will do to assist the patient with his/her identified problems with compliance with medical treatment.]

Social Worker - "Interpersonal Skills...2x Weekly to encourage compliance with treatment through group attendance."

OTR [Registered Occupational Therapist] - "Successful Living Group...Weekly to encourage group attendance through improving relationship with others."

Problem 3 - "Poor Impulse Control ..."

There were no interventions listed for this problem.

4. Patient B25 was admitted 10/20/11 with a diagnosis of "Bipolar I Disorder, Most Recent [sic]" identified on the census list. The patient's Master Treatment Plan updated 9/6/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following psychiatric problem:

Problem 3 - "Delusional Thought Process..."

Physician - "1:1 with Physician, [MD's name] or designee. 1x weekly to prescribe medications and assess for effectiveness on reality-based conversations."

Registered Nurse - "1:1 with Nursing to encourage looking at life issues realistically."

5. Patient C7 was admitted 6/14/12 with a diagnosis of "Schizophrenia, Paranoid Type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 7/16/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following problem:

Problem 1 - "Unsuccessful attempt at completion of Act 911 requirements..."

Physician - "1:1 with Physician, weekly to evaluate thought process, review/develop program requirement and individual conditions of release."

Registered Nurse - "1:1 with Nursing, daily to review behavioral observations and to provide behavioral support."

Social Worker - "1:1 with Social Worker, weekly to review program requirements and conditions of release and to affect discharge plan."

6. Patient C21 was admitted 7/9/12 with a diagnosis of "Schizophrenia, Bipolar Type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 7/13/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following psychiatric problem:

Problem 1 - "Manic with violence..."

Physician - "1:1 with Physician, weekly. MD will meet with patient to monitor response to medications."

Registered Nurse - "1:1 with Nursing, daily to stress reality, assess patient ' s mental status, & administer medication."


Social Worker - "1:1 with Social Worker weekly to stress reality and assist pt [patient] in gaining insight into illness & need for compliance with tx [treatment]."

7. Patient D4 was admitted 7/24/12 with a diagnosis of "Mood Disorder, NOS [Not Otherwise Specified], Psychotic Disorder, NOS" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 8/24/12 and updated 9/7/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following psychiatric problem:

Problem 1 - "Aggression related psychosis..."

Physician - "1:1 with MD, [MD ' s name] or designee biweekly to assess [Patient's name] response to treatment."

Registered Nurse - "Nursing, daily to redirect behaviors and encourage [Patient's name] to report presence or absence of hallucinations."

Social Worker - "1:1 with Social Worker, [staff's name] 1x/week to encourage respectful reality based conversation."

8. Patient D8 was admitted 2/22/11 with diagnoses of "Conduct Disorder, Unspecified Onset, Mood disorder NOS [Not Otherwise Specified]" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 9/10/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following problem:

Problem 1 - "Difficulty with Transitioning..."

Physician - "1:1 with MD, [MD ' s name] or designee. Biweekly to assess [Patient's name] response to treatment and adjust or modify treatment as needed."

Registered Nurse - "Nursing. [RN's name] or designee. Daily to... redirect [his/her] behavior as needed."

9. Patient E5 was admitted 8/7/12 with diagnoses of "Sexual Abuse of a Child, Perpetrator ... Posttraumatic Stress Disorder, Disruptive Behavior Disorder, Not Otherwise Specified..." identified on the patient ' s Master Treatment Plan (MTP). The patient's MTP dated 9/4/12 noted the following routine and generic staff functions written as interventions for the following psychiatric problems:

Problem 1 - "Sexually Abusive Behavior."

Registered Nurse - "Maintenance Cycle, [RN's name], 1x weekly to encourage honest and respectful discussion of maintenance behaviors."

Social Worker - "Psycho Ed [Education] Group [Social Worker's name] or designee, 2x weekly to encourage the development of accountability and empathy while calmly engaging in treatment and gaining an understanding of sex offender concepts."

Problem 2 - "Aggressive and Disruptive Behavior."

Physician - "1:1 with MD, [MD's name] or designee. biweekly x2 months then monthly and as needed to encourage positive expression of thoughts and feelings and calm, safe behaviors and interactions with others."

Registered Nurse - "Nursing, [RN ' s name] or designee, 1x week [sic] to encourage positive and safe expression of feelings and calm interactions with others."

Psychology - "DBT [Dialectical Behavior Therapy] [staff's name] 2x week ...to encourage the healthy and safe expression of emotions."

Recreation - "Leisure Skill Group, [Recreational Therapist's name], 1x week [sic] to encourage positive and safe social interaction with peers."

10. Patient E7 was admitted 12/13/10 with diagnoses of "Sexual Abuse of a Child, Perpetrator, Conduct Disorder..." identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 8/21/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following problems:

Problem 1 - "Sexually Abusive Behavior"

Social Worker - "Psychoed [Psycho-education] [staff's name] or designee. 2x week to work towards clarification by identifying the short and long term effects [his/her] behaviors have had on his/her brothers, both emotionally and physically."

Problem 2 - "It's all about me."

Physician - "1:1 with MD, [MD's name] or designee. Monthly and as needed to discuss progress and role model behaviors." "Check-in Group, [MD's name] or designee. 2x week to process interpersonal issues [s/he] presents in groups."

Registered Nurse - "Nursing, [RN's name] or designee. 1x weekly to encourage respectful acceptance of redirection and responsible behavior."

Recreation - "Leisure Skills Group, [staff's name] weekly learn to accept and follow rules respectively."

11. Patient H12 was admitted 7/2/94 with recent diagnosis of "Depressive Disorder" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 9/4/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following problems:

Problem 1 - "No insight to Appropriate Interpersonal Boundaries..."

Social Worker - "1:1 with Social Worker, [staff's name], Weekly and prn [Pro re nata/as needed] with LSW to assess patient's acceptance of diagnosis and responsibilities."

Problem 2 - "Depression..."

Physician - "1:1 with Physician. [Physician's name] or designee. 1x monthly to monitor medication effectiveness and side effects and monitor subjective mood and objective affect improvements."

Registered Nurse - "1:1 with Nursing, document daily subjective moods and objective affect including document meal intake." "Medication Compliance group once weekly [RN's name] to encourage patient to comply with treatment and participate in discussions."

Social Worker - " Successful Living. [Staff's name] or designee. 1x Weekly to encourage patient to participate in discussions r/t [related to] life skills."

12. Patient H19 was admitted 12/1/04 with a diagnosis of "Schizoaffective Disorder, Bipolar Type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 9/11/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following psychiatric problem.

Problem 1 - "Delusional thinking resulting inability to assist in her/his defense..."

Physician - "1:1 with Physician. [Physician's name] or designee. 1x monthly and prn [as needed] to assess effectiveness of meds [medications] and [his/her] progress toward having reality-based conversations."

Registered Nurse - "Nursing Daily [RN's name] or designee to provide meds [medications] and assess and document behavior and ability to have reality-based conversations daily, weekly to... assess/doc [document] progress."

Social Worker - "1:1 with Social Worker [staff's name] or designee Weekly or prn [as needed] to engage [Patient's name] in reality-based conversations r/t [related to] [his/her] legal charges and dc [discharge] planning."

13. Patient I13 was admitted 7/23/12 with diagnoses of "Major Depressive Disorder, Single Episode; Cognitive Disorder NOS [Not Otherwise Specified]" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 8/16/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following psychiatric problem.

Problem 1 - "Depressed Mood and possible cognitive impairment..."

Physician - "1:1 with MD weekly to improve mood and increase appetite..."

Registered Nurse - "Medication/Mental Health, [staff name] or designee once weekly to encourage [patient's name] to discuss her/his personal, medical, and mental health issues and provide praise when [s/he] is able to participate."

Social Worker - "Survive and Thrive Group [Staff's name] to encourage [patient's name] to identify physical sensations when under emotional distress."

14. Patient I19 was admitted 4/16/12 with a diagnosis of "Schizophrenia, Paranoid Type " identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 8/8/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following psychiatric problem.

Problem 1 - "Psychosis with homicidal actions..."

Physician - "1:1 with physician [staff ' s name] weekly to evaluate level of psychosis and the need for any medication changes."

Registered Nurse - "Nursing Daily [Staff ' s name] to discuss how medication can help reality based thinking." "Medication and Treatment Compliance - once weekly to emphasize medication compliance with court order treatment including medication and medical appointments."

Social Worker - "1:1 with Social Worker [Staff ' s name]. Weekly to build therapeutic rapport with [patient's name] in order to establish level of comfort in conversing with staff members."

B. Staff Interviews

1. In an interview with RN 11 on 9/18/12 at 10:30 a.m., the master treatment plans for Patient I13 and I19 were reviewed. RN 11 agreed that statements on the treatment plan were routine staff functions and some statements were generic and vague statements written as treatment interventions.

2. In an interview on 9/19/12 at 2:30 p.m. with RN 12, the treatment plans for Patient A15 and A16 were reviewed. RN 12 agreed that statements on the treatment plan were routine staff functions and some statements were generic and vague statements written as treatment interventions.

3. In an interview on 9/19/12 at 2:00 p.m. with the Clinical Director, the Master Treatment Plans for active sample patients were discussed. The Clinical Director acknowledged that treatment plans contained discipline functions and generic statements written as individualized treatment interventions.

Based on observation, interview and document review, the facility failed to ensure that active individualized psychiatric care was provided for 4 of 16 active sample patients (B9, E7, G19 and I13), and 10 of 10 non-sample patients (C26, C27, E1, E2, E9, E12, E13, F6, F15 and G11) and 2 of 4 discharged patients (K1 and K4) who were added to the sample for review of active treatment. Specifically there was failure to:

I. Provide necessary medical care for 2 of 4 discharged patients (K1 and K4) whose medical records were reviewed because of adverse treatment outcomes. The facility failed to provide immediate physician and laboratory assessment of potentially serious medical conditions. Patient K1 was transferred to a medical intensive care unit because of a low blood sodium level. Patient K4 was transferred to a medical facility for blood transfusion and treatment of an infection. This failure to assess and treat medical problems resulted in adverse outcomes for these patients and is a potential risk for morbidity and mortality for patients in the facility with serious medical problems.

II. Provide active psychiatric treatment as the primary focus of hospitalization for patients served on 1 of 9 Units (Unit E), an 18-bed unit serving adolescent male sex offenders. All patients were admitted to Unit E to complete the sex offender program and were not acutely ill when admitted. The treatment for all patients in this unit (13 on the first day of the survey) consisted of a formal psycho-educational program . The focus of this program was on areas other than treatment for psychiatric symptomatology. Although all 13 patients had Axis I diagnoses (most related only to sex offenses), the patients received no treatment for psychiatric symptomatology. This results in failure of the facility to focus its function on psychiatric treatment of patients in need of acute inpatient care.

III. Ensure that active individualized psychiatric treatment was the primary focus of hospitalization provided for 2 of 2 active sample patients (B9 and G24) and 2 patients added to the sample (F15 and G11) who were hospitalized by judicial order without specific psychiatric problems, or continued to be hospitalized beyond the time that their psychiatric problems were resolved. This failure results in patients remaining hospitalized without defined psychiatric treatment needs that can be addressed.

IV. Provide interpreter services according to facility policy for 1 of 1 patients (I13) on Unit 6 Lower who was not proficient in the English language. This failure compromises the ability of all patients who are non-proficient in English to adequately participate in treatment.

V. Provide active treatment as the primary focus of hospitalization for 3 of 3 non-sample patients (C26, C27, and F6) added to the sample from the Developmental Disability Program. These patients were admitted due to mental retardation or other cognitive disorders and attended a Developmental Disability Program as their only treatment. This program is designed for persons having a developmental disability and is based on a cognitive approach consistent with a residential model that focuses on other issues rather than psychiatric symptomatology. This results in prolonged hospitalization of patients in an acute setting rather than treatment in a less restrictive environment.

Findings include:


I. Medical Care:

A. Patient K1

Patient K1 was admitted 4/26/11 on a court order to restore competency. The admission Psychiatric Evaluation stated that Patient K1 had a past history of "some degree of renal insufficiency, sometimes judged to be of moderate degree." The progress note for Patient K1 on 1/22/12 at 9:00 p.m. stated "we found approx (approximately) 500 [to] 1000 cc emesis in sink. . ." A review of the progress notes indicated that Patient K1 continued to have episodes of vomiting documented on 1/23/12 at 8:35 p.m., on 1/24/12 at 9:30 a.m., on 1/25/12 at 8:45 p.m., on 1/26/12 at 3:30 a.m., and on 1/26/12 at 10:00 a.m. In addition, on 1/26/12 at 2:30 a.m., Patient K1 was "noted to be drinking lg (large) amts (amounts) of water." Progress notes stated that on 1/25/12 at 3:00 p.m., "Lab has been ordered & apparently he refused to allow blood drawn this AM" and on 1/26/12 at 9:00 a.m., Patient K1 "continues to request water and states he is thirsty. . . refused lab draw." After blood was obtained from Patient K1 on 1/26/12 at 10:50 a.m., the laboratory called the unit and "reported sodium level 115" at 12:00 noon. On 1/26/12 at 1:45 p.m., the progress notes stated "Talked to [medical physician] referred to Medical Clinic. [Medical physician] stated to inform [attending psychiatrist] that pt needs to go to... ER (emergency room)." Patient K1 was transported to the emergency department (ED) of a medical facility on 1/26/12 around 2:30 p.m.

The "ED Primary Triage Note" in the medical record from the medical facility dated 1/26/12 at 2:51 p.m. stated "Hx (history) from ASH (Arkansas State Hospital) states NA (sodium) of 115 today, moderate renal insufficiency, water drinker, vomiting today."

The "General Medical - Adult" assessment in the medical record from the medical facility dated 1/26/12 (no time) stated: "Chief Complaint: Vomiting/abnormal labs" and "Pt has been vomiting x (times) 1 week. Pt drinks a lot of water/ice water. Has only been drinking water." The "Clinical Impression" included "primary polydipsia." "Will admit to MICU (Medical Intensive Care Unit)."

A review of the medical record indicated no physician examination or assessment of the physical status of Patient K1 was documented from the time of the onset of vomiting until the arrival of Patient K1 at the emergency department of an outside medical hospital. No fluid input or output was documented in the medical record during this period. No laboratory studies were obtained until the day of transfer to the outside medical hospital.

During an interview with the Medical Director on 9/19/12 at 2:30 p.m., he stated that staff "have to watch him (Patient K1). He drinks water." The Medical Director acknowledged that no physician evaluation was documented for Patient K1 from 1/22/12 until he was evaluated at an outside medical facility on 1/26/12. He stated that the patient's symptoms "could have been addressed more aggressively."

B. Patient K4

Patient K4 was admitted 7/13/12 due to "agitated and disorganized behavior." Referral information, including the "Discharge Summary Note" dated 6/15/12 from an outside medical facility, indicated Patient K4 had a history of sickle cell disease with a history of multiple sickle cell crises and serious complications from the disease including priapism with surgery, splenectomy, hip and shoulder replacement, and multiple blood transfusions. An infusion port had been placed in a blood vessel for access to draw blood. The admission "Medical History & Physical Examination" dated 7/14/12 at 9:20 a.m. stated the diagnosis as "sickle cell." The RN progress noted on 7/14/12 at 2:10 p.m. stated that Patient K4 "c/o [complained of] chest pain. . . [physician] called orders to monitor him. . ." The psychiatrist progress note on 7/16/12 at 11:21 a.m. stated that Patient K4 "said he doesn't feel well because of headache and body aches. Says I need to talk to his sickle cell doctor." Admission laboratory studies were not obtained until 7/18/12. The psychiatrist note on 7/18/12 at 1:12 p.m. stated that Patient K4's "hemoglobin was 5.3 and hematocrit was 15.7. Wonder if psychosis is secondary to delirium. Will transfer to [medical facility]. . ." Patient K4 was transported to the ED of a medical facility on 7/18/12 around 2:30 p.m.

Laboratory studies in the ED on 7/18/12 at 3:37 p.m. included: white blood count = 17.08 K/mm3 (normal values 4.5-10.00), hemoglobin = 4.9 Gram/deciLiter (normal values 2.5-16.3), and hematocrit = 14.8% (normal values 36.0-55.0).

The "Discharge Summary Note" from the medical facility, dated 7/21/12 at 4:58 p.m., stated that Patient K4 presented to the ED with "probable sickle cell crisis" and "received 4 units of blood transfusion." In addition, "as a part of sepsis work up for leucocytosis, blood culture was done from infusion port which grew coagulase negative staph (staphylococcus) and he was started on vancomycin IV (intravenous)." The infusion port was removed at the medical facility on 7/23/12 because of an infection.

Patient K4 was transferred back to the current facility on 7/30/12.

The discharge summary for Patient K4 dated 8/2/12 summarizing the re-hospitalization of Patient K4 after returning to the facility on 7/30/12 stated that while Patient K4 was hospitalized at the medical facility, he "was treated for severe anemia. . . received several transfusions. . . [Patient K4] was also found to have an infection on his infusion port which had to be removed. He received antibiotics for septicemia." Patient K4's "mental status was much improved" at time of re-admission to the facility on 7/30/12 and the "Admission Diagnosis" on this discharge summary stated "Psychotic disorder not otherwise specified, delirium resolved."

A review of the medical record indicated no physician examination or assessment of the physical status of Patient K4 was documented after the initial Physical Examination on 7/14/12 until the arrival of Patient K4 at the emergency department of an outside medical hospital on 7/18/12. No laboratory studies were obtained during this hospitalization until the day of transfer to the outside medical hospital despite a history of severe sickle cell anemia.

During an interview with the Medical Director on 9/19/12 at 2:30 p.m., he acknowledged that, based on the patient's history, a laboratory evaluation should have occurred earlier in the hospitalization. He stated that the blood work should have been obtained "certainly by the next day [following admission]" or "immediately if symptomatic."

II. Adolescent Sexual Offender Program:

A. Unit E was an 18-bed unit serving male adolescent sex offenders. On the first day of the survey (9/17/12), there were 13 adolescent patients. All patients were admitted to Unit E to attend the sexual offender program and were not acutely ill when admitted. Even though all 13 patients had Axis I diagnoses, the focus of the program was on areas other than treatment for psychiatric symptomatology.

B. The "Arkansas State Hospital Plan for Patient Services 2012/2013," in the section "Treatment Program Overview Adolescent Offender Program," states "The unit provides treatment for adolescent males who have engaged in sex offending behaviors. Evaluations address severity of offenses, family situation, risk factors for re-offending, and the primacy of sex offenses within the problematic behaviors of the individual. The Adolescent Sex Offender Program follows a highly structured cognitive behavioral residential model. Efforts are made to restructure problematic cognitive and behavioral patterns that lead to offending."

C. During interview on 9/18/12 at 8:30 a.m., the Clinical Director stated that patients on Unit E were "all residential." She stated that patients on Unit E were admitted to the facility for a "residential" level of treatment for sexual offenses with the majority being adjudicated prior to admission. She stated that programming on Unit E involved five levels or tasks that the patients must complete to "graduate" from the program. She stated these were cognitive-behavioral tasks. She stated that acutely ill patients, such as those who were psychotic, who could not benefit from the cognitive nature of the programming, would be transferred to another unit for treatment.

D. During interview on 9/19/12 at 3:45 p.m., the Medical Director stated, "This is a good residential program [Unit E] in an acute care setting. The primary reason for admission is a sex offense." When asked how the staff knew when the patient is ready for discharge, the Medical Director responded, "When they have reached the cognitive and behavioral bench marks of the program in each level. When they graduate from the program or can go no further in the program. This is the only program of this type with this level of security in the state (Arkansas). It is not the level of treatment, but more the security [of the program]."

E. During an interview with the Medical Director on 9/19/12 at 10:00 a.m., he stated that "none [of the patients were] admitted under acute circumstances" to Unit E. He stated "the primary issue is their sexual offense." He acknowledged that the treatment being provided could be performed as an outpatient except that the community programs "are not as secure." He acknowledged that the treatment being provided for patients on Unit E was residential level and stated "we call it a residential sex offender program."

F. Review of the records revealed that 6 of the 6 patients reviewed on Unit E on the first day of the survey (9/17/12) were admitted solely for the cognitive sex offender program and did not present diagnoses requiring active psychiatric treatment, including psychotropic medications for such illnesses. Patient findings include:

1. Sample Patient E7 was admitted on 12/13/10. The only Axis I diagnoses for this patient were "Sexual Abuse of a Child, Perpetrator" and "Conduct Disorder." This patient received no treatment for psychiatric symptomatology.

2. Non-sample Patient E1 was admitted on 9/13/12. The only Axis I diagnoses for this patient were "Sexual Abuse of a Child, Perpetrator" and "Attention Deficit Hyperactive Disorder." This patient received no treatment for psychiatric symptomatology.

3. Non-sample Patient E2 was admitted on 9/30/11. The only Axis I diagnoses for this patient were "Sexual Abuse of a Child, Perpetrator" and "Oppositional Defiant Disorder." This patient received no treatment for psychiatric symptomatology.

4. Non-sample Patient E9 was admitted on 5/31/12. The only Axis I diagnoses for this patient were "Sexual Abuse of a Child, Perpetrator" and "Attention Deficit Disorder." This patient received no treatment for psychiatric symptomatology.

5. Non-sample Patient E12 was admitted on 2/13/2. The only Axis I diagnoses for this patient were "Sexual Abuse of a Child, Perpetrator" and "R/O [Rule out] ADHD [Attention Deficit Hyperactive Disorder]." This patient received no treatment for psychiatric symptomatology.

6. Non-sample Patient E13 was admitted on 8/20/12. The only Axis I diagnoses for this patient were " Sexual Abuse of a Child, Perpetrator," "Conduct Disorder," and "ADHD." This patient received no treatment for psychiatric symptomatology.

III. Judicial-Ordered Hospitalization:

A. Specific Patient Findings

1. Patient B9

Patient B9 was an adult who was admitted to the facility on 3/13/12. S/he was admitted under a court order that was initiated 3/5/2008. According to psychiatric evaluations dated 3/13/12 and 3/15/12, diagnoses on admission were "Dementia-vascular" and "Mood Disorder, not otherwise specified." S/he was admitted after throwing a tray and jumping the fence at a nursing home. The 3/13/12 psychiatric evaluation documented "...denied Hallucinations, delusions, paranoia or ideas of reference. [S/he] denied symptoms of depression...changes in appetite or suicidal ideation. [S/he] denied homicidal ideation as well ...did not endorse symptoms of overwhelming anxiety, re-experiencing symptoms, obsessions or compulsions."

On Patient B9 ' s treatment plan (dated 8/30/12), problem 1 was identified as "Noncompliance with Conditions on Act 911 as manifested by the patient reportedly refused medication at the nursing home; cursed nursing home staff; threw a food tray on the floor; and climbed a fence," with long term goal listed as "The patient will demonstrate compliance with treatment while hospitalized and will verbalize agreement to be compliant in regard to the terms of [his/her] conditions of release when [s/he] is ready for discharge." Interventions to address this problem included groups listed as "interpersonal skills, medical/mental health group, stress management and successful living."

During interview on 9/18/12 at 10:30 a.m., RN 10 stated "[Patient] was kicked out of nursing home...not appropriate for acute care. We are not able to discharge this patient because of a court order." RN10 stated that she felt that Patient B9 had "reached ... baseline but the nursing home will not take [Patient] back at their facility and another placement has not been found". RN 10 reported that Patient B9 is non-compliant with group attendance, "especially during the last three weeks."

Review of the medical record revealed that Patient B9 attended only 12 of the 23 treatment groups assigned from 8/27/12 through 9/17/12.

2. Patient G19

Patient G19 was an adult who was admitted to the facility on 5/30/12 ordered by the legal system to undergo fitness restoration to stand trial. The Psychiatric Evaluation, dated 5/30/12, stated [Patient G19] had "no historical axis I diagnosis; however [s/he] carries an axis II diagnosis of moderate mental retardation. . . reports no current signs or symptoms of mental distress, including no signs or symptoms of depression, mania, hypomania, anxiety or psychosis . . . No overwhelming feelings of hopelessness, helplessness and worthlessness . . . has never required inpatient hospitalization . . . has never required outpatient psychiatric treatment or substance abuse treatment." Admission diagnoses included: "Axis I: None. Axis II: Moderate mental retardation with a reported full-scale IQ (intelligence quotient) of 47."

The "Problem Status" section of the "Multi-Disciplinary Master Treatment Plan" (MTP), revised 8/23/12, indicated that the problem was "Lacks Fitness to Proceed," and the Long Term Goal was "[Patient G19] will possess sufficient legal knowledge to undergo (his/her) forensic re-evaluation." The "Modality/Focus" to address this problem only included educational interventions. Patient G19 received no psychiatric medications or psychiatric interventions during his/her hospitalization. Physician progress notes indicated no mental status abnormalities except "appearance" "unkempt" and "judgment/insight" "fair."

During an interview with MD1 on 9/17/12 at 1:30 p.m., she stated that she was not sure that Patient G19 would ever regain competency to stand trial due to his cognitive limitations. She acknowledged that Patient G19 was hospitalized only because of his forensic order and received no active psychiatric interventions during this hospitalization. She stated that Patient G19 would receive the next competency evaluation at the end of the current court order on January 23, 2013 and that Patient G19 would remain hospitalized until that time.

3. Patient F15

Patient F15 was an adult admitted on 6/8/12 based on a court treatment order "to restore (him/her) to fitness to proceed in this matter [to assist effectively in his/her own defense]." The psychiatric evaluation dated 6/9/12 stated "does not report any recent suicide attempts ...denies suicidal ideation or intent...does complain of a considerable amount of anxiety." The admitting diagnoses were "Schizophrenia Disorder, Bipolar Type" and "Cannabis Abuse."

During interview on 9/18/12 at 3:00 p.m., RN9 stated that Patient F15 remains in the hospital "because (s/he) is waiting for his evaluation (competency)."

During interview on 9/18/12 at 3:15 p.m., MD5 reported that Patient F15 "was not acutely ill when [patient] came in and does not now get any psychiatric medications since July 25, 2012. [Patient] is currently stable but can't release as [s/he] is under a legal hold."

4. Patient G11

Patient G11 was an adult who was admitted to the facility on 2/16/12 ordered by the legal system to undergo fitness restoration to stand trial.

A review of the "Physician Progress Notes" from 3/2/12 to 9/5/12 indicated no psychiatric symptoms on the mental status examination except "judgment/insight" "fair" or "poor." There were no abnormalities noted for "mood," "process," "thought content," "hallucinations," or "delusions" during this period.

The psychological testing dated 9/17/12 indicated a Full Scale Intelligence Quotient of 49 and that Patient G11's " psychotic symptoms and behavioral disturbances have been much more stable in recent months. . . [Patient G11] would benefit from a referral to DDS (Developmental Disability Services) for supportive assistance and discharge placement."

During an interview with MD1 and SW1 on 9/17/12 at 2 p.m., they acknowledged that Patient G11 was ready to be discharged from the facility but could not be discharged until a community provider and a source for community funding could be obtained.

During an interview with MD1 on 9/19/12 at 9:00 a.m., she stated that Patient G11 was "institutionalized in many ways" and that the staff had "become [Patient G11's] family." "When [s/he] came back (readmitted), [s/he] felt like [s/he] was home." MD1 stated that problem behaviors demonstrated by G11 since February 2012 were related to his/her level of cognitive functioning rather than his psychiatric illness and that only minor adjustments had been made in his psychotropic medications since February 2012. She stated that G11 had "reached baseline" and ready for discharge for at least "two to three months."

B. Additional Interviews

1. During an interview on 9/19/12 at 9 a.m., MD1 stated that patients who were admitted by court order for fitness restoration did not necessarily have a psychiatric illness and some remained hospitalized after the resolution of their psychiatric illness until they could understand and cooperate with the legal process. MD1 stated that some patients might never meet fitness for trial criteria but remained hospitalized by court order. She stated that patients remained hospitalized up to 21 days after the recommendation was made for them to return to court.

2. During an interview on 9/19/12 at 11:00 a.m. with MD2 and Therapist 1, Therapist 1 stated that there were two areas in which patients could be found unfit to stand trial. The first area was behavioral problems that disrupted the court process or ability of the patient to cooperate with legal counsel. The second area was the cognitive ability of the patient to demonstrate a basic understanding of the legal system. MD2 and Therapist 1 acknowledged that some forensic patients were hospitalized for a deficiency in the knowledge area only, without behavioral or psychiatric issues. MD2 and Therapist 1 also acknowledged that the behavioral problems of some of the forensic patients resolved but they continued to be hospitalized until the cognitive and knowledge criteria were also met.

3. During an interview on 9/19/12 at 2:30 p.m., the Medical Director stated that patients hospitalized for fitness restoration repeatedly attended many of the same groups due to their long length of stay, that they became over-familiar with the content of the groups. He stated that the level of clinical care needed for many of the patients admitted for fitness restoration was residential rather than acute psychiatric inpatient. He stated that the legal system did not allow a more appropriate level of care due to the security requirements of the court order.

C. Policy Review

The facility policy "Court Fitness Restoration," dated 11/99, states, "Patients requiring inpatient fitness restoration services will be sent to [the facility]... with a court order...The presiding judge makes the final decision related to the patient's fitness (to stand trial). Once a patient is ordered to be fit by the presiding judge, he/she will be discharged from the hospital on his/her court date."

07809
IV. Failure to provide necessary interpreter services:

A. Observations

1. During an observation on Unit 6 Lower on 9/18/12 from 10:00 a.m. to 10:18 a.m., Patient I13 attended the Medication/Treatment Compliance Group in the Treatment Mall conducted by RN 11. The patient sat with his/her head down and eyes closed during this time. At the end of the group, RN 11 asked the patient about his/her medications. Patient I13 did not respond verbally and shook his/her head and appeared confused about what was being asked.

2. During an observation on Unit 6 Lower on 9/18/12 from 10:35 a.m. to 11:15 a.m., Patient I13 attended the "Interpersonal Problem Solving Group" conducted by Psychologist 1. Patient I13 sat with his/her eyes closed and did not participate during the session. Psychologist 1 did not engage the patient to participate during the period of this observation.

B. Document Review

1. A review of the medical record revealed that Patient I13 was a 51 year-old Hispanic patient with a diagnosis of Major Depressive Disorder, admitted to the facility on 7/23/12.

2. A review of the Master Treatment Plan (MTP) for Patient I13 dated 8/16/12 stated that Patient EI "speaks little to no English and required a translator for initial interview." The signature page contained the following statement, "Interpreter not available, will review [with] pt [patient] when interpreter is available." Short-Term Goals listed on the MTP included: "Identify 3 coping skills to help manage depressed mood and anxiety two times weekly for one month; [Patient's name] will have controlled seizures with use of daily medication. She will be pain free from migraine headaches with use of PRN medication; and Patient will be able to identify the roles of the judge, lawyers, and jury two times a week for four weeks."

3. Interventions on the MTP included: Physician - "1:1 with MD weekly to improve mood and increase appetite and to educate [Patient's name] about the possible side effects of [his/her] medication." RN or designate: - "to encourage [Patient's name] to discuss when [s/he] is sad and anxious and provide positive feedback for sharing feelings appropriately. " Social Worker - "1:1 with Social Worker to discuss 3 boundary types and to increase self-esteem." RN or designee - "Medication/Mental Health ... once weekly to encourage [Patient's name] to discuss her personal, medical, and mental health issues and provide praise when she is able to participate." Social Worker- "Survive and Thrive Group ... to encourage [Patient's name] to identify physical sensations when under emotional distress." Social Worker - "Competency Group [staff name] or designee, 2x Week to teach patient court proceedings and how to assist with [his/her] defense with use of a Spanish competency workbook."

Except for the Competency Group, the plan contained no other strategies for implementing these interventions with the assistance of an interpreter or how to address her communication needs without the presence of an interpreter.

4. A review of the progress notes from 7/26/12 through 9/16/17 included but was not limited to the following documentation:

a. Surviving and Thriving Group - Progress Notes dated 7/26/12 at 14:15 stated, "Patient did not attend." Progress note dated 8/2/12 stated, "Today was [Patient's name] first day in the group. [S/he] said [s/he] does not speak English. [S/he] was able to participate in the group discussion." Progress note dated 8/23/12 at 12:12 stated, "No progress.....
[Patient's name] was attentive in group but the language barrier prohibited [his/her] from fully participating in the discussion." Progress Notes dated 9/6/12 at 13:42 stated "No progress ... [Patient's Name] was quiet and attentive but was not able to fully participate because of language barriers."

b. Interpersonal Problem Solving Group - Progress Notes dated 7/27/11 (no time entered), stated "Absent. Refused." Progress Notes dated 8/3/12 (no time entered), stated "Absent. Excused." Progress notes dated 8/14/12 (no time entered), stated... "[S/he] was smiling and discussed limitations due to non English speaking interactions with others." Progress notes dated 8/12/12 (no time entered), stated... "Identified ways to increase self-esteem." There were no notes regarding Patient I13's response to this intervention. Progress Notes dated 8/24/12 (no time entered), stated "0 progress. Did not participate but was awake." Progress notes dated 8/28/12 stated, "0 progress. Had difficulty understanding discussion regarding self esteem and boundaries due to English being a second language." Progress notes dated 9/4/12... "Listened to the different boundary types explained with use of Spanish speaking staff to assist in communicating group discussion." Progress Notes dated 9/11/12 (no time entered), stated "0 progress. Quiet and asleep."

c. Competency Group - Progress Notes dated 7/30/12 at 12:19 p.m., stated "... The patient did not attend group this week due to 6 lower being placed on lock down. 0 progress." Progress Notes dated 8/1/12 at 12:49 p.m. stated, "... The patient did attend group. [S/he] is minimally attentive to the topic today regarding crimes of the person, but did not take part in the discussion. [S/he] keeps her head down and states [s/he] cannot speak English..." Progress Notes dated 8/27/12 at 2:01 p.m. stated, "... The patient did attend group today. However, [s/he] would not even try to answer any of the questions on the test ... 0 progress." Progress Notes dated 8/29/12 at 12:33 p.m. stated, "... The patient did not attend group today. 0 progress." Progress Notes dated 9/5/12 at 1:47 p.m. stated, "... The patient did attend group today. [S/he] is minimally attentive and uninterested... 0 progress." Progress Notes dated 9/12/12 at 12:21 p.m. stated, "... The patient did not attend group today. 0 progress."

d. Medication/Mental Health - Progress Notes dated 8/14/12 (no time entered) stated, "Patient arrived in group late and sat quietly. - No participation."

A review of the progress notes revealed that clinical staff documented "0 Progress" in groups attended by Patient I13 during the period from 7/26/12 and 9/16/12. The progress notes also revealed that the patient did not attend groups 5 times and staff recorded mixed progress (+/-) 7 times. Despite Patient I13's continued lack of participation and progress in treatment groups, the medical record revealed that there was no revision of the MTP to assign alternative treatment approaches or 1:1 sessions to address the treatment goals identified nor was an interpreter provided to assist in groups, except for once in the Interpersonal Problem Solving Group.

5. The facility's "Policy#: ASH 11.07.01 - Service to Hearing Impaired Patients / Foreign Language Interpreters" stated, "... The Social Work Department will have ultimate responsibility for establishing contracts or locating qualified interpreters the deaf and non-English speaking persons that come to the [Name of Hospital]." The Social Work Department will have the responsibility of notifying, the agency with a contract for this service [Foreign Language Patients] or will activate community resources to obtain this interpreter.

C. Interviews

1. During an attempted interview with Patient I13 on 9/17/12 at 11:30 a.m., [s/he] did not respond verbally to the surveyor or RN 2. RN 2 stated that Patient E17 did not understand English and stated "The interpreter comes on Wednesday to meet with the treatment team and go with the patient for medical clinic appointments." RN 2 stated that the interpreter was not available for group treatment.

2. During an interview with RN 11 on 9/18/12 at 10:30 a.m. following the "Med[Medication/Tx [treatment] Compliance Group," RN 11stated, "I can't say why the patient doesn't have medication information in Spanish."

3. During an interview with Psychologist 1 on 9/18/12 at 11:15 a.m. following the "Interpersonal Problem solving Group", Psychologist 1 stated that Patient I13 had not been participating in the group and agreed that group without an interpreter was not appropriate for this patient. Psychologist 1 stated that she sometimes used the interpreter during the treatment team meeting to translate content covered in the group but agreed that this was not adequate.

4. During an interview on 9/19/12 at 10:15 a.m., with the Clinical Director, the availability of medication information for patient written in Spanish was discussed. The Clinical Director was not aware of information but later informed the surveyor, that medication information for patients in Spanish wa

Based on interview and document review, the Medical Director failed to provide adequate medical oversight to ensure quality medical services. Specifically, the Medical Director failed to:

I. Ensure that problems/issues presented by 8 of 16 sample patients (B9, B25, D4, E5, E7, G19, G24 and H12) were clearly stated on the patients' Master Treatment Plans. The stated problems on the treatment plans included diagnoses, lists of symptoms and generalized, confusing statements rather than specific problem behaviors which had to be reduced/resolved for the patient to live in a less restrictive environment. For some plans, the goals and/or interventions failed to correlate with the identified problems. This failure results in fragmented treatment plans and lack of specific direction for patients and staff in addressing specific patient problems. (Refer to B119)

II. Ensure the development and documentation of treatment goals in the Master Treatment Plans were based on individual patient findings for 8 of 16 active sample patients (B25, C7, C21, E5, E7, G19, G24 and H12). Goals were stated in non-measurable terms or were absent for some problems. Deficient goal statements hinder the ability of the team to individualize treatment and to measure change in the patient in response to treatment interventions. (Refer to B121)

III. Ensure that individualized physician treatment modalities were developed to address the identified needs of 14 of 16 active sample patients (A15, A16, B9, B25, C7, C21, D4, D8, E5, E7, H12, H19, I13 and I19). Instead, the Master Treatment Plans included routine discipline functions and/or vague, generic and global statements. This deficiency results in failure to provide specific guidance for medical staff to care for each patient, based on the patient ' s individual psychiatric needs.

Findings include:

A. Record Review

1. Patient A15 was admitted 10/7/10 with a diagnosis of "Schizoaffective Disorder, Bipolar type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 2/7/12 noted the following routine staff function and vague, generic and global statements written as an intervention for the following psychiatric problem:

Problem 1 - "Delusional, disorganized and agitated behavior..."

Physician - "1:1 to evaluate thinking and assess the need for any changes in treatment by use of scheduled medication."

2. Patient A16 was admitted 9/4/12 with a diagnosis of "Psychotic Disorder, NOS [Not Otherwise Specified]" identified on the patient's Master Treatment Plan (MTP). The
patient's MTP dated 9/7/12 noted the following routine discipline function and/or vague, generic and global statements written as an intervention for the following psychiatric problem:

Problem 1 - "Psychotic thought process with violence/threats..."

Physician - "1:1 to monitor symptoms and side effects and adjust medications as indicated."

3. Patient B9 was admitted 3/13/12 with diagnoses of "Vascular Dementia and Mood Disorder NOS [Not Otherwise Specified]" identified on the Psychiatric Evaluation dated 3/13/12 and 3/15/12. The patient's Master Treatment Plan dated 8/2/12 noted the following routine discipline functions and vague, generic and global statements written as interventions for the following psychiatric problems:

Problem 1 - "Noncompliance with Conditions of Act 911..."

Physician - "1:1 with Physician, [MD's name] or designee. 1x weekly to assess the effectiveness of his/her medication."

Problem 3 - "Poor Impulse Control..."

There were no physician interventions listed for this problem.

4. Patient B25 was admitted 10/20/11 with a diagnosis of "Bipolar I Disorder, Most Recent [sic]" identified on the patient census list. The patient's Master Treatment Plan updated 9/6/12 noted the following routine discipline functions and vague, generic and global statements written as interventions for the following psychiatric problem:

Problem 3 - "Delusional Thought Process..."

Physician - "1:1 with Physician, [MD's name] or designee. 1x weekly to prescribe medications and assess for effectiveness on reality-based conversations."

5. Patient C7 was admitted 6/14/12 with a diagnosis of "Schizophrenia, Paranoid Type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 7/16/12 noted the following routine discipline function and vague, generic and global statements written as an intervention for the following problem:

Problem 1 - "Unsuccessful attempt at completion of Act 911 requirements..."

Physician - "1:1 with Physician, weekly to evaluate thought process, review/develop program requirement and individual conditions of release."

6. Patient C21 was admitted 7/9/12 with a diagnosis of "Schizophrenia, Bipolar Type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 7/13/12 noted the following routine discipline function and vague, generic and global statements written as an intervention for the following psychiatric problem:

Problem 1 - "Manic with violence..."

Physician - "1:1 with Physician, weekly. MD will meet with patient to monitor response to medications."

7. Patient D4 was admitted 7/24/12 with a diagnosis of "Mood Disorder, NOS [Not Otherwise Specified], Psychotic Disorder, NOS" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 8/24/12 and updated 9/7/12 noted routine discipline function and/or vague, generic and global statements written as an intervention for the following psychiatric problem:

Problem 1 - "Aggression related psychosis..."

Physician - "1:1 with MD, [MD ' s name] or designee. biweekly to assess [Patient's name] response to treatment."

8. Patient D8 was admitted 2/22/11 with a diagnosis of "Conduct Disorder, Unspecified Onset, Mood disorder NOS [Not Otherwise Specified]" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 9/10/12 noted the following routine discipline function and vague, generic and global statements written as an intervention for the following problem:

Problem 1 - "Difficulty with Transitioning..."

Physician - "1:1 with MD, [MD's name] or designee. Biweekly to assess [Patient's name] response to treatment and adjust or modify treatment as needed."

9. Patient E5 was admitted 8/7/12 with a diagnosis of "Sexual Abuse of a Child, Perpetrator ...Posttraumatic Stress Disorder, Disruptive Behavior Disorder, Not Otherwise Specified..." identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 9/4/12 noted the following routine and generic staff functions written as interventions for the following psychiatric problems:

Problem 2 - "Aggressive and Disruptive Behavior."

Physician - "1:1 with MD, [MD's name] or designee. biweekly x2 months then monthly and as needed to encourage positive expression of thoughts and feelings and calm, safe behaviors and interactions with others."

10. Patient E7 was admitted 12/13/10 with a diagnosis of "Sexual Abuse of a Child, Perpetrator, Conduct Disorder..." identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 8/21/12 noted the following routine discipline functions and/or vague, generic and global statements written as interventions for the following problem:

Problem 2 - "It ' s all about me."

Physician - "1:1 with MD, [MD's name] or designee. Monthly and as needed to discuss progress and role model behaviors." "Check-in Group, [MD ' s name] or designee. 2x week to process interpersonal issues [s/he] presents in groups."

11. Patient H12 was admitted 7/2/94 with a diagnosis of "Depressive Disorder..., Alcohol
"identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 9/4/12 noted the following routine discipline function and vague, generic and global statement written as an intervention for the following problem:

Problem 2 - "Depression..."

Physician - "1:1 with Physician. [Physician's name] or designee, 1x monthly to monitor medication effectiveness and side effects and monitor subjective mood and objective affect improvements."

12. Patient H19 was admitted 12/1/04 with a diagnosis of "Schizoaffective Disorder, Bipolar Type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 9/11/12 noted the following routine discipline function and vague, generic and global statements written as an intervention for the following psychiatric problem.

Problem 1 - "Delusional thinking resulting inability to assist in her/his defense..."

Physician - "1:1 with Physician. [Physician's name] or designee. 1x monthly and prn [as needed] to assess effectiveness of meds [medications] and her/his progress toward having reality-based conversations."

13. Patient I13 was admitted 7/23/12 with a diagnosis of "Major Depressive Disorder, Single Episode; Cognitive Disorder NOS [Not Otherwise Specified]" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 8/16/12 noted routine discipline function and vague, generic and global statement written as an intervention for the following psychiatric problem.

Problem 1 - "Depressed Mood and possible cognitive impairment..."

Physician - "1:1 with MD weekly to improve mood and increase appetite..."

14. Patient I19 was admitted 4/16/12 with a diagnosis of "Schizophrenia, Paranoid Type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 8/8/12 noted routine discipline function and/or vague, generic and global statements written as an intervention for the following psychiatric problem:

Problem 1 - "Psychosis with homicidal actions..."

Physician - "1:1 with physician [staff's name] weekly to evaluate level of psychosis and the need for any medication changes."

B. Staff Interview

In an interview on 9/19/12 at 2 p.m., with the Clinical Director, the Master Treatment Plans for active sample patients were discussed. The Clinical Director acknowledged that treatment plans contained discipline functions and generic statements written as treatment interventions.

IV. Ensure necessary medical care for 2 of 2 discharged patients (K1 and K4) whose medical records were reviewed for adverse outcomes of treatment. One patient (K1) was admitted to a medical intensive care unit because of a low blood sodium level, and another patient (K4) was admitted to a medical facility for blood transfusion and treatment of an infection. The Medical Director failed to implement an effective method of monitoring the provision of medical care for all patients, resulting in the failure of the facility to adequately assess their medical problems, leading to adverse outcomes for these patients and a potential risk for morbidity and mortality for all patients with needed medical assessments/treatments.

Findings include:

A. Refer to B125, Part I for patient findings

B. During an interview with the Medical Staff Quality Improvement Coordinator on 9/20/12 at 8:45 a.m., she stated that there was no current monitoring or evaluation of the medical services being provided to patients by the medical staff.

C. During an interview with the Medical Director on 9/19/12 2:30 p.m., he stated that he was not currently monitoring, reviewing or evaluating the quality of medical care being provided by the facility.

V. Ensure that 1 of 16 active sample patients (D8), who had reached the maximum benefit of treatment, was discharged from the hospital. Failure to complete discharges in a timely way results in patients being retained in the facility who are not receiving active treatment based on their treatment needs.

Findings include:

A. Record review revealed Patient D8 was an adolescent who was admitted to the facility on 2/22/11 and ordered by the legal system to undergo fitness restoration to stand trial. The annual Psychiatric Evaluation dated 3/12/12 stated the diagnosis was "Axis I. Mood Disorder, NOS." The Psychological Evaluation dated 6/13/12 stated Patient D8 "has been here for sixteen months, and there are still no plans to discharge [him/her], owing to [pt's.] 'difficult' behaviors." Testing indicated a composite IQ of 52 and "functioning in the moderate range of mental retardation."

B. The revised MTP (9/10/12) listed all scheduled unit groups as interventions for the problem of "Difficulties with Transitioning." These groups are offered to all patients on the unit, and except for one group, were the same groups listed on the treatment plan for Patient D8 since his admission. In addition to the MTP, Patient D8 had a "Behavioral Management Plan" which consisted of a reward of spending time 1:1 with a staff member or engaging in a "special activity" with a staff member. A review of the medications for Patient D8 showed only three dosage adjustments in medications from February to September 2012.

C.The MTP review dated 9/10/12 stated that Patient D8 "has remained at [the facility] for an extended period of time largely due to his continued disruptive behaviors and his lack of motivation to work towards and discomfort with returning to the community." Patient D8 "was only able to discuss and practice positive, non-hurtful ways to get his needs met during 4 groups this review period [8/6/12-9/10/12]." "In the remaining 18 groups, patient either slept during the group, refused to participate, or refused to attend the group altogether."

D. During an interview on 9/19/12 at 10 a.m., MD3 stated that Patient D8's treatment had "stalled." She stated that Patient D8's behaviors were stable "several months ago" but that no community placement was available. She stated that Patient D8 viewed the hospital as "home" and did not want to leave. She stated that Patient D8's "problem is more residential level of care." She stated that the unit where Patient D8 was hospitalized had "very few straightforward acute [admissions]."

During an interview with the Clinical Director on 9/18/12 at 8:30 a.m., she stated that "most" patients on the unit where Patient D8 was hospitalized were receiving residential level of care. She stated "it's rare that we have acute [level of care] kids. . .I don't think we have any acute today."

VI. Assure that patients admitted to Unit E required and received active psychiatric treatment. The treatment for the patients in this unit (13 on the first day of the survey) consisted of a formal cognitive program presented at a residential, rather than an active level of treatment. Six of six patients--1 sample patient (E7) and 5 non-sample patients added (E1, E2, E9, E12 and E13)--on Unit E had Axis I diagnoses related to sexual issues and had no psychiatric problems identified requiring treatment for acute psychiatric disorders. This results in failure of the facility to focus its function on psychiatric treatment of patients in need of acute inpatient care. (Refer to B125, Part II)

VII. Ensure that active individualized psychiatric treatment was the primary focus provided for 2 of 2 active sample patients (B9 and G24) and 2 patients added to the sample (F15 and G11) who were hospitalized by judicial order without specific psychiatric problems, or who continued to be hospitalized beyond the time that their psychiatric problems were resolved. (Refer to B125, Part III)

VIII. Provide interpreter services according to facility policy for 1 of 1 active sample patients (I13) on Unit 6 Lower who was not proficient in the English language. This failure compromises the ability of all patients who are not proficient in English to adequately participate in treatment. (Refer to B125, Part IV)

IX. Ensure active treatment as the primary focus of hospitalization for 3 of 3 non-sample patients (C26, C27, and F6) added to the sample from the Developmental Disability Program. These patients were admitted due to mental retardation or other cognitive disorders and attended a Developmental Disability Program as their only treatment. This program is designed for persons having a developmental disability and is based on a cognitive approach consistent with a residential model focusing on issues other than psychiatric symptomatology. This results in prolonged hospitalization of patients in an acute setting rather than treatment in a less restrictive environment for patients who attend the DD Program as their sole treatment. (Refer to B125, Part V)

Based on record review and interview, the Director of Nursing (DON) failed to provide adequate oversight to ensure quality nursing services. Specifically, the DON failed to:

I. Provide Master Treatment Plans (MTPs) for 14 of 16 active sample patients (A15, A16, B9, B25, C7, C21, D4, D8, E5, E7, H12, H19, I13 and I19) which included nursing interventions that were specific treatment modalities with a specific focus or purpose, based on the each patient ' s individual problems and goals. Instead, the MTPs included routine nursing functions and vague, generic and global statements written as treatment interventions. This failure results in lack of guidance to nursing staff in providing consistent and effective treatment related to patients ' presenting problems and goals identified on the Master Treatment Plans.

Findings include:

A. Record Review

1. Patient A15 was admitted 10/7/10 with a diagnosis of "Schizoaffective Disorder, Bipolar type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 2/7/12 noted a routine nursing function and/or vague, generic and global statement written as a nursing intervention for the following psychiatric problem:

Problem 1 - "Delusional, disorganized, and agitated behavior..."

Registered Nurse (RN) - "1:1 with Nursing [Staff's name] to stress reality and help organize [his/her] day to day activities."

2. Patient A16 was admitted 9/4/12 with a diagnosis of "Psychotic Disorder, NOS [Not Otherwise Specified]" identified on the patient's Master Treatment Plan (MTP). The
patient's MTP dated 9/7/12 noted a routine nursing function and/or vague, generic and global statement written as a nursing intervention for the following psychiatric problem:

Problem 1 - "Psychotic thought process with violence/threats..."

Registered Nurse - "...to monitor pt's [patient's] level of paranoia, promote trust, meet [his/her] needs, administer medication."

3. Patient B9 was admitted 3/13/12 with a diagnosis of "Vascular Dementia and Mood Disorder NOS [Not Otherwise Specified]" identified on the Psychiatric Evaluation dated 3/13/12 and 3/15/12. The patient's Master Treatment Plan dated 8/2/12 noted routine nursing functions and/or vague, generic and global statements written as nursing interventions for the following problem:

Problem 1 - "Noncompliance with Conditions of Act 911..."

Registered Nurse - "Nsg [Nursing] to administer medication and assess for result."

"Medical/Mental Health Group... 2x Weekly to encourage group attendance in order for [him/her] to learn the importance of compliance with medical treatment." [This statement was not a specific intervention which described what the staff will do to assist the patient with his/her identified problems with compliance with medical treatment.]

Problem 3 - "Poor Impulse Control..."

There were no interventions listed for this problem.

4. Patient B25 was admitted 10/20/11 with a diagnosis of "Bipolar I Disorder, Most Recent [sic]" identified on the census list. The patient's Master Treatment Plan updated 9/6/12 noted a routine nursing function and/or vague, generic and global statement written as a nursing intervention for the following psychiatric problem:

Problem 3 - "Delusional Thought Process..."

Registered Nurse - "1:1 with Nursing to encourage looking at life issues realistically."

5. Patient C7 was admitted 6/14/12 with a diagnosis of "Schizophrenia, Paranoid Type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 7/16/12 noted a routine nursing function and/or vague, generic and global statement written as a nursing interventions for the following problem:

Problem 1 - "Unsuccessful attempt at completion of Act 911 requirements..."

Registered Nurse - "1:1 with Nursing, daily to review behavioral observations and to provide behavioral support."

6. Patient C21 was admitted 7/9/12 with a diagnosis of "Schizophrenia, Bipolar Type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 7/13/12 noted a routine nursing function and/or vague, generic and global statement written as a nursing intervention for the following psychiatric problem:

Problem 1 - "Manic with violence..."

Registered Nurse - "1:1 with Nursing, daily to stress reality, assess patient's mental status, & administer medication."

7. Patient D4 was admitted 7/24/12 with a diagnosis of "Mood Disorder, NOS [Not Otherwise Specified], Psychotic Disorder, NOS" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 8/24/12 and updated 9/7/12 noted a routine nursing function and/or vague, generic and global statement written as a nursing intervention for the following psychiatric problem:

Problem 1 - "Aggression related psychosis..."

Registered Nurse - "Nursing, daily to redirect behaviors and encourage [Patient's name] to report presence or absence of hallucinations."

8. Patient D8 was admitted 2/22/11 with a diagnosis of "Conduct Disorder, Unspecified Onset, Mood disorder NOS [Not Otherwise Specified]" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 9/10/12 noted a routine nursing function and/or vague, generic and global statement written as a nursing intervention for the following problem:

Problem 1 - "Difficulty with Transitioning..."

Registered Nurse - "Nursing. [RN ' s name] or designee. Daily to... redirect [his/her] behavior as needed."

9. Patient E5 was admitted 8/7/12 with a diagnosis of "Sexual Abuse of a Child, Perpetrator ...Posttraumatic Stress Disorder, Disruptive Behavior Disorder, Not Otherwise Specified..." identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 9/4/12 noted routine nursing functions written as nursing interventions for the following psychiatric problems:

Problem 1 - "Sexually Abusive Behavior."

Registered Nurse - "Maintenance Cycle, [RN's name], 1x weekly to encourage honest and respectful discussion of maintenance behaviors."

Problem 2 - "Aggressive and Disruptive Behavior."

Registered Nurse - "Nursing, [RN ' s name] or designee, 1x week [sic] to encourage positive and safe expression of feelings and calm interactions with others."

10. Patient E7 was admitted 12/13/10 with a diagnosis of "Sexual Abuse of a Child, Perpetrator, Conduct Disorder..." identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 8/21/12 noted a routine nursing function and/or vague, generic and global statement written as a nursing intervention for the following problem:

Problem 2 - "It's all about me."

Registered Nurse - "Nursing, [RN's name] or designee. 1x weekly to encourage respectful acceptance of redirection and responsible behavior."

11. Patient H12 was admitted 7/2/94 with a diagnosis of "Depressive Disorder..., Alcohol" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 9/4/12 noted routine nursing functions and/or vague, generic and global statements written as nursing interventions for the following problem:

Problem 2 - "Depression..."

Registered Nurse - "1:1 with Nursing, document daily subjective moods and objective affect including document meal intake." "Medication Compliance group once weekly [RN's name] to encourage patient to comply with treatment and participate in discussions."

12. Patient H19 was admitted 12/1/04 with a diagnosis of "Schizoaffective Disorder, Bipolar Type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 9/11/12 noted routine nursing functions and/or vague, generic and global statements written as nursing interventions for the following psychiatric problem:

Problem 1 - "Delusional thinking resulting inability to assist in her/his defense..."

Registered Nurse - "Nursing Daily [RN's name] or designee to provide meds [medications] and assess and document behavior and ability to have reality-based conversations daily, weekly to ... assess/doc [document] progress."

13. Patient I13 was admitted 7/23/12 with a diagnosis of "Major Depressive Disorder, Single Episode; Cognitive Disorder NOS [Not Otherwise Specified]" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 8/16/12 noted the following routine nursing functions and/or vague, generic and global statements written as a nursing intervention for the following psychiatric problem:

Problem 1 - "Depressed Mood and possible cognitive impairment..."

Registered Nurse - "Medication/Mental Health, [staff name] or designee once weekly to encourage [patient's name] to discuss her/his personal, medical, and mental health issues and provide praise when s/he is able to participate."

14. Patient I19 was admitted 4/16/12 with a diagnosis of "Schizophrenia, Paranoid Type" identified on the patient's Master Treatment Plan (MTP). The patient's MTP dated 8/8/12 noted the following routine nursing functions and/or vague, generic and global statements written as nursing interventions for the following psychiatric problem:

Problem 1 - "Psychosis with homicidal actions..."

Registered Nurse - "Nursing Daily [Staff ' s name] to discuss how medication can help reality based thinking." "Medication and Treatment Compliance - once weekly to emphasize medication compliance with court order treatment including medication and medical appointments."

B. Staff Interviews

1. In an interview with RN 11 on 9/18/12 at 10:30 a.m., the treatment plans for Patient I13 and I19 were reviewed. RN 11 agreed that statements on the treatment plan were routine nursing functions and some statements were generic and vague statement written as nursing interventions.

2. In an interview with the Director of Nursing (DON), the treatment plans for Patients I13 and I19 were reviewed. The DON agreed that statements on the treatment plan were routine nursing functions and some statements were generic and vague statement written as nursing interventions.

II. Provide adequate numbers of Registered Nurses (RNs) especially on the evening shifts (7 p.m. to 7 a.m.) for the General Adolescent Program - Unit D. Specifically, on the 7 p.m. to 7 a.m. shift, only one registered nurses (RN) was assigned on this high acuity unit with a bed capacity of 18 and an average census of 15. This potentially results in limited time for this RN to provide and supervise active treatment and nursing activities and limited opportunity to provide direction and supervision of non-professional nursing personnel in the provision of nursing care. (Refer to B150)

Based on document review and interviews, the facility failed to provide adequate numbers of Registered Nurses (RNs) primarily on the evening shifts (7 p.m. to 7 a.m.) for the General Adolescent Program - Unit D. Specifically, on the 7 p.m. to 7 a.m. shift, only one registered nurse (RN) was assigned on this high acuity unit with a bed capacity of 18 and an average census of 15. This potentially results in limited time for this RN to provide and supervise active treatment and nursing activities and limited opportunity to provide direction and supervision of non-professional nursing personnel in the provision of nursing care.

Findings include:

A. Document Review

1. The facility's "Plan of Patient Services" states, "The General Adolescent Program (Unit D) has 18 beds combining both acute and residential patients. The unit provides treatment for both male and female adolescents from around the State...They tend to present with severe behavioral problems that have led to failures in both school and living settings. Once acute treatment is completed, the adolescent can then be transferred to one of the adolescent residential beds if necessary."

2. An analysis of the staffing data for Unit D on the first day of the survey (9/17/12) revealed the unit had a census of 15 patients and was staffed with 1.33 RNs on the 7 p.m. to 7 a.m. shift, two Licensed Practical Nurses (LPNs), and four Behavior Health Aides (BHAs)

3. A review of the staffing patterns for a two-week period (9/2/12 through 9/15/12) revealed the following staffing:

7 a.m. to 7 p.m. shift: One RN available to cover on two weekend shifts during the two week period.

7 p.m. to 7 a.m. shift: One RN available to cover 13 of fourteen (14) shifts and 1.33 RN for one of the 14 shifts with a census of 15 to 16 adolescents.

4. Review of needs assessment data for Unit D revealed the following:

a. Fifteen patients were identified as potentially assaultive (adolescents who have occasionally demonstrated aggressive behavior during their hospitalization) and three (3) were identified as actively assaultive. These patients had shown physical/verbal aggression within the prior 48 hours.

b. Two patients were placed in Seclusion and/or restraint during the 48 hours prior to the first day of the survey (9/17/12).

5. A review of the incident reports for a six month period (April 2012 through September 2012) revealed that a total of 51 incidents occurred on Unit D. Of these incidents, 21 (41%) occurred on the 7 p.m. to 7 a.m. shift. Fourteen of the 21 incidents (67%) occurred during the change of shift between 7 p.m. and 8 p.m.

6. A review of seclusion and restraint data from 9/2/12 through 9/17/12 revealed that 37 restrictive measures were applied between 7 p.m. and 11 p.m. which required an RN to complete assessments, monitoring, documentation, and supervision. These restrictive measures included 9 episodes of seclusion, 22 episodes of physical holds, and 6 chemical restraints (forced medications).

B. Interviews

1. During an interview on 9/19/12 at 9:30 a.m., the Director of Nursing acknowledged that there were insufficient registered nurses to manage and supervise the nursing care and active treatment measures on the 7 p.m. to 7 a.m. shift during times that adolescents are up and awake (7 p.m. through 11 p.m.).

2. During an interview on 9/19/12 at 3:30 p.m., the Medical Director agreed that two RNs are necessary for Unit D and noted that there is a new staffing model that the facility is beginning to use to increase nursing staff. However, he also stated that Unit D was one of the units that had not been updated yet.

3. During an interview on 9/20/12 at 8:45 a.m., RN 1 and the surveyor reviewed the staffing on Unit D. When asked about only one RN covering the unit between 7 p.m. and 11 p.m. when the adolescents are up and awake, RN 1 stated, "It shouldn't be. The best practice is two RNs because you need the second RN to effectively handle and manage the adolescents on this unit. We are still waiting for positions and administration is aware."