HospitalInspections.org

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

I. Ensure that the Psychosocial Assessments met professional social work standards for eight (8) of eight (8) active sample patients (A1, A3, A5, A13, A15, A17, A18, A19, and A20). These assessments did not contain a psychosocial formulation of the data obtained and lacked a description of the social work efforts in treatment and discharge planning during these patients' hospitalization. This failure results in a lack of professional social work involvement, especially when the patient has an assigned psychologist as their primary therapist. (Refer to B108.)

II. Provide comprehensive Master Treatment plans (MTPs) that included treatment interventions by all members of the interdisciplinary team who provided direct care to patients. Eight (8) of eight (8) active sample patients (A1, A3, A5, A13, A17, A18, A19, and A20) had no interventions on the MTPs by Recreation Activity staff. Two (2) of eight (8) active sample patients (A5 and A17) had no Social Work interventions. Three (3) of five (5) active sample patients (A3, A5, and A20) had interventions by physicians that were too illegible to understand. Failure to clearly specify interventions by all members of the interdisciplinary team involved in providing direct care to patients hampers staff's ability to provide coordinated treatment and potentially results in patients not receiving all needed treatment to address their problems. (Refer to B118.)

III. Provide multidisciplinary treatment plans that identified patient related short and long-term goals listed in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (A1, A3, A5, A13, A17, A18, A19, and A20).The goal was a direct quote from the patient about what s/he wanted to accomplish during this admission. The objectives were what the staff wanted the patient to accomplish. This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to the failure of the team to modify plans in response to patient needs. (Refer to B121.)

IV. Ensure that the Master Treatment plan interventions for eight (8) of eight (8) active sample patients (A1, A3, A5, A13, A17, A18, A19, and A20) addressed their specific problems and needs. Each discipline had a separate page for describing what they were going to do for the patient. The interventions consisted of a list of choices from which a discipline could put a check mark next to the ones s/he selected. The available choices for the same discipline (i.e., a physician, a nurse, etc.) were identical and consisted of generic discipline functions. In some instances, staff did not check off any selections offered (the section was blank). The selection of interventions listed related to a patient's diagnosis, not specific problems. In addition, the listed interventions failed to include the method of delivery (individual or group), frequency or the specific focus of treatment. These failures result in a lack of guidance for staff in providing individualized patient treatment that is purposeful and goal directed. (Refer to B122.)

V. Use or follow proper release criteria for two (2) of five (5) patients (R1 and R2) whose records were reviewed for facility and/or Centers for Medicare/Medicaid Services compliance on seclusion/restraint policy and procedure protocol. Record documentation revealed that these two (2) patients were kept in 4-point restraints longer than necessary after they fell asleep. This deficient practice results in failure to ensure a patient's right to be free from restriction of movement. (Refer to B125.)

Based on record reviews and interviews, it was determined that for eight (8) of eight (8) active patients (A1, A3, A5, A13, A15, A17, A18, A19, and A20), the facility failed to ensure that the Psychosocial Assessments met professional social work standards. These assessments did not contain a psychosocial formulation of the data obtained and lacked a description of the social work efforts in treatment and discharge planning during these patients' hospitalization. This failure results in a lack of professional social work involvement especially when the patient has an assigned psychologist as their primary therapist.

Findings include:

A. Record Review

None of the following eight (8) of eight (8) active sample patients (date of the Psychosocial Assessments in parenthesis) had a conclusion or psychosocial formulation for the data gathered and all failed to describe the role of the social work staff in treatment and discharge planning: (A1 (12/5/14), A3 (12/1/14), A5 (12/4/14), A13 (12/4/13), A17 (12/5/14), A18 (12/6/14), A19 (12/2/14), and A20 (12/5/14)).

B. Interview

In an interview on 12/8/14 with the Director of Social Work Services, who is a Masters Level Psychologist, the Psychosocial Assessments of Patients A1, A3, and A5 were reviewed. He agreed these Psychosocial Assessments lacked a psychosocial formulation based on the data obtained. He also agreed that there was not a description of the anticipated role of the social work staff. He stated "It is not written."

Based on record review and interview, the facility failed to provide comprehensive Master Treatment plans (MTPs) that included treatment interventions by all members of the interdisciplinary team who provided direct care to patients. Eight (8) of eight (8) active sample patients (A1, A3, A5, A13, A17, A18, A19, and A20) had no interventions on the MTPs by Recreation Activity staff. Two (2) of eight (8) active sample patients (A5 and A17) had no Social Work interventions. Three (3) of five (5) active sample patients (A3, A5, and A20) had interventions by physicians in which the writing was too illegible to read. Failure to clearly specify interventions by all members of the interdisciplinary team involved in providing direct care to patients hampers staffs ability to provide coordinated treatment and potentially results in patients not receiving all needed treatment to address their problems.

Findings include:

A. Record Review

1. Eight (8) of eight (8) active sample patients (dates of MTPs in parenthesis) had no interventions by Recreational Therapist (A1 (12/5/14), A3 (12/1/14), A5 (12/6/14), A13 (12/4/14), A17 (12/5/14), A18 (12/6/14), A19 (12/4/14) and A20 (12/7/14)).

2. Two (2) of eight (8) active sample patients (dates of MTPs in parenthesis) had no interventions by Social Workers (A5 (12/6/14) and A17 (12/5/14)).

3. Three (3) of eight (8) active sample patients (dates of MTPs in parenthesis) (A3 (12/1/14), A5 (12/6/14), and A17 (12/5/14)) had physician interventions in which the writing was too illegible to understand.

B. Interviews

1. In an interview on 12/9/14 at 9:00 a.m., RN2, who was helping the surveyor interpret the charts which were primarily written in Spanish, could not read the physician's documentation on the Master Treatment plans for active sample patients A3, A5, and A17. She stated, "I have no idea what those [physician treatment interventions] say."

2. In an interview on 12/9/14 at 11:30 a.m. with the Director of Therapeutic Activities, which include social workers, psychologists and recreational therapist, the lack of inclusion of interventions on some of the records of the eight (8) active sample patients was discussed. He stated that in the case of the social workers, the patients that psychologist provide direct treatment to, they (psychologists) decide that if these patients need any social issues resolved (i.e. referrals, help with housing, financial issues) then they (the psychologist) will refer these patients to the social worker. Otherwise, according to the Director of Therapeutic Services, the psychologist provide all the treatment for the patient without any Social Work involvement.

Based on record review and interview, the facility failed to provide multidisciplinary treatment plans that identified patient related short and long-term goal/objectives listed in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (A1, A3, A5, A13, A17, A18, A19, and A20). The goal was a direct quote from the patient about what s/he wanted to accomplish during this admission. This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to the failure of the team to modify plans in response to patient needs.

Findings include:

A. Record Review

1. Facility policy titled "Plan of Treatment," (no number), last revised January, 2014, stated: "According to the problem identified, it [treatment plan] will be established, with a check mark, to indicate the type of intervention that will be selected according to the goals and/or treatment of each situation that will be worked upon [sic]." The treatment plans consisted of a quote from the patient of what s/he wanted to accomplish. The "objective" was what the staff wanted the patient to accomplish. There was a separate page of problems selected from a long list of choices, but no problems were mentioned in the Master Treatment Plans (MTPs). Each discipline had his/her own separate treatment goals and interventions page.

2. Patient A1

The Master Treatment Plan (MTP), dated 12/5/14, listed the following goals and objectives for the diagnosis of "Major Depression Psychosis":

Psychiatrist: For patient goal- "Eliminate depressive symptoms." For generic and non-measurable behavioral staff objectives: "Eliminate depressive symptoms within seven (7) days. Eliminate hallucinations within seven (7) days. Eliminate suicidal thoughts within seven (7) days."

Nursing: For patient goal- "I want to feel better." For generic and non-measurable behavioral staff objectives: "Patient will lower level of anxiety within seven (7) days. Patient will recover patterns of sleep within seven (7) days."

Social Work: For patient goal- "I wish to be more peaceful." For generic and non-measurable behavioral staff objectives: "Patient will be free of suicidal ideas within six (6) days. Patient will recognize the negative consequences and organic damage internally. Patient will decrease depressive and psychotic symptoms within six (6) days."

3. Patient A3

The MTP, dated 12/1/14, listed the following goals and objectives for the diagnosis of "Schizoaffective Disorder":

Psychiatrist: For patient goal- "to leave." The two staff objectives were too eligible to read.

Nursing: For patient goal- "I didn't want to be here." The generic and non-measurable behavioral staff objectives were: "Patient will decrease anxiety levels within seven (7) days. Patient will have self control within seven (7) days."

Social Work: For patient goal- "I want to be stable." The generic and non-measurable behavioral staff objectives were: "Decrease suicidal symptoms and anxiety within seven (7) days." Eradicate suicidal ideas in seven (7) days." "Extinguish perceptual disturbance within seven (7) days."

4. Patient A5

The MTP, dated 12/6/14, listed the following goals and objectives for the diagnosis of "Major Depression with Psychosis":

Psychiatrist: Patient goal and staff objectives were illegible.

Nursing: For patient goal- "Feel better." For generic and non-measurable behavioral staff objectives: "No suicidal thoughts in 23 hours. To diminish patient's level of anxiety within seven (7) days."

Psychologist: For patient goal- "I want to be free from everything that is affecting me."
The generic and non-measurable behavioral staff objectives were: "In 23 hours patient will decrease levels of anxiety. Stabilize symptoms of depression in the patient within five (5) days. Evidence the patient's suicidal thought within five (5) days."

There were no Social Work objectives.

5. Patient A13

The MTP, dated 12/4/14, listed the following goals and objectives for the diagnosis "Recurrent Major Depression":

Psychiatrist: For patient goal- "feeling better." The generic and non-measurable behavioral staff objectives were: "Free of depressive symptoms in seven (7) days. Free of suicidal ideations in seven (7) days."

Nursing: For patient goal- "feeling better." Generic and non-measurable behavioral staff objective was- "Patient will decrease anxiety levels in 24 hours."

Social Work: For patient goal- "I hope to feel more relaxed." Generic and non-measurable behavioral staff objectives were: "In six (6) days patient will decrease anxiety levels. In six (6) days patient will extinguish symptoms that affect [his/her] mind."

6. Patient A17

The MTP, dated 12/5/14, listed the following goals and objectives for the diagnosis of "Drug Induced Mood Disorder":

Psychiatrist: For patient goal- "to feel better." The generic and non-measurable behavioral staff objectives were: "Will be free of depression in seven (7) days. Will be free of suicidal ideations in seven (7) days. Will be free of auditory hallucinations in seven (7) days."

Psychologist: For patient goal- "Get out of addiction." The generic and non-measurable behavioral staff objectives were: "Eliminate symptoms of substance drug abuse problems. Understand negative consequences of drug abuse. Acquire skills to maintain [sic] off drugs."

Nursing: For patient goal- "Get off drugs." The generic and non-measurable behavioral staff objectives were: "Decrease anxiety in 23 hours. Deny visual and auditory hallucinations in 24 hours. Deny suicidal intent with medication [sic] in 23 hours."

There were no Social Work objectives.

7. Patient A18

The MTP, dated 12/6/14, listed the following goals and objectives for the diagnosis of "Major Depression with Psychosis":

Psychiatrist: For patient goal- "feeling better." Generic and non-measurable behavioral staff objectives were: "Keep free of depressive symptoms. Free of auditory hallucinations. Free of suicidal ideations or thoughts."

Social work: For patient goal- "Don't use alcohol." The generic and non-measurable behavioral staff objectives were: "Decrease depressive symptoms in seven (7) days. Stop suicidal ideations in seven (7) days. Recognize negative of alcohol abuse in seven (7) days."

Nursing: Patient goal was not listed. The generic and non-measurable behavioral staff objectives were: "Does not keep suicidal thoughts in six (6) days. Decrease in anxiety in six (6) days."

8. Patient A19

The MTP, dated 12/4/14, listed the following goals and objectives for the diagnosis of "Drug Induced Mood Disorder":

Psychiatrist: For patient goal- "Improve." The generic and non-measurable behavioral staff objectives were: "To obtain remission of aggression and delusions in less than 23 hours. To obtain remission of symptoms [suicidal ideations] in less than eight (8) days."

Social Work: For patient goal- "I want to have peace of mind and medication." The generic and non-measurable behavioral staff objectives were: "In 23 hours, patient will decrease anxiety levels. In 23 hours patient can control impulse in substance [sic]. Patient will have impulse control in consuming drugs."

Nursing: For patient goal- "I have anxiety and suicidal thoughts [sic]." The generic and non-measurable behavioral staff objectives were: "Decrease patient's anxiety levels in 23 hours, Patient is not going to have suicidal ideations in 23 hours."

9. Patient A20

The MTP, dated 12/7/14, listed the following goals and objectives for the diagnosis of "Schizoaffective Disorder":

Psychiatrist: For patient goal- "to leave." The staff objectives were too illegible. To understand.

Nursing: For patient goal- "I don't sleep." The generic staff objective was- "Patient will sleep within 23 hours."

Social Work: For patient goal- "Patient does not identify a goal." The generic and difficult to measure staff objectives were: "In 23 hours patient will decrease aggressive behavior. In 23 hours patient will decrease paranoid thoughts."

B. Interview

In an interview on 12/8/14 at 1:25 p.m., the lack of specificity of short and long-term goals on the Master Treatment plans were discussed with the Director of Social Work. He stated that he thought the "patient goals" were for long-term and the "staff objectives" were for short-term, but admitted that there is no mention of long or short-term goals in the treatment plan policy. When told that the staff objectives were generic and non-measurable, he did not dispute the findings.

Based on record review and interview, the facility failed to ensure that the Master Treatment plan interventions for eight (8) of eight (8) active sample patients (A1, A3, A5, A13, A17, A18, A19, and A20) addressed their specific problems and needs. Each discipline had a separate page for describing what they were going to do for the patient. The interventions consisted of a list of pre-printed choices from which a discipline could put a check mark next to the ones s/he selected. The available choices for the same discipline (i.e., a physician, a nurse, etc.) were identical and consisted of generic discipline functions. In some instances, staff did not check off any selections offered (the section was left blank). The selection of interventions listed related to a patient's diagnosis, not specific problems. In addition, the listed interventions failed to include the method of delivery (individual or group), frequency or the specific focus of treatment. These failures result in a lack of guidance for staff in providing individualized patient treatment that is purposeful and goal directed.

Findings include:

A. Record Review

1. Facility policy, titled "Plan of Treatment," no number, last revised January, 2014, stated: "Each discipline will establish the type of modality for treatment, the time frame, frequency and quantity of the interventions to be utilized according to the problems identified. The type of intervention will be established with a check mark according to goals and treatment of each situation that will be worked upon [sic]. Time frame will be projected to comply with goals that are required."

2. Patient A1

The Master Treatment plan, dated 12/5/14, listed the following generic and routine discipline functions for the diagnosis of "Major Depression Psychosis":

Psychiatrist- "Will be less depressive in seven (7) days, will be free of suicidal ideations in seven (7) days, will be free of auditory hallucinations about suicide in seven (7) days."

Nursing- "Administer medication, educate about treatment, preventive rounds, fall precautions, take vital signs, anxiety management, emotional support, assist with ADL's [Activities of Daily Living]."

Social Work- "Cognitive behavior, Emotional support."

3. Patient A3

The MTP, dated 12/1/14, listed the following generic and routine discipline functions for the diagnosis of "Schizoaffective Disorder":

Psychiatrist- "Educate about medications, education on diagnosis and treatment."

Social Work- "Emotional support, anxiety management and cognitive behavior."

Nursing- "Administer medication, education about treatment, preventive rounds, prevention of aggression, take vital signs, anxiety management, emotional support, and assist with ADL's [Activities of Daily Living]."

4. Patient A5

The MTP, dated 12/6/14, listed the following generic and routine discipline functions for the diagnosis of "Major Depression with Psychosis":

Psychiatrist- "Educate about medication, educate about diagnosis and treatment."

Nursing- "Administer medications, educate about treatment, preventive rounds, fall
prevention, take vital signs, anxiety management, emotional support, 1:1 observation, and assist with ADL's."

Psychologist- "Control of emotions and impulses, problem solving, anxiety management, emotional support, education about treatment and cognitive behavior."

There were no Social Work interventions.

5. Patient A13

The MTP, dated 12/4/14, listed the following generic and routine discipline functions for the diagnosis of "Recurrent Major Depression":

Psychiatrist- "Medication education, education on diagnosis and treatment."

Nursing- "Take vital signs, and anxiety management."

Social Work- "Control of emotions and impulses, problem solving, anxiety management, emotional support and education about treatment."

6. Patient A17

The MTP, dated 12/5/14, listed the following generic and routine discipline functions for the diagnosis of "Drug Induced Mood Disorder":

Psychiatrist: For patient goal- "To feel better."

Psychologist: "Screening for substance abuse, cognitive behavior, education for use and abuse, referral to support groups."

Primary therapist (same psychologist as above): "Cognitive behavior, problem solving, management of anxiety, education of treatment."

Nursing: "Administer medication, education of treatment, take vital signs, management of anxiety, emotional support."

There were no Social Work interventions.

7. Patient A18

The MTP, dated 12/6/14, listed the following generic and routine discipline functions for the diagnosis of "Major Depression with Psychosis":

Psychiatrist- "Medication education, education on diagnosis and treatment."

Social Work- "Substance abuse management, motivational focus, education on drugs and abuse."

Nursing- "Administer medications, educate about treatment, preventive rounds, fall prevention, take vital signs, anxiety management, emotional support, 1:1 observation, assist with ADL's."

Social Work- "Anxiety management, emotional support, education about treatment, cognitive behavior."

8. Patient A19

The MTP, dated 12/4/14, listed the following generic and routine discipline functions for the diagnosis of "Drug Induced Mood Disorder":

Psychiatrist- "Medication education, education about diagnosis and treatment."

Social Work- "Substance abuse assessment, cognitive behavior."

Nursing- "Medication administration, education about treatment, preventive rounds, fall prevention, take vital signs, anxiety management, emotional support."

9. Patient A20

The MTP, dated 12/7/14, listed the following generic and routine discipline functions for the diagnosis of "Schizoaffective Disorder":

Psychiatrist- "Medication education, education about diagnosis and treatment."

Nursing- "Administer medication, educate about treatment, preventive rounds, fall prevention, take vital signs, manage anxiety, emotional support."

Social Work- "Control of emotions and impulses, manage anxiety, emotional support, education about treatment."

B. Interviews

1. In an interview on 12/8/14 at 9:00 a.m., the generic and routine discipline functioned interventions was discussed with the Nursing Director. She stated "I understand what you are saying."

2. In an interview on 12/8/14 around 11:30 a.m., the pre-printed treatment plan forms with generic discipline interventions was discussed with the Medical Director. He did not dispute the findings.

Based on record review and interview, the facility failed to use or follow proper release criteria for two (2) of five (5) patients (R1 and R2) whose records were reviewed for facility and/or Centers for Medicare/Medicaid compliance on seclusion/restraint policy and procedure protocol. Record documentation revealed that these two (2) patients were kept in 4-point restraints longer than necessary after they fell asleep. This deficient practice results in failure to ensure patient's right to be free from restriction of movement.

Findings include:

A. Record Review

1. Facility policy and procedure, titled "Restriction/Isolation", number 319, dated October, 2014, stated that "the patient in restraints must be re-evaluated by the physician every hour to determine the necessity to continue with the restriction." Under the section related to patient behavior to be considered by the staff who were responsible for observing the patient to assess readiness for removal was a category to note "If patient is sleeping for more than 45 minutes [sic]." There was nothing found in the policy giving the charge nurse the option of calling the physician about the patients' sleeping and discuss possible removal from restraints prior to the physician's next evaluation visit.

2. Patient R1 was placed in 4-point restraints on 11/15/14 at 6:00 p.m. for "aggressive conduct with potential harm to himself, others or property." The physician's order for 4-point restraint for up to two (2) hours was written on 11/15/14 at 6:00 a.m. The patient's log sheet documenting his/her behavior every 15 minutes while in 4-point restraints listed patient as falling asleep at 7:15 p.m. And not released until 8:00 p.m. at the time that the physician's order for release was written.

3. Patient R2 was placed in 4-point restraints on 11/8/14 at 7:40 p.m. for "aggression in area with everything [objects/people in surroundings], physically and verbally. The physician order for 4-point restraints for up to two (2) hours was written on 11/8/14 at 7:40 p.m. The patient was described as "sleeping" at 8:30 p.m. The patient was released from restraints at 9:45 p.m., 15 minutes after the physician wrote the order for release at 9:30 p.m.

B. Interview

1. In an interview with RN 1 on 12/9/14 at 9:00 a.m. on why patients (R1 and R2) had not been released after both had fallen asleep, she stated that the physician has to re-evaluate patients in restraints every hour to assess patient's behavior and write the order for release.

2. In an interview with the Director of Nursing at 9:00 a.m. on 12/9/14, the fact that patients' rights for freedom of movement were compromised as a result as the prolonged restriction was discussed. She agreed that the patients should have been released sooner.

Based on record reviews and interviews, it was determined that the Medical Director failed to adequately monitor and evaluate the care provided to patients at this facility. Specifically, the Medical Director failed to:

I. Assure that for eight (8) of eight (8) active patients (A1, A3, A5, A13, A15, A17, A18, A19, and A20), the facility failed to ensure that the Psychosocial Assessments met professional social work standards. These assessments did not contain a psychosocial formulation of the data obtained and lacked a description of the social work efforts in treatment and discharge planning during these patients' hospitalization. This failure results in a lack of professional social work involvement especially when the patient has an assigned psychologist as their primary therapist. (Refer to B108.)

II. Provide comprehensive Master Treatment plans (MTPs) that included treatment interventions by all members of the interdisciplinary team who provided direct care to patients. Eight (8) of eight (8) active sample patients (A1, A3, A5, A13, A17, A18, A19, and A20) had no interventions on the MTPs by Recreation Activity staff. Two (2) of eight (8) active sample patients (A5 and A17) had no Social Work interventions. Three (3) of five (5) active sample patients (A3, A5, and A20) had interventions by physicians that were too illegible to understand. Failure to clearly specify interventions by all members of the interdisciplinary team involved in providing direct care to patients hampers staffs ability to provide coordinated treatment and potentially results in patients not receiving all needed treatment to address their problems. (Refer to B118.)

III. Provide multidisciplinary treatment plans that identified patient related short and long-term goals listed in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (A1, A3, A5, A13, A17, A18, A19, and A20). The goal was a direct quote from the patient about what s/he wanted to accomplish. The objectives were what the staff wanted the patient to accomplish. This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to the failure of the team to modify plans in response to patient needs. (Refer to B121.)

IV. Ensure that the Master Treatment plan interventions for eight (8) of eight (8) active sample patients (A1, A3, A5, A13, A17, A18, A19, and A20) addressed their specific problems and needs. Each discipline had a separate page for describing what they were going to do for the patient. The interventions consisted of a list of pre-printed choices from which a discipline could put a check mark next to the ones s/he selected. The available choices for the same discipline (i.e., physician, nurse, etc.) were identical and consisted of generic discipline functions. In some instances, staff did not check off any selections offered (the section was blank).The selection of interventions related to a patient's diagnosis, not specific problem. In addition, the listed interventions failed to include the method of delivery (individual or group), frequency or the specific focus of treatment. These failures result in a lack of guidance for staff who are providing individualized patient treatment that is purposeful and goal directed. (Refer to B122.)

V. Use or follow proper release criteria for two (2) of five (5) patients (R1 and R2) whose records were reviewed for facility and/or Centers for Medicare/Medicaid Services compliance on seclusion/restraint policy and procedure protocol. Record documentation revealed that these two (2) patients were kept in 4-point restraints longer than necessary after they fell asleep. This deficient practice results in failure to ensure a patient's right to be free from restriction of movement. (Refer to B125.)

Based on record review and interview, the Nursing Director failed to monitor and evaluate the quality of care provided to patients by nursing staff. Specifically, the Nursing Director failed to ensure that nursing interventions on the Master Treatment plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A3, A5, A13, A17, A18, A19, and A20) were specific and related to each patient's individual problems and needs.

Findings include:

A. Record Review

1. Patient A1

The Master Treatment plan, dated 12/5/14, listed the following generic and routine discipline functions for the diagnosis of "Major Depression Psychosis":

Nursing- "Administer medication, educate about treatment, preventive rounds, fall precautions, take vital signs, anxiety management, emotional support, assist with ADL's [Activities of Daily Living]."

2. Patient A3

The MTP, dated 12/1/14, listed the following generic and routine discipline functions for the diagnosis of "Schizoaffective Disorder":

Nursing- "Administer medication, education about treatment, preventive rounds, prevention of aggression, take vital signs, anxiety management, emotional support, and assist with ADL's."

3. Patient A5

The MTP, dated 12/6/14, listed the following generic and routine discipline functions for the diagnosis of "Major Depression with Psychosis."

Nursing- "Administer medications, educate about treatment, preventive rounds, fall prevention, take vital signs, anxiety management, emotional support, 1:1 observation, assist with ADL's."

4. Patient A13

The MTP, dated 12/4/14, listed the following generic and routine discipline functions for the diagnosis of "Recurrent Major Depression":

Nursing- "Take vital signs, anxiety management."

5. Patient A17

The MTP, dated 12/5/14, listed the following generic and routine discipline functions for the diagnosis of "Drug Induced Mood Disorder":

Nursing- "Administer medication, education of treatment, take vital signs, management of anxiety, emotional support."

6. Patient A18

The MTP, dated 12/6/14, listed the following generic and routine discipline functions for the diagnosis of "Major Depression with Psychosis":

Nursing- "Administer medications, educate about treatment, preventive rounds, fall prevention, take vital signs, anxiety management, emotional support, 1:1 observation, and assist with ADL's."

7. Patient A19

The MTP, dated 12/4/14, listed the following generic and routine discipline functions for the diagnosis of "Drug Induced Mood Disorder."

Nursing- "Medication administration, education about treatment, preventive rounds, fall prevention, take vital signs, anxiety management, emotional support."

8. Patient A20

The MTP, dated 12/7/14, listed the following generic and routine discipline functions for the diagnosis of "Schizoaffective Disorder":

Nursing- "Administer medication, educate about treatment, preventive rounds, fall prevention, take vital signs, manage anxiety, emotional support":

B. Interviews

In an interview on 12/8/14 at 9:00 a.m., the generic and routine discipline functioned interventions was discussed with the Nursing Director. She stated "I understand what you are saying."

II. Based on record review and interview, the Nursing Director failed to ensure that the nursing staff used or followed proper release criteria for two (2) of five (5) patients (R1 and R2) whose records were reviewed for facility and/or Centers for Medicare/Medicaid Services compliance on seclusion/restraint policy and procedure protocol. Record documentation revealed that these two (2) patients were kept in 4-point restraints longer than necessary after they fell asleep. The nurse in charge failed to notify the attending physician that these patients had fallen asleep prior to the physician's next hourly visit to access readiness for removal from restraints. This deficient practice results in failure to ensure a patient's right to be free from restriction of movement.

Findings include:

A. Record Review

1. Facility policy and procedure, titled "Restriction/Isolation", number 319, dated October, 2014, stated that the patient in restraints must be re-evaluated by the physician every hour to determine the necessity to continue with the restriction. Under the section of patient behavior to be considered by the staff who were responsible for observing the patient to assess readiness for removal was a category to note "If patient is sleeping for more than 45 minutes." There was nothing found in the policy giving the charge nurse the option of calling the physician about the patients' sleeping and discuss possible removal from restraints prior to the physician's next evaluation visit.

2. Patient R1 was placed in 4-point restraints on 11/15/14 at 6:00 p.m. for "aggressive conduct with potential harm to himself, others or property." The physician's order for 4-point restraint for up to two (2) hours was written on 11/15/14 at 6:00 p.m. The patient's log sheet documenting his/her behavior 15 minutes while in 4-point restraints listed patient as falling asleep at 7:15 p.m. and not released until 8:00 p.m. at the time the physician's order for release was written.

3. Patient R2 was placed in 4-point restraints on 11/8/14 at 7:40 p.m. for "aggression in area with everything [objects and people), physically and verbally" The physician order for 4-point restraints for up to two (2) hours was written on 11/8/14 at 7:40 p.m. The patient was surrendering was described as "sleeping at 8:30 p.m. The patient was released from restraints at 9:45 p.m., 15 minutes after the physician wrote the order for release at 9:30 p.m.

B. Interview

1. In an interview with RN1 on 12/9/14 at 9:00 a.m. on why patients (R1 and R2) had not been released after both had falling asleep. She stated that the physician has to re-evaluate patients in restraints every hour to assess patient's behavior and write the order for release.

2. In an interview with the Director of Nursing on 12/9/14 at 9:00 a.m., the fact that patients' rights for freedom of movement were compromised as a result of the prolonged restriction was discussed. She agreed that the patients should have been released sooner.

Based on record review and interview, the Nursing Director failed to monitor and evaluate the quality of care provided to patients by nursing staff. Specifically, the Nursing Director failed to ensure that nursing interventions on the Master Treatment plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A3, A5, A13, A17, A18, A19, and A20) were specific and related to each patient's individual problems and needs.

Findings include:

A. Record Review

1. Patient A1

The Master Treatment plan, dated 12/5/14, listed the following generic and routine discipline functions for the diagnosis of "Major Depression Psychosis":

Nursing- "Administer medication, educate about treatment, preventive rounds, fall precautions, take vital signs, anxiety management, emotional support, assist with ADL's [Activities of Daily Living]."

2. Patient A3

The MTP, dated 12/1/14, listed the following generic and routine discipline functions for the diagnosis of "Schizoaffective Disorder":

Nursing- "Administer medication, education about treatment, preventive rounds, prevention of aggression, take vital signs, anxiety management, emotional support, and assist with ADL's."

3. Patient A5

The MTP, dated 12/6/14, listed the following generic and routine discipline functions for the diagnosis of "Major Depression with Psychosis":

Nursing- "Administer medications, educate about treatment, preventive rounds, fall prevention, take vital signs, anxiety management, emotional support, 1:1 observation, assist with ADL's."

4. Patient A13

The MTP, dated 12/4/14, listed the following generic and routine discipline functions for the diagnosis of "Recurrent Major Depression":

Nursing- "Take vital signs, anxiety management."

5. Patient A17

The MTP, dated 12/5/14, listed the following generic and routine discipline functions for the diagnosis of "Drug Induced Mood Disorder":

Nursing- "Administer medication, education of treatment, take vital signs, management of anxiety, emotional support."

6. Patient A18

The MTP, dated 12/6/14, listed the following generic and routine discipline functions for the diagnosis of "Major Depression with Psychosis":

Nursing- "Administer medications, educate about treatment, preventive rounds, fall prevention, take vital signs, anxiety management, emotional support, 1:1 observation, and assist with ADL's."

7. Patient A19

The MTP, dated 12/4/14, listed the following generic and routine discipline functions for the diagnosis of "Drug Induced Mood Disorder":

Nursing- "Medication administration, education about treatment, preventive rounds, fall prevention, take vital signs, anxiety management, emotional support."

8. Patient A20

The MTP, dated 12/7/14, listed the following generic and routine discipline functions for the diagnosis of "Schizoaffective Disorder":

Nursing- "Administer medication, educate about treatment, preventive rounds, fall prevention, take vital signs, manage anxiety, emotional support."


B. Interviews

In an interview on 12/8/14 at 9:00 a.m., the generic and routine discipline functioned interventions was discussed with the Nursing Director. She stated "I understand what you are saying."


II. Based on record review and interview, the Nursing Director failed to ensure that the nursing staff used or followed proper release criteria for two (2) of five (5) patients (R1 and R2) whose records were reviewed for facility and/or Centers for Medicare/Medicaid Services compliance on seclusion/restraint policy and procedure protocol. Record documentation revealed that these two (2) patients were kept in 4-point restraints longer than necessary after they fell asleep. The nurse in charge failed to notify the attending physician that these patients had fallen asleep prior to the physician's next hourly visit to access readiness for removal from restraints. This deficient practice results in failure to ensure a patient's right to be free from restriction of movement.

Findings include:

A. Record Review

1. Facility policy and procedure, titled "Restriction/Isolation", number 319, dated October, 2014, stated that the patient in restraints must be re-evaluated by the physician every hour to determine the necessity to continue with the restriction. Under the section of patient behavior to be considered by the staff who were responsible for observing the patient to assess readiness for removal was a category to note "If patient is sleeping for more than 45 minutes." There was nothing found in the policy giving the charge nurse the option of calling the physician about the patients' sleeping and discuss possible removal from restraints prior to the physician's next evaluation visit.

2. Patient R1 was placed in 4-point restraints on 11/15/14 at 6:00 p.m. for "aggressive conduct with potential harm to himself, others or property." The physician's order for 4-point restraint for up to two (2) hours was written on 11/15/14 at 6:00 p.m. The patient's log sheet documenting his/her behavior fifteen minutes while in 4-point restraints listed patient as falling asleep at 7:15 p.m. and not released until 8:00 p.m. at the time the physician's order for release was written.

3. Patient R2 was placed in 4-point restraints on 11/8/14 at 7:40 p.m. For "aggression in area with everything (objects and people), physically and verbally" The physician order for 4-point restraints for up to two (2) hours was written on 11/8/14 at 7:40 p.m. The patient was surrendering was described as "sleeping at 8:30 p.m. The patient was released from restraints at 9:45 p.m., 15 minutes after the physician wrote the order for release at 9:30 p.m.

B. Interview

1. In an interview with RN1 on 12/9/14 at 9:00 a.m. on why patients (R1 and R2) had not been released after both had falling asleep. She stated that the physician has to re-evaluate patients in restraints every hour to assess patient's behavior and write the order for release.

2. In an interview with the Director of Nursing on 12/9/14 at 9:00 a.m., the fact that patients' rights for freedom of movement were compromised as a result of the prolonged restriction was discussed. She agreed that the patients should have been released sooner.