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Based on observation, record review, and interviews, the hospital failed to ensure that 1 of 5 patients (#5) was informed of the provisions of the state mental health code governing voluntary admission, consent for treatment and the conditions of admission by: 1) having a family member sign a formal voluntary admission consent for patient #5, and 2) having patient #5 sign consents regarding medications and admission to the facility when documentation indicated that patient #5 had altered mental status. Findings:

On 11/03/2010 at 9:30 AM observation of patient #5 revealed he was sitting in a chair in the day room while 2 MHTs (mental health technicians) were monitoring the patient. Further observation of the patient while he was verbally interacting interacting with staff revealed the patient was disoriented and had altered thought processes.

Interview with the MHTs at that time revealed patient #5 had been confused and disoriented since admission to the hospital and that the patient required total care with ADLs (activities of daily living). The MHTs reported the patient was incontinent of bowel and bladder and required 2 staff to provide the patient's toileting needs due to his physical aggression and confusion.

On 11/03/2010 at 10:00 AM a member of the survey team attempted to interview patient #5, but the patient was oriented to person only. Patient #5 could not recall where he was or why he was in the facility.
On 11/04/2010 at 10:35 AM an interview with S6 MHT revealed that he was working the day patient #5 was admitted and that RN S3 asked him to leave the facility to transport patient #5 to the hospital. S6 MHT stated when he and the recreational therapist arrived at the patient's home, patient #5 was confused and disoriented and initially refused to come with them. Further interview revealed while at the patient's home, the daughter who is the primary caregiver, signed a formal voluntary admission form for patient #5 to be admitted to the psychiatric hospital. Review of the open medical record revealed that patient # 5 did not have a family member or advocate that had power of attorney.

Further review of the medical record failed to reveal an intake assessment in the record for patient #5 or documentation that a clinician assessed the patient prior to hospitalization. The record indicated when patient #5 arrived at the facility on 10/22/2010 at 1345 (1:45 PM), S3 RN performed the admission assessment and documented that patient #5 "appears labile, with confused thought processes. Patient restless and anxious, and easily agitated. Consents signed and explained to patient. FVA (formal voluntary admission) signed- rules and regulations explained".

Review of the voluntary admission form revealed on 10/22/2010 at 1:45 PM that patient #5 signed another name in the space designated for his signature. The admission signature was witnessed by 2 nurses and signed by the medical director confirming that patient #5 was suitable for voluntary admission. Further review of the voluntary admission form revealed that by signing the form, patient #5 requested admission to the hospital and the form certified that the patient had been informed of the provisions of the state mental health code governing voluntary admission and that he fully understood the provisions of the admission.

Review of the Psychiatric Evaluation completed on 10/24/2010, 2 days after admission, by Dr. S8 revealed the psychiatrist noted that patient #5's mental status was "disoriented with altered perception and blunted affect". His Axis I diagnosis was noted to be Dementia; Early Onset Alzheimer's.

On 11/04/2010 at 1:00 PM interview with Dr. S8, attending psychiatrist and medical director, confirmed that patient #5 should not have been allowed to sign a voluntary admission to the facility due to his severe altered mental status. Further interview with S8 confirmed that patient #5 should not have signed consents for psychopharmacological medications in which the patient signed that he read and agreed that the medications and treatments had been adequately explained and discussed with him.

Based on observation, interviews, and record review, the hospital failed to ensure that each patient receives care in a safe setting as evidenced by: 1) the failure of staff to adequately monitor patients who are considered high risk and 2) failure of staff to report incidents in a timely manner. This was identified for 2 of 5 sampled patients (#1, #2). Findings:

1. Review of the closed medical record for patient #1 revealed an admission date of 10/14/2010 with an Axis I diagnosis of Major Depression, recurrent, severe, without psychotic features, an Axis II diagnosis of Borderline personality disorder (causes emotional instability leading to risky behavior) and an Axis V-GAF (global assessment functioning) score of 30 (major impairment in judgment). Further review of the record revealed that patient #1 was admitted on an observation status of LOS (line of sight) and remained on LOS status until her observation level was increased to 1:1 (1 patient to 1 staff) on 10/22/2010 due to high risk behavior.

Review of hospital policy regarding patient #1's observation status revealed that line of sight is very restrictive toward the patient and involves continuous visual monitoring at all times. The policy indicated that staff must be within visual contact of the patient at all times with the exception of toileting and showering during which times staff must be present outside a door left ajar but remain in audible contact with the patient. Continued review of the policy revealed that if a staff member was observing more than one patient and one or more patients went to separate areas, then staff must transfer responsibility for line of sight to other staff members so that there is continuous observation of all patients on line of sight. The policy indicated patients on line of sight are considered high-risk.

Review of an investigative report by S1 DON of an alleged sexual contact between patients, #1 and #2, revealed on the evening of 10/19/2010 these patients were found on the bed together in patient #1's room. Further review of the report revealed that the MHTs on duty reported the incident to charge nurse S15 RN after it occurred. S1 DON noted in the report that S15 RN did not immediately report the incident as per hospital policy and did not complete a variance report regarding the issue.

In a telephone interview on 11/05/2010 at 10:12 AM, S15 RN confirmed she worked the evening of 10/19/2010 when the alleged sexual encounter occurred between patient #1 and patient #2. S15 said after the 9:00 PM med pass on 10/19/2010, S9 MHT came to her and reported that she found patient #2 in patient #1's room and he was lying on the bed next to patient #1. S15 said someone, she thought it was the day RN, told her at shift change to watch the two patients closely because the MHTs and day nurses had noticed the two liked to be together (talking, touching) and she shared this information with the MHTs on her shift.

S15 RN stated she thought that patient #1 was on every 15 minute observations (must see the patient every 15 minutes) at the time of the incident. Further interview with S15 RN confirmed that she did not complete an incident report, notify the DON or the attending psychiatrist, or document an entry in the medical records for patients #1 and #2.

In an interview on 11/05/2010 at 9:45 PM S13 MHT reported he was working the 7:00 PM-7:00 AM shift on 10/19/2010 when they found patient #2 in patient #1's room. He said they had 3 MHTs on duty that night and between 7:30 and 8:00 PM he went to the nurses' station get his paperwork. S13 said when he returned to the dayroom, S9 MHT asked where was patient #2. S13 said he told the MHT that he did not know but the patient should be in his room.

S13 further stated that S9 MHT told him that they must find the patient and they started looking for patient #2. He said the patient wasn't in his room so they immediately went to patient #1's room. S13 indicated patient #1's room was connected to another room by a shared bathroom so he went through the other room into patient #1's room and found patient #2 lying on the bed fully dressed and patient #1 was under the cover fully dressed.

S13 MHT did not have an exact time since staff had last seen patient #2 but S13 said he did see him earlier with his box of personal care items and the patient was going to shower. S13 said S9 MHT told him that she unlocked patient #1's room approximately 5 minutes before they missed patient #2. The survey team asked S13 who was watching the other patients while he and S9 were looking for patients #1 and #2 and he replied, "No one because all three of us (MHTs) were in patient #1's room".

An interview on 11/4/2010 at 1:00 PM with Dr. S8 Psychiatrist revealed a staff member called her to report the patient to patient contact. S8 stated she talked with patient #1 on the phone and then had a face to face interview with her. S8 stated patient #2 never did admit to having sex with patient #1. During the interview the survey team read Dr. S8 her handwritten progress notes dated 10/26/2010 from patient #2's closed medical record. Dr. S8 documented, "He (patient #2) finally admitted to having sex with a peer (patient #1) on the unit". S8 stated she felt that the incident did happen but "I'm not sure he said it in those exact words". S8 also stated she was assured the investigation of the incident was done and that extra training needed to be done immediately. Dr. S8 confirmed supervision was lacking for this incident to have happened because both patients were on line of sight observation when it occurred.

In an interview on 11/03/10 at 2:55 PM S1 DON stated the incident between patient #1 and #2 supposedly happened on 10/19/2010 around 9:00 PM and it was 2 days before she was informed of the incident. S1 DON indicated as a result of the investigation she determined that staff did not follow protocol in monitoring patients by failing to observe patients #1 and #2 who were both on line of sight observation. S1 confirmed that lack of supervision and observation by the MHTs was a breach in hospital policy.

Further interview with S1 revealed that the nurses on duty were aware when patients #1 and #2 were found together. She stated S15 RN told her that she talked with both patients at the time of the incident and since they were found "sitting on the bed fully clothed" that she and S9 MHT did not think there was time for them to have had sex, that nothing happened, and there was nothing to report to the DON.

2. Review of a grievance filed by patient #1 dated 10/22/2010 (during her hospitalization) revealed the patient alleged that on the evening of 10/17/2010 a male MHT personally bought her snacks, gave her money, and made the comment to her that "I'm going to take care of you while you're here". Further review of the grievance revealed patient #1 alleged that evening the same male tech came into her room with a blanket, put the blanket over her and bent down and kissed her. Patient #1 indicated that the following day (10/18/2010) the male MHT said to her "I thought about you last night" and made an (offensive gesture). Patient #1 documented in the grievance that the male MHT came into her room that night around 10:00 PM and said he wanted a nude picture of her from her back side, she said "No" and the MHT left.

On 11/04/2010 at 3:10 PM an interview was held with S4 MHT who confirmed she worked on 10/22/2010 when she overheard patient #1 talking with another patient about a male MHT who came into her room and told her as long as she was there (a patient in the hospital) that he would take care of her. S4 said she asked patient #1 who she was referring to and she named a staff MHT. S4 said she told patient #1 that she would have to report the incident and then patient #1 changed her story and said it was another patient who came into her room. S4 said she told patient #1 that she was in a hospital and male staff could not go into female patient rooms and the patient became angry.

S4 MHT indicated nursing staff and counselors told her that she should always report anything suspicious she heard or saw to the nurses immediately, but she felt she could not leave her patients at that time. S4 stated that she intended to report what she overheard to the nurses when the patients went to group therapy later that morning.

S4 MHT did acknowledge that it was approximately 2 hours before she reported to the nurse the allegation about the male MHT going into patient #1's room. S4 said after she reported the incident to the RN and LPN she asked patient #1 to tell the nurses what she was saying about the MHT and the patient said to her, "Oh, I didn't know you were going to tell"! S4 stated the nurse changed patient #1's observation level immediately from line of sight to 1:1.

In an interview on 11/04/2010 at 9:25 AM S12 ADON stated she was not working when patient #1 reported that a male MHT on staff kissed her. S12 said according to patient #1, this occurred not long after she arrived at the hospital. S12 said staff had not reported anything about the MHT acting inappropriately toward a patient prior to this incident. S12 stated she heard that the MHT made sexual statements around female staff and that the male MHT was terminated after the investigation of the incident. S12 confirmed the employees had not been provided with reinforced training to prevent a reoccurrence of the incident.

In an interview on 11/04/2010 at 11:20 AM, S5 MHT stated he was on the patio when S4 MHT overheard patient #1 tell another patient that a male MHT came into her room and kissed her. He stated patient #1 came to him and told him about the incident and he told the patient to go then and report it to the nurses. He stated the patient went toward the nurses' station, was gone about 20 minutes and when she returned told him that she talked to someone about the incident. S5 further stated later he mentioned it to S2 LPC (licensed professional counselor) and found that patient #1 had not reported the incident as she told him. S5 stated this happened around 4:00-5:00 PM in the afternoon. Review of investigative report failed to reveal that patient #1 was interviewed regarding this incident.

In a telephone interview on 11/04/2010 at 2:55 PM the survey team asked S10 RN who made MHT assignments. S10 indicated as the charge nurse she did not always make patient assignments for the MHTs. S10 stated the MHTs make their own assignments.

S10 further stated S1 DON called her on the telephone and asked what she knew about a male MHT going into a female patient's room to give her a blanket. S10 recalled she told S1 DON that the male MHT told her patient #1 wanted a blanket. S10 stated she assumed patient #1 would be standing in her doorway waiting for the blanket and thought there was no reason for him to go into her room, so she dismissed the issue. S10 heard later that the male MHT went into the patient's room.

During an interview on 11/03/2010 at 9:30 AM the survey team asked S17 about staffing. She stated there were 4 MHTs working that day and since the census was 16 she was assigned 4 patients, both male and female. S17 also stated only female staff was allowed to attend female patients with toileting needs. S17 stated there were normally 3 MHTs assigned to work the 7:00 PM-7:00 AM shift.

Interview on 11/04/2010 at 1:00 PM with Dr. S8 psychiatrist revealed patient #1 informed her that the male MHT who came into her room was flirtatious with her and that she flirted back. S8 said patient #1 told her the male MHT kissed her and told her he would take care of her while she was in the hospital. Dr. S8 confirmed 3 MHTs were assigned to the night shift and when there are 2 patients that require line of sight observation, only 1 tech was available to monitor the other patients on the night shift. S8 confirmed that the number of MHT did not provide adequate monitoring, but stated she considered the hospital was adequately staffed when the RN and LPN was factored in for each shift because they should also help with patient monitoring.
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Based on review of 1 of 3 closed medical records in a total sample of 5 and interviews, the hospital failed to ensure that patient #1 was free from abuse by failing to develop, implement and/or enforce policies and procedures to prevent a staff member from engaging in abuse of a sexual nature toward patient #1 who was identified at high risk with a diagnosis of borderline personality disorder and an observation status of line of sight. Findings:

Review of the closed medical record for patient #1 revealed an admission date of 10/14/2010 with an Axis I diagnosis of Major Depression and an Axis II diagnosis of Borderline Personality Disorder (exhibits impulse behavior). The record indicated the patient #1 was admitted on an observation status of LOS (line of sight) and remained on LOS status until her observation level was increased to 1:1 on 10/22/2010 due to high risk behavior.

Review of a grievance filed by patient #1 dated 10/22/2010 revealed the patient alleged that on the evening of 10/17/2010 a male MHT personally bought her snacks, gave her money, and made the comment to her that "I'm going to take care of you while you're here". Further review of the grievance revealed patient #1 alleged the same evening the same male tech came into her room with a blanket, put the blanket over her and bent down and kissed the patient. Patient #1 indicated that the following day (10/18/2010) the male MHT said to her "I thought about you last night" and made an (offensive gesture). Patient #1 documented in the grievance that the male MHT came into her room that night around 10:00 PM and said he wanted a nude picture of her from her back side, she said "No" and the MHT left.

On 11/04/2010 at 3:10 PM an interview was held with S4 MHT who confirmed she worked on 10/22/2010 when she overheard patient #1 talking with another patient about a male MHT who came into her room and told her as long as she was there (a patient in the hospital) that he would take care of her. S4 said she asked patient #1 who she was referring to and she named a MHT. S4 said she told patient #1 that she would have to report the incident and that patient #1 changed her story and said it was another patient who came into her room and then she stopped talking. S4 said she told patient #1 that she was in a hospital and male staff could not go into female patient rooms and the patient became angry.

S4 MHT indicated nursing staff and counselors told her that she should always report anything suspicious she heard or saw to the nurses immediately but she felt she could not leave her patients at that time. S4 stated that she intended to report what she overheard to the nurses when the patients went to group therapy later that morning.

S4 MHT further stated she knew in orientation the DON had stressed if a patient needed anything, they were not to go in patient rooms alone. S4 did acknowledge that it was approximately 2 hours before she reported to the nurse the allegation about the male MHT going into patient #1's room. S4 said after she reported the incident to the RN and LPN she asked patient #1 to tell the nurses what she was saying about the MHT and the patient said to her, "Oh, I didn't know you were going to tell"! S4 stated the nurse changed patient #1's observation level immediately from line of sight to 1:1.

In an interview on 11/04/2010 at 9:25 AM S12 ADON stated she was not working when patient #1 reported that a male MHT on staff kissed her. S12 said according to patient #1, this occurred not long after she arrived at the hospital. S12 said staff had not reported anything about the MHT acting inappropriately toward a patient prior to this incident. S12 stated she heard that the MHT made sexual statements around female staff and that the male MHT was terminated after the investigation of the incident. S12 confirmed the employees had not been provided with reinforced training to prevent a reoccurrence of the incident.

In an interview on 11/05/2010, S13 MHT stated he worked nights with the male MHT whom patient #1 said made sexual advances toward her. S13 stated the MHT made inappropriate sexual comments toward female staff, but away from patients.

In an interview on 11/04/2010 at 11:20 AM, S5 MHT stated he was on the patio when S4 MHT overheard patient #1 tell another patient that a male MHT came into her room and kissed her. He stated patient #1 came to him and told him about the incident and he told the patient to go then and report it to the nurses. He stated the patient went toward the nurses station and was gone about 20 minutes and when she returned told him that she talked to someone about the incident. S5 further stated later he mentioned it to S2 LPC and found that patient #1 had not reported the incident as she told him. S5 stated this happened around 4:00-5:00 PM in the afternoon. Review of investigative report failed to reveal that patient #1 was interviewed regarding this incident.

Interview on 11/04/2010 at 1:00 PM with Dr. S8 Psychiatrist revealed patient #1 told her the male MHT was flirtatious with her and she flirted back. S8 stated that patient #1 told her the male MHT kissed her and told her he would take care of her while she was there. S8 confirmed that patient #1 was on line of sight observation at the time of the incident. Further interview with S8 confirmed that male staff are not to enter a female patient room without the presence of female staff.

In a telephone interview on 11/04/2010 at 2:55 PM the survey team asked S10 RN who made MHT assignments. S10 indicated as the charge nurse she did not always make patient assignments for the MHTs. S10 stated the MHTs assign themselves and make a copy of the assignments sheets for her.

S10 further stated S1 DON called her on the telephone and asked what she knew about a male MHT going into a female patient's room to give her a blanket. S10 recalled she told S1 DON the male MHT told her patient #1 wanted a blanket. S10 stated she assumed patient #1 would be standing in her doorway waiting for the blanket and thought there was no reason for him to go into her room, so she dismissed the issue. S10 heard later that the male MHT went into the patient's room.

During an interview on 11/03/2010 at 9:30 AM, S17 MHT was asked about staffing. She stated there were 4 MHTs working that day and since the census was 16 she was assigned 4 patients, both male and female. S17 also stated only female staff was allowed to attend female patients with toileting needs. S17 stated there were normally 3 MHTs assigned to work the night shift, 7P-7A.

Interview on 11/04/2010 at 1:00 PM with Dr. S8 psychiatrist revealed patient #1 informed her that the male MHT who came into her room was flirtatious with her and that she flirted back. S8 said patient #1 told her the male MHT kissed her and told her he would take care of her while she was in the hospital. Dr. S8 confirmed 3 MHTs were assigned to the night shift and when there are 2 patients that require line of sight observation, only 1 tech was available to monitor the other patients on the night shift. S8 confirmed that the number of MHT did not provide adequate monitoring, but stated she considered the hospital was adequately staffed when the RN and LPN was factored in for each shift because they should also help with patient monitoring.

S1 DON stated in an interview on 11/03/2010 at 2:55 PM S2 LPC called her on 10/19/10 to report on 10/17/10 a male MHT went into patient #1's room to give her a blanket. S1 stated she interviewed the male MHT over the telephone (he was scheduled to work the night shift that night) and he confirmed he took a blanket into patient #1's room. S1 reported that the male MHT also told her that he informed the RN on duty that the patient asked for a blanket and that he was taking it to her. S1 stated she interviewed the RN about the incident and the nurse reported to S1 that she recalled the male MHT told her that. S1 also stated she only interviewed S10 RN and the MHT about the incident and thought she had enough information to suspend the MHT, so did not interview other staff. S1 confirmed the hospital did not have a policy that directed male MHTs not to go into female patient rooms alone.

Review of policy titled, "Identification and Reporting Suspected Abuse, Exploitation and/or Neglect (reference #2010) revealed, "Each employee who suspects or has the knowledge of or is involved in an allegation must report the incident to their supervisor immediately".

Based on review of hospital policy and procedures and interviews with licensed and unlicensed staff, the hospital failed to ensure the RN supervised and evaluated nursing care by allowing an unaccompanied male mental health tech to enter a female patient's (#1) room which resulted in alleged sexual abuse/harassment and by allowing a male patient (#2) to enter a female patient's (#1) room which resulted in sexual contact. Findings:

Review of policy (reference #2003) regarding Room Assignments and Commingling (effective 7/2010) revealed, "No male or female patients will share rooms or visit each other in their rooms at any time".
Review of policy (reference # 1029) regarding Rounds for Patient Observation revealed, "If any patient is unaccounted for, the charge nurse will be notified and unit/compound search will be done immediately".

In a telephone interview on 11/04/2010 at 2:55 S10 RN reported her duties as charge RN included providing ongoing patient assessments, participating in shift report and to providing initial nursing assessments for new admits.

S10 stated that on 10/17/10, a male MHT told her patient #1 wanted a blanket. S10 stated she assumed patient #1 would be standing in her doorway waiting for the blanket and thought there was no reason for him to go into her room, so she dismissed the issue. S10 confirmed she did not watch the male MHT go to patient #1's room with the blanket. S10 stated she heard later that the male MHT went into the patient's room.

In a telephone interview on 11/05/2010 at 10:12 AM S15 RN S15 confirmed she worked the evening of 10/19/2010 when the alleged sexual encounter occurred between patient #1 and patient #2. S15 said after the 9:00 PM med pass, S9 MHT came to her and reported that she found patient #2 in patient #1's room lying on the bed next to patient #1. S15 further stated the MHT reported that both patients were fully clothed. S15 said someone, she thought it was the day RN, told her at shift change to watch the two patients closely because the MHTs and day nurses noticed the two liked to be together (talking, touching) and she shared this information with the MHTs on her shift.

S15 RN said she went to patient #1 ' s room and the patient denied anything happened with patient #2. S15 added that S9 MHT told her that she knew what time patient #1 asked her to unlock her room and the time the two MHTs went to find patient #2. S15 said they concluded that the two did not have time for a sexual encounter to occur. S15 said she thought patient #1 was on every 15 minute observation at the time of the incident.

The survey team questioned S15 if she completed a Variance Report after the incident, contacted the attending psychiatrist or the DON, or noted the occurrence in the medical records. S15 RN stated she did not. S15 did state she talked to the DON later that evening, but not at the time of the occurrence because she did not consider the incident an emergency. The survey team asked S15 RN who makes the MHT patient assignments and the nurse responded that the MHTs make their own patient assignments and not the nurses.

An interview on 11/05/2010 1:15 PM revealed S13 MHT S13 MHT reported he was working the night they found patient #2 in patient #1's room. He said between 7:30 and 8:00 PM he went to get his paperwork and when he returned to the dayroom, S9 MHT asked where patient #2 was and he told her that he did not know but he should be in his room.

S13 MHT indicated after they found the patients, he reported it to the RN and she reported it to the DON the following morning. S13 said he was not aware that the patients were trying to "get together" until that evening. He confirmed that he received training on not to go into female patient rooms alone. S13 further stated that it's difficult to watch the patients closely especially since the hospital now admits older patients. He said it takes 2 MHTs to provide personal care for the geriatric population and the nurses are too busy to help. S13 stated, "The RN can't leave the nurses' station because she needs to be there to answer the phone".

During an interview on 11/3/10 at 2:55 PM, S1 DON stated she received a phone call from S2 LPC on 10/22/10 who informed her that on 10/17/10 a male MHT went into patient #1's room to give her a blanket. S1 stated she interviewed the male MHT over the telephone and he confirmed he took a blanket into patient #1's room. He also told S1 that he informed the RN (S10) on duty that patient #1 asked for a blanket and he was taking it to her. S1 stated she asked the RN about that and she reported to S1 that she recalled when the male MHT told her that he was taking a blanket to patient #1. S1 also stated she only interviewed S10 RN and the male mental health tech about the incident and thought she had enough information to suspend his employment so did not interview other staff.

Based on interview with licensed and unlicensed staff, the hospital failed to ensure all patient care assignments are made by the RN by allowing the MHTs (mental health technicians) to make their own assignments. Findings:


In a telephone interview on 11/04/2010 at 2:55 PM S10 RN reported her duties as a charge RN included providing ongoing assessments, participating in shift report and to providing assessments on newly admitted patients.


The survey team asked S10 who made assignments for the MHTs and she indicated that she did not always make the assignments. S10 stated after shift report she provided the techs with the census log which included patient observation status and the MHTs made their own assignments and made a copy of the assignment sheet for her.


An interview on 11/05/2010 revealed S13 MHT worked the 7:00 PM-7:00 AM shift. S13 indicated in the interview that the RNs did not make patient assignments for the MHTs.


During an interview with S9 MHT on 11/04/2010 at 11:40 AM the survey team asked who made MHT patient assignments. S9 stated the nurses used to make the MHT assignments, but now the techs make their own patient assignment at the beginning of their shift.


During an interview on 11/04/2010 at 2:00 PM with S1 DON, the survey team asked who made patient care assignments for the MHT staff. S1 DON indicated the RN made the assignment and expressed surprise that the MHTs were making their own patient assignments.

Based on record review and interview, the hospital facility failed to ensure that each patient has an individual comprehensive treatment plan based on an assessment of the patient's needs by failing to develop and modify treatment plans for 2 of 5 sampled patients ( #1, #5). Findings:

1. Review of the medical record for patient #1 revealed an admission date of 10/14/2010 with an admitting diagnosis of Axis I-Bipolar Disorder and Axis II-Borderline Personality Disorder. Further review of the record revealed a revised diagnosis on 10/16/2010 of Major Depression, severe. Review of the master treatment plan problem list revealed only two problems of depressed mood and risk for directed violence were documented for patient #1. The treatment plan failed to reflect an addendum or a modification of the plan to address patient #1's high risk behavior at any point during her hospitalization. On 11/04/2010 at 1:00 PM, an interview with Dr. S8 psychiatrist, confirmed that the treatment plan for patient #1 did not reflect high risk behavior and Borderline Personality Disorder.

2. Review of the medical record for patient #5 revealed an admission date of 10/22/2010 at 1345 (1:45 PM) with and admission diagnosis of Axis I- Dementia; Axis III-Hypertension, TIA (Trans ischemia attack) and Osteoarthritis. Review of the history and physical performed on 10/22/2010 revealed a history of bowel and bladder incontinence and impaired vision and hearing. Further review revealed the patient had generalized weakness and was at risk for falls.

Review of the initial treatment plan for patient #5 dated 10/22/2010 revealed that the expected outcome was for the patient to describe unit routines, state the purpose and process of prescribed treatments and procedures, attend assigned groups, identify signs and symptoms of illness and relapse prevention, identify prescribed medications and state purpose, dosage and explain the necessity for medication. Further review revealed the target date of goals was noted as 10/28/2010.

Further review of the master treatment plan review dated 10/26/2010 revealed problem #1 of disturbed thought process, problem #2 of ineffective health maintenance, problem #3 of impaired physical mobility and problem #4 of impaired skin integrity. Further review of the progress towards goals revealed that the patient was not attending group sessions, he was restless, sometimes combative; and he urinated on the floor when the "urge strikes patient". The treatment plan indicated patient #5 was confused, sometimes combative and refused group sessions. Further review failed to reveal any new approaches were documented or implemented to address the problems.

On 11/04/2010 at 1:00 PM interview with Dr. S8 psychiatrist confirmed that problems and approaches identified in the treatment for patient #5 were not individualized. S8 confirmed the expected outcomes and the interventions did not reflect the mental status and the physical limitations of patient #5.