HospitalInspections.org

Based on observation, record review, and interview, the facility failed to provide active treatment, including alternative interventions, for 3 of 8 active sample patients (E3, F3, and G8) who were either not cognitively capable of participating in treatment or were not motivated to attend the assigned group treatment. Rather than providing individualized treatment for these patients, the staff expected them to attend all groups listed on each unit's activity schedule. The patients regularly and reportedly did not attend group therapies. They spent many hours without any structured activity and occupied their time by sleeping, watching television, smoking during smoke breaks or wandering around the hallways or courtyards when that option was available. Staff made little effort to encourage them to attend groups. Failure to provide active and appropriate treatment for patients results in the patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their improvement. (Refer to B125)

Based on record review and interview, the facility failed to provide Social Work (SW) Assessments that included conclusions and recommendations describing social worker's anticipated roles in treatment and discharge planning for 8 of 8 active sample patients (A1, B1, B2, C3, D1, E3, F3, and G8). As a result, social work recommendations regarding treatment of patients' psychosocial problems were not available for the treatment team.

Findings include:

A. Record Review

1. Patient A1 (admitted 6/14/13) had a Psychosocial Assessment completed 6/17/13. The Social Worker's Summary including recommendations and identified barriers to treatment was: "Barriers to treatment include psychosis/altered thoughts, mood disturbance and intermittent medication non-compliance. Drug study team will follow up with patient and provide aftercare referrals." No specific role for the social worker was identified.

2. Patient B1 (admitted 6/18/13) had a Psychosocial Assessment completed 6/20/13. The Social Worker's Summary including recommendations and identified barriers to treatment was: "Barriers- chronicity of illness, medication non-compliance, poor coping strategies and limited support system." Recommendations: "F/u [follow-up] w/ [with] [her/his] outpatient psychiatrist and psychotherapist, be compliant w/ meds [medications], and return to home to family." No specific role for the social worker was identified.

3. Patient B2 (admitted 6/20/13) had a Psychosocial Assessment completed 6/22/13. The Social Worker's Summary including recommendations and identified barriers to treatment was: "Barriers include mood d/o [disorder], impulsivity, hx [history] of chemical dependence, homelessness, poor coping skills, limited social support." Recommendations: "F/u with psychiatrist, PHP [Partial Hospitalization Program], transitional housing, anger management group, and 12 step recovery." Specific role(s) of the social worker was/were not identified.

4. Patient C3 (admitted 6/21/13) had a Psychosocial Assessment completed 6/24/13. The Social worker's Summary including recommendations and identified barriers to treatment was: "Chronicity of illness, hx [history] of trauma, poor coping skills, poor self-image ...financial instability, family discord w/ ex-boyfriend [father of children], employment issues, depression w/ si [suicidal ideation]." Recommendations included: "counseling which provide psychiatric & [and] therapeutic appointments, attend 12 step support group meetings, f/u w/ transfer therapist." No specific role for the social worker was identified.

5. Patient D1 (admitted 6/12/13) had a Psychosocial Assessment completed 6/13/13. The Social Worker's Summary including recommendation and identified barriers to treatment was: "Barriers - chronicity of illness, inability to care for self, medications non-adherence, limited insight." Recommendations: "F/u with outpatient psychiatrist and therapist, needs housing, medication adherence, social services with f/u with discharge plans and services." In spite of the references to discharge plans, no specific social worker role related to discharge needs and services was identified.

6. Patient E3 (admitted 5/22/13) had a Psychosocial Assessment completed 5/23/13. The Social Worker's Summary, including recommendations and identifying barriers in treatment was: "Barriers - altered thought process, mood disturbance, impaired social judgment and med [medication] non-compliance adherence." Recommendations: "F/u [with] psychiatrist and psychotherapist ...be placed for residence, attend support group and 12 step. Social services will f/u [with] d/c [discharge] plans and options." No specific follow-up plans were identified.

7. Patient F3 (admitted 6/15/13) had a Psychosocial Assessment completed 6/18/13. The Social Worker's Summary including recommendation and identified barriers to treatment was: "Barriers - chronicity of illness, mood disturbances, altered thought process, poor coping skills, lack of insight, limited social support, judgment, and family stressors. SW recommends pt. f/u [with] outpt. psychiatrist, f/u [with] outpt. psychologist, attend outpt. Tx [treatment] program. SW will f/u as needed." No specific role of the social worker during hospitalization was identified.

8. Patient G8 (admitted 6/21/13) had a Psychosocial Assessment completed 6/24/13. The Social Worker's Summary including recommendations and identifying barriers to treatment was: "Barriers - chronicity of illness, poor insight, poor coping skills psychosis, paranoia. SW recommends - pt. f/u [with] psychiatrist, psychologist, outpt. therapist." No specific social work role was identified.

B. Interview

In an interview on 6/25/13 at 12:10 p.m., the lack of including the specific role of the social work staff in facilitating active sample patients' movement towards discharge in the Psychosocial Assessment was discussed with the Social Work Director. She stated, "I am in total agreement."

Based on record reviews and interviews, the facility failed to ensure that the multidisciplinary Master Treatment Plans (MTPs) for 3 of 8 active sample patients (C1, F3 and G8) included social work interventions. Several social work interventions were absent because facility policy states that Psychosocial Assessments are due in 72 hours [3 days] after the patient is admitted and Master Treatment plans are due in the same time frame. With the average length of stay being from 5 - 6 days [per information gathered through the Risk Management Director on 6/24/13 around 9:00 a.m.], there was little time to work on social work interventions before a patient was ready for discharge. This failure hampers the staff's ability to provide coordinated treatment by all disciplines involved in a patient's care, potentially resulting in patients not receiving all needed treatment services to address their problems.

Findings include:

A Record Review

1. Facility policy, titled "Interdisciplinary Treatment Plan", last revised 1/12, stated: "Each patient admitted to the hospital shall have a written, individualize treatment plan....Treatment shall be planned, reviewed and evaluated at regular intervals by a multidisciplinary treatment team. This team shall consist of the physician and representations of each clinical discipline involved in the treatment as appropriate."

2. The following MTPs (dates of plans in parenthesis) did not include any interventions by social work staff: C3 (6/24/13), F3 (6/15/13), and G8 (6/24/13). The pre-printed MTP forms listed examples of interventions by various clinical staff, including social workers. A space for a check mark was located at the beginning of the listed interventions. None of the available social work interventions printed on the MTP forms had a check mark on the 3 plans listed above.

B. Interview

In an interview on 6/25/13 at 12:10 p.m., the lack of social work interventions on patient F3's MTP was discussed with the Director of Social Work. She stated that social work interventions are usually placed on the MTPs at the first treatment team meeting after admission, which was scheduled for 6/26/13. She went on to say that the reason for this was to give the social work staff time to gather information on the patients from other disciplines. After it was noted that social workers also gather data to determine patient's needs in their psychosocial assessments which are due in 72 hours after admission, the same timeframe as the development of the treatment plans, she stated, "You are right (agreeing that both of the sources are due at the same time)."

Based on record review and interview, the facility failed to develop multidisciplinary treatment plans that evidenced sufficient individualized planning of interventions with specific focus for 8 of 8 active sample patients (A1, B1, B2, C3, D1, E3, F3 and G8). These patients' treatment plans were developed from pre-printed forms that included lists of generalized interventions for various identified problems. The interventions selected from the available lists were selected by putting a check mark to the left of the desired choice. Each of the patient units had a master schedule. All patients were expected to attend the groups listed on the activity schedule for their unit. However, only a few groups from the schedule were included on the MTPs, and because the plans were pre-printed, the focus of a group was the same for all patients who attended the group. Failure to develop individualized comprehensive treatment plans impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Record Review

1. Facility policy, titled "Interdisciplinary Treatment Plan", last revised 1/12, stated: "Each patient admitted to the hospital shall have a written, individualized treatment plan based on assessments of clinical needs. The plan shall describe...clinical interventions prescribed....In essence, the treatment plan serves as an organizational tool where by the care rendered each patient is designed." The Master Treatment Plans of the 8 active sample patients reflect the use of pre-printed forms that lack individual focus for treatment.

2. Active sample patient A1's MTP, dated 6/17/13, had as a problem "psychosis/hallucinations as evidenced by visual hallucinations, command hallucinations, paranoid thoughts and disorganized thoughts." The staff specific interventions chosen were: (1) "RN to meet 1-1 for 10 minutes to evaluate presenting symptoms of paranoid schizophrenia and document mood, mental status and effectiveness of medications." (2) "Gather patient with verbal prompts to actively participate in their treatment; offer goals and wrap-up groups to assist pt. in identifying small steps towards discharge for adaptive and healthy coping skills with productive goals for treatment." (3) "Verbally invite patient to actively participate in all groups and offer process groups to provide an opportunity for reality orientation, gain insight into the issues of psychosis related to paranoid schizophrenia and help to build stress management and relaxation exercise to manage symptoms of AH/VH [audio [sic] hallucinations/visual hallucinations [illegible word]."

3. Active sample patient B1's MTP, dated 6/21/13, had as a problem "Psychosis/hallucinations as evidenced by: auditory hallucinations, disorganized thoughts and inability to care for self." The interventions chosen were: (1) "RN to meet with client 1:1 for 10 minutes to evaluate presenting symptoms of hallucinations and document mood, mental status, and effectiveness of medications." (2) "Gather clients with verbal prompts to actively participate in their treatment; offer goals and wrap-up groups to assist in identifying small steps towards healthy coping skills, productive goals for treatment, and discharge for [blank space]." (3) "Verbally invite client to actively participate in all groups and offer process groups to provide an opportunity for reality orientation, gain insight into the issue of psychosis related to [blank space] and help to build stress management and relaxation exercises to manage symptoms of hallucinations."

4. Active sample patient B2's MTP, dated 6/23/13, had as a problem "psychosis/hallucinations as evidenced by paranoid thoughts." The interventions chosen were: (1) "RN to meet with client 1:1 for 10 minutes to evaluate presenting symptoms of paranoia and document mood, mental status, and effectiveness of medications." (2) "Gather clients with verbal prompts to actively participate in their treatment; offer goals and wrap-up groups to assist in identifying small steps towards healthy coping skills, productive goals for treatment, and discharge for [blank space]." (3) "Verbally invite client to actively participate in all groups and offer process groups to provide an opportunity for reality orientation, gain insight into the issue of psychosis related to [blank space] and help to build stress management and relaxation exercises to manage symptoms of paranoia."

5. Active sample patient C3's MTP, dated 6/24/13, had as a problem of "Alteration in Mood Depressive Symptoms." The interventions chosen were: "Educate the pt. about Major Depression illness to promote self-care and prevent relapse, use coping mechanisms rationalization and relaxation for patient education." "Gather patient with verbal prompts to actively participate in groups; offer goals and wrap-up groups to assist pt. in identifying healthy coping skills and productive goals to manage stress and anxiety." "Gather patient to attend group activities by verbally prompting prior to group to offer an opportunity for active therapies groups to help with concentration and insight to depression." "Dr. will discuss symptoms, adjust medication as indicated, and provide education on medications to stabilize moods and anxiety."

6. Active sample patient D1's MTP, dated 6/12/13, had as a problem "psychosis/hallucinations as evidenced by [no checks selected from 8 available choices]." The interventions chosen were: (1) "RN to meet 1-1 for 10 minutes to evaluate presenting symptoms of delusional ideation and document mood, mental status and effectiveness of medications." (2) "Gather client with verbal prompts to actively participate in their treatment, offer goals and wrap-up groups to assist pt. in identifying small steps towards discharge for daily goals[sic] and healthy coping skills with productive goals for treatment." (3) "Verbally invite patient to actively participate in all groups and offer process groups to provide an opportunity for reality orientation, gain insight into the issues of psychosis related to schizophrenia and help to build stress management and relaxation exercise to manage symptoms of auditory/visual hallucinations."

7. Active sample patient E3's MTP, dated 6/15/13, had a problem of "psychosis/hallucinations as evidences by "disorganized thoughts."" The interventions chosen were: (1) "RN to meet 1-1 for 10 minutes to evaluate presenting symptoms of auditory hallucinations and document mood, mental status and effectiveness of medications." (2) "Gather client with verbal prompts to actively participate in their treatment, offer goals and wrap-up groups to assist pt. in identifying small steps towards discharge for gaining independence and healthy coping skills with productive goals for treatment." (3) "Verbally invite patient to actively participate in all groups and offer process groups to provide an opportunity for reality orientation, gain insight into the issues of psychosis related to hallucinations and help to build stress management and relaxation exercise to manage symptoms of disorganized thoughts."

8. Active sample patient F3's MTP, dated 6/15/13, had a problem of psychosis/hallucinations as evidenced by "racing thoughts, paranoid thoughts, disorganized thoughts" and "inability to care for self." The interventions chosen were: (1) "RN to meet 1-1 for 10 minutes to evaluate presenting symptoms of bipolar d/o [disorder] and document mood, mental status and effectiveness of medications." (2) "Gather patient with verbal prompts to actively participate in their treatment, offer goals and wrap-up groups to assist pt. in identifying small steps towards healthy coping skills, productive goals for treatment ,and discharge for psychosis, manic."

9. Active sample patient G8's MTP, dated 6/24/13 had a problem of "psychosis/hallucinations" as evidenced by: "Paranoid thoughts, disorganized thoughts". The interventions chosen were: (1) "RN to meet 1-1 for 10 minutes to evaluate presenting symptoms of paranoia and document mood, mental status and effectiveness of medications." (2) "Gather client with verbal prompts to actively participate in their treatment; offer goals and wrap-up groups to assist pt. in identifying small steps towards discharge for gaining independence and healthy coping skills with productive goals for treatment."
All of the MTPs of the 8 active sample patient showed that the interventions were very general statements with the same focus for each activity listed. Specific needs of each patient were not addressed.

B. Interviews

1. In an interview on 6/25/13 at 9:30 a.m. the fact that Master Treatment Plans were not patient specific in focus and were the same for each patient with the same identified problem was discussed with the Medical Director. He did agree with the findings.

2. In an interview on 6/25/13 at 11:30 a.m. the lack of individualized treatment plans was discussed with the Nursing Director. The Master Treatment plan of patient F3 was reviewed with her. It was pointed out that the interventions did not address specific patient needs in that the interventions were stated in general terms, the groups listed were basic titles such as "goals group" and "wrap-up group", did not include all the groups listed on the unit schedule which the patient was supposed to attend [Mariah East for patient F3], and had the same focus of treatment for all patients who attended a group. She stated, "We instruct the nurses to write down what's appropriate to patients. Nurses do not have to use the examples listed on the pre-printed forms. They can put what they want. They [nurses] should look at a patient and write what's specific to the patient. A plan should stand alone."

Based on observation, record review, and interview, the facility failed to provide active treatment, including alternative interventions, for 3 of 8 active sample patients (E3, F3, and G8) who were either not cognitively capable of participating in treatment or were not motivated to attend the assigned group treatment. Rather than providing individualized treatment for these patients, the staff expected them to attend all groups listed on each unit's activity schedule. The patient's regularly and reportedly did not attend group therapies. They spent many hours without any structured activity and occupied their time by lying and/or sleeping on bed, or wandering around the hallways. Staff made little effort to encourage them to attend groups. Failure to provide active and appropriate treatment for patients results in the patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their improvement.

Findings include:

A. Active Sample Patient E3

1. Patient E3 was admitted on 5/22/13. The Psychiatric Evaluation, dated 5/23/13, stated that "the patient has been in and out of mental institutions, alternatively diagnosed as bipolar or schizoaffective, [s/he] may have also, at one point, been given a schizophrenic diagnosis." "[S/he] has also had a history of sexual abuse, both by [his/her] mother's lover who was also [his/her] tutor and there is some strong evidence [his/her] mother may have an incestual relationship with [him/her]." "In terms of cognitive testing, [s/he] did okay except [s/he] can only remember one of three words at five minutes. Clearly [his/her] insight is poor. [His/her] judgment is poor."

2. In an interview on 6/24/13 at 10:50 a.m. (prior to the surveyor meeting the patient), MD #1 who was patient E3's treating psychiatrist, stated that the patient won't participate in any treatment. "The patient is too severely impaired to make rational judgments."

3. Patient E3 was observed on 6/24/13 at 11:08a.m. on his/her bed during the start of the "Therapeutic Task" group being held in the dayroom. When approached for an interview, the patient said s/he did not want to talk to the surveyor. The patient was not observed attending the group.

4. Patient E3's Master Treatment plan, dated 5/26/13, and target dates of review of 5/29/13, 6/12/13, 6/19/13 and 6/26/13 showed no revisions in the Master Treatment Plan . However, the "Patient Treatment Summary signature page" weekly notes stated the following:
5/29/13 - "Pt [patient] paces unit, stays to self, has poor insight into condition."
6/12/13 - "Pt is isolated [sic] to self."
6/26/13 - "Pt is making progress and no behavior issues noted, but not attending groups."
There were no updates or revisions on the treatment plan to address the patient's inability to participate or benefit from the group therapy or other unit activities, nor was there other evidence of staff attempting to provide alternative programming.

5. Some of patient E3's "Daily Program" group notes stated -
6/21/13 - "Goals" group at 9:00 a.m. - "Did not attend"
6/22/13 at 9:00 a.m. - "Goals" group - "Pt unable to respond to prompts to attend AEB [as evidenced by] isolated in room [with] head phones."
6/23/13 at 9:00a.m. "Goals" group - "Did not attend." On 6/23/13 at 1:30 p.m. "Process" group - "Pt did not attend Process group."
"Symptom Management" group at 10:00 a.m. (date not visible) - "Pt did not attend group."
"Symptom Management" group at 10:00 a.m. (date not visible) - "Did not attend...Pt prompted, but pt did not attend group."

6. Patient was on "q 15 minute [every 15 minutes]" checks. Patient observation record reflects the same isolation as the "program group notes" above. For example, the documentation on 6/17/13 stated - "In room either awake or sleeping" from midnight to 10:00 p.m. (Exception was meal times).

7. "RN Assessment" sheets -
6/17/13 11:30 a.m. - "Isolative in room and bed."
6/18/13 10:00 p.m. - "Denies help for information. Isolative in room most of shift"
6/18/13 9:00 p.m. - "Isolative in room."
6/20/13 7:00 p.m. - "Isolated in room and withdrawn from peers."
6/22/13 5:30 p.m. - "Pt is isolative to room. [S/he] comes on the unit for food and coffee."
With the exception of 6/18/13 10:00 a.m. when a "Process" group was being held at the time of the documentation, no other groups were being held during the documentation times. However, the patient's continual habit of isolation throughout the day was reflected.

8. During an interview on 6/24/13 at 1:05 p.m., RN #1 was asked if patient E3 attended any groups that day. RN #1 stated, "No. [S/he] isolates in [his/her] room most of the time." When asked what staff did to get patients to attend groups, RN #1 stated, "We encourage them to go, but if they don't want to, we don't force them." It should be noted that an "Arts and Crafts" group was being held in the dayroom at that time. Patient E3 did not attend.

B. Active Sample Patient F3

1. Patient F3 was admitted on 6/15/13. The Psychiatric Evaluation, dated 6/16/13, stated, "The patient was admitted to the hospital on an involuntary hold [called "5150"] for being a danger to self and gravely disabled ....[Patient's name] had not slept for the last three days and had decompensated. [Patient's] was screaming, yelling and making suicidal threats. [Patient's name] exhibited pressured speech....[patient's name] was extremely manic and very labile and had to be medicated to calm self-down....The patient had had six to seven inpatient psychiatric treatments....has been diagnosed with bipolar disorder....Insight and judgment are totally lacking....immediate memory is impaired....[Patient's name] is not able to recall even one out of three objects after five minutes."

2. The surveyor went to the patient's room to conduct an interview since the patient was not seen to be present in the group being held on the unit at that time. Patient F3 was observed in room in bed with eyes closed at 9:30 a.m. during exercise group, which was held outside in the courtyard of the unit (Mariah East). Another attempt was made to interview the patient at 12:20 p.m. The patient, who seemed very groggy and lethargic, was asked what groups s/he attends since s/he was not at the 9:00a.m. Patient F3 stated, "They don't have any groups here."

3. Patient F3's Master Treatment plan, dated 6/15/13, with target date 6/18/13 showed no revision made. The "Patient Treatment Summary signature page" sheet, dated 6/26/13, stated, "Pt.is loud, agitated easily, disruptive to the therapeutic milieu and easily falls. 1:1 [one to one] staff provided for pt. to monitoring [sic] for safety. Fall precautions."
The "Patient Treatment Summary signature page", dated 6/25/13 stated, "Appears to much less slurred [sic], appears more clear." The note did not mention any group attendance by the patient.

4. Patient F3's "daily program Group Notes" stated the following;
6/21/13 - "Goals group" at 9:00 a.m.: "Staff removed patient." "Process group" at 9:30 a.m.: "Pt did not attend." "Symptom Management group" at 10:00 a.m.: "Did not attend." "Wrap-up group" at 9:00 p.m.: "Pt was unable to participate in group, however made concerted effort in physical presence... [was sleeping] ....SW [social worker] provided redirects [sic]/ and excused pt."
6/23/13 - "Goals group" at 9:00 a.m.: "Pt. loud and directing of others at times. Pt. appears anxious." "Symptom Management group" at 10:30 a.m. and 1:30 p.m.: "Pt did not attend group."
6/24/13 - "Process group" at 10:00 a.m.: "Did not attend." "Support Management group" at 5:20 p.m.: "Did not attend."

5. RN Assessment sheets [done every shift for 3 days, then once daily after that on either day or evening shifts] did not contain any information on whether patient F3 attended any groups or not:
6/16/13 [no time] - "Pt observed visibly on unit"
6/16/13 at 5:30 p.m., 6/17/13 at midnight and 6/17/13 at 5:30 a.m.: No mention of patient activity.
6/18/13 [no time] - "Group attended" box checked.
6/19/13 - "Group attendance" box not checked.
6/20/13 - "Group attendance" box checked with word "with prompt."
6/21/13 - "Denied need for information."
6/22/13 - No designation for "Group attendance" marked.

6. Patient F3 did not attend "Therapeutic Task" group on 6/24/13 in the Dayroom due to observed drowsy behavior.

7. In an interview on 6/24 at 12:50 p.m. about patient group attendance, RN #2 stated, "We encourage patients to go to groups. If they don't want to, we don't push them."

C. Active Sample Patient G8

1. Patient G8 was admitted on 6/21/13. The Psychiatric Evaluation, dated 6/22/13, stated, "was admitted on a 5150 [involuntary hold for up to 72 hours] for being gravely disabled and danger to self...the patient appears to be extremely pressured with tangential thoughts, flight of ideas, and being extremely hyperverbal with expressive affect, irritability, and difficulty to get information because of [his/her] tendency to be extremely tangential and over involving with unnecessary details. [S/he] has no insight into [his/her] illness claiming that [s/he] was diagnosed in the past with ADHD [Attention Deficit Hyperactive Disorder], and [s/he] does not know why [s/he] was in the hospital ....The patient is talking non-stop and is jumping from one idea to others....insight is impaired. Judgment is impaired. Memory and concentration are impaired." The patient's diagnoses were: "Bipolar affective disorder, type I, manic, with psychotic features, r/o [rule out] schizoaffective disorder and attention deficit hyperactivity disorder."

2. On 6/24/13 at 10:50 a.m. RN #4 was asked if patient G8 was available to be interviewed, since a group was being conducted at that time in the Dayroom (Therapeutic Task from 10:00 a.m. - 10:30 a.m.) RN #4 stated, "I'll go get [him/her]. [S/he] is in [his/her] room." (According to state surveyors on site Patient G8 was upset because s/he was sleeping in the seclusion room due to lack of an available bed and the room contained a surveillance camera that was located in the nurse's station. The patient was concerned about his/her privacy.) The patient was unable to answer any questions about his/her treatment, including what groups s/he attended, due to his/her hyperactive state.

3. G8's Master Treatment plan, dated 6/24/13, consisted of the same pre-printed form as for all the other active sample patients, with a list of interventions from which the staff could choose for each patient based on the identified problem. The plans did not address the patient's current inability to attend groups for any length of time or the problem with the patient's inability to process what was going on in the groups s/he did go to.

4. Patient G8's "Program Daily Group Notes" sheet, dated 6/24/13, had only one documentation. It was "Goals group" at 9:00 a.m. However it had no notation as to whether patient G8 attended or not. A "Compliance with Group Attendance" sheet had a "yes" that pt. G8 attended "Therapeutic Task Group" on 6/23/13 at 10:00 a.m. and a "Process group" at 11:15 a.m., but no other documentation related to how long the patient stayed in the group or if the patient actively participated.

5. Patient G8 did attend a "Symptom Management" group which was scheduled on 6/24/13 from 2:00 p.m. to 3:00 p.m. The group, with 9 patients in attendance, started around 2:05 p.m. The leader started the group by asking everyone to state his or her name because she did not know all the patients in attendance. Patient G8 got up and left the group at 2:15 p.m. and wandered around the hallways. Three other patients eventually left by 2:20 p.m. The group leader, SW #1, did not encourage patient G8 or any of the others to stay. The group leader ended the group at 2:30 p.m. In an interview on 6/24/13 at 2:30 p.m., the group leader, SW #1, was asked how she documented on each patient in the group and how she knew what each patient's specific focus in group was, since she did not know all the patients who attended. SW #1 stated, "We do daily group notes on which we just document what the group was about in general. We don't address specific patient's issues."

6. In an interview with RN #1 on 6/25/13 at 11:10 a.m., she was asked if patient G8 had attended any groups so far that day. She stated, "No. We just couldn't get the patients to attend the Therapeutic Task group [scheduled from 10:00 a.m. to 10:30 a.m.]. We try to encourage them, but our patients are not higher functioning so may not go. Most of the patients slept in this morning."

Based on record review and interview, the Medical Director failed to monitor the quality and appropriateness of clinical care provided. Specifically, the Medical Director failed to ensure that:

I. The multidisciplinary Master Treatment Plans (MTPs) for 3 of 8 active sample patients (C1, F3 and G8) included social work interventions. This failure hampers the staff's ability to provide coordinated treatment, potentially resulting in patients not receiving all needed treatment to address their problems. (Refer to B118)

II. The multidisciplinary Master Treatment Plans were developed with sufficient individualized planning of interventions with specific focus for 8 of 8 active sample patients (A1, B1, B2, C3, D1, E3, F3 and G8). These patients' treatment plans were developed from pre-printed forms that included lists of generalized interventions for various identified problems. The interventions from each available list were chosen by putting a check mark to the left of the desired selection. Each of the patient units had a master schedule. All patients were expected to attend the groups listed on the activity schedule for their unit. However, only a few groups from the schedule were included on the MTPs. Due to the pre-printed forms, the focus of an intervention for each patient who attended a listed group was the same. Failure to develop individualized comprehensive treatment plans impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B122)

III. Active treatment, including alternative interventions, was provided for 3 of 8 active sample patients (E3, F3, and G8) who were either not cognitively capable of participating in treatment or were not motivated to attend the assigned group treatment. Rather than providing individualized treatment for these patients, the staff expected them to attend all groups listed on each unit's activity schedule. The patients regularly and reportedly did not attend group therapies. They were observed spending many hours without any structured activity and occupied their time by lying awake and/or sleeping on their beds or wandering around the hallways. Staff made little effort to encourage them to attend groups. Failure to provide active and appropriate treatment for patients results in the patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their improvement. (Refer to B125)

In an interview on 6/25/13 at 9:30 a.m., the following information was presented to the Medical Director:

1. Treatment interventions from social service were not included.

2. Multidisciplinary treatment plans were not patient specific, were generalized and were the same for all active sample patients with the same identified problems.

3. The active sample patients on the locked units were not getting active treatment.

The Medical Director agreed with the findings.

Based on record review and interview, the Nursing Director failed to develop multidisciplinary treatment plans that evidence sufficient individualized planning of nursing interventions with specific focus for 8 of 8 active sample patients (A1, B1, B2, C3, D1, E3, F3 and G8). These patients' treatment plans were developed from pre-printed forms that included lists of generalized goals and interventions for various identified problems. The MTPs were primarily initiated and completed by registered nurses who worked on the night shift. The night nurses read the individual assessments in order to choose which forms to fill out based on identified problems on the assessment. The interventions from the available list were chosen by putting a check mark to the left of the desired choice. The Nursing interventions on the MTPs were generic functions expected of the discipline regardless of a patient's problems and/or needs. Failure to develop individualized comprehensive treatment plans impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Record Review

1. Active sample patient A1's MTP, dated 6/17/13, had as a problem "psychosis/hallucinations as evidenced by usual hallucinations, command hallucinations, paranoid thoughts and disorganized thoughts." The nursing intervention chosen was: "RN to meet 1-1 for 10 minutes to evaluate presenting symptoms of paranoid schizophrenia and document mood, mental status and effectiveness of medications."

2. Active sample patient B1's MTP, dated 6/26/13, had as a problem "Psychosis/hallucinations as evidenced by: auditory hallucinations, disorganized thoughts and inability to care for self." The nursing intervention chosen was: "RN to meet with client 1:1 for 10 minutes to evaluate presenting symptoms of hallucinations and document mood, mental status, and effectiveness of medications."

3. Active sample patient B2's MTP, dated 6/23/13, had as a problem "psychosis/hallucinations as evidenced by paranoid thoughts." The nursing intervention chosen was: "RN to meet with client 1:1 for 10 minutes to evaluate presenting symptoms of paranoia and document mood, mental status, and effectiveness of medications."

4. Actively sample patient C3's MTP, dated 6/24/13, had as a problem "substance abuse." The nursing intervention chosen was: "CD [chemical dependency] staff to provide education groups on relapse prevention and cross addiction to develop self-care and relapse-prevention skills of alcohol abuse."

5. Active sample patient D1's MTP, dated 6/12/13, had as a problem "psychosis/hallucinations as evidenced by [no checks selected for the 8 available choices)." The nursing intervention chosen was: "RN to meet 1-1 for 10 minutes to evaluate presenting symptoms of delusional ideation and document mood, mental status and effectiveness of medications."

6. Active sample patient E3's MTP, dated 6/15/13, had a problem of "psychosis/hallucinations as evidences by "disorganized thoughts." The nursing intervention chosen was: "RN to meet 1-1 for 10 minutes to evaluate presenting symptoms of auditory hallucinations and document mood, mental status and effectiveness of medications."

7. Active sample patient F3's MTP, dated 6/15/13, had a problem of "psychosis/hallucinations" as evidenced by "racing thoughts, paranoid thoughts, disorganized thoughts" and "inability to care for self." The nursing intervention chosen was: "RN to meet 1-1 for 10 minutes to evaluate presenting symptoms of bipolar d/o [disorder] and document mood, mental status and effectiveness of medications."

8. Active sample patient G8's MTP, dated 6/24/13 had a problem of "psychosis/hallucinations" as evidenced by: "Paranoid thoughts, disorganized thoughts". The nursing intervention chosen was: "RN to meet 1-1 for 10 minutes to evaluate presenting symptoms of paranoia and document mood, mental status and effectiveness of medications."

B. Interview

In an interview on 6/25/13 at 11:30 a.m., the lack of individualized treatment plans was discussed with the Nursing Director. The Master Treatment plan of patient F3 was reviewed with her. It was pointed out that the interventions did not address specific patient needs in that the interventions were stated in general terms. The groups were basic titles such as "goals group" and "wrap-up group." The MTPs did not include all the groups listed on the unit schedule, which every patient is supposed to attend [Mariah East for patient F3]. The interventions had the same focus of treatment for all patients who attend a group. She stated, "We instruct the nurses to write down what's appropriate to a patient. Nurses do not have to use the examples listed on the pre-printed forms. They can put what they want. They [nurses] should look at a patient and write what's specific to the patient. A plan should stand alone."

Based on record review and interview, the Social Work Director failed to:

I. Assure that social work staff provided Social Work Assessments that included conclusions and recommendations describing anticipated Social Work roles in treatment and discharge planning for 8 of 8 active sample patients (A1, B1, B2, C3, D1, E3, F3, and G8). As a result social work recommendations regarding treatment of patients' psychosocial problems were not available for the treatment team. (Refer to B108)

II. Ensure that the multidisciplinary Master Treatment Plans (MTPs) for 3 of 8 active sample patients (C1, F3 and G8) included social work interventions. This failure hampers the staff's ability to provide coordinated treatment, potentially resulting in patients not receiving all needed treatment to address their problems. (Refer to B118)

III. Assure that the facility policy for the completion of Psychosocial Assessments is compatible with the policy related to the completion of the Master Treatment Plans. Several social work interventions on the MTPs were absent because facility policy states that Psychosocial Assessments are due in 72 hours [3 days] after the patient is admitted and Master Treatment plans are due in the same time frame. With the average length of stay being from 5 - 6 days [per information gathered through the Risk Management Director on 6/24/13 around 9:00 a.m.], there was insufficient time to work on social work assessments, and the interventions which should have been identified there, before a patient was ready for discharge.