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Based on observation, record review, and interview, the facility failed to provide active treatment, including alternative interventions, for 3 of 8 active sample patients (E6, F1, and G2) who were either not cognitively capable of participating in treatment or were not motivated to attend the groups offered on their respective units. Rather than providing individualized treatment to meet these patients' specific needs at present time, the patients were encouraged to attend any and all available groups held on the units. These patients spent most of their day either lying on their beds or wandering around the hallways. Failure to provide active and appropriate treatment for patients results in the patients being hospitalized without all intervention for recovery being provided to them, potentially delaying their improvement. (Refer to B125)

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 (A3, B8, C8, D5, E1, E6, F1, and G2). These patients' treatment plans were developed from pre-printed forms that included lists of generalized psychiatric interventions for various identified problems. The generalized interventions were actually disciplines tasks written as treatment intervention selected from the available lists with a check mark to the left of the desired choice. All patients were expected to attend the groups listed on the activity schedule for their unit. However, the MTPs did not include the specific groups assigned from the group schedule. In addition, most psychiatric treatment intervention statements did not state whether they would be delivered in group or individual sessions. Some of the interventions did not include the frequency of the intervention. Failure to develop individualized comprehensive treatment plans impedes the provision of active treatment to meet specific treatment needs of patients.

Findings include:

A. Record Review

1. Active sample patient A3's MTP dated 10/15/13 had as a problem, "Excessive Anxiety as evidenced by: patient will stabilize on medication and experience [sic] anxiety." The staff specific interventions chosen were:

(a) Registered Nurse (RN) Interventions: "RN to meet with patient 1-1 for individual assessment to evaluate mood, mental status and effectiveness of medications." "RN to administer anxiety med (medication) at dosage and schedule prescribed to decrease anxiety and panic attacks, document outcome of medication." These intervention statements contained nursing tasks (assessing, evaluating, administering medication and documenting outcome) written as treatment interventions. "Pt (Patient) Education related to Mania for recognition of side effects and expected outcome." "Pt (Patient) Education regarding illness to promote self-care of anxiety and panic feelings." This intervention did not discuss how this information would be provided-individually or in a group.

(b). MD Intervention: "Dr. will discuss symptoms and provide education on diagnosis related to psychosis and importance of medication compliance to maintaining stability." This intervention did not discuss how this information would be provided-individually or in a group.

(c) Social Work Intervention: "Invite to participate in Psychoeducational groups on Symptom Management to develop self-care and relaxation skills." This statement contained a social work task (inviting the patient's participation) written as a treatment intervention, failed to list specific SW groups assigned, and did not reflect the staff's intent to provide or deliver this group. "Social Services will provide education and appropriate follow-up referrals as indicated." This intervention did not discuss how this information would be provided-individually or in a group

2. Active sample patient B8's MTP dated 10/12/13 had as a problem, "Psychosis/Hallucinations as evidenced by: auditory hallucinations, disorganized thoughts." [There was no information describing the hallucination and disorganized thoughts]. The staff specific interventions chosen were:

(a) Registered Nurse (RN) Interventions: "RN to meet with client 1-1 for 10 minutes to evaluate presenting symptoms of psychosis and document mood, mental status, and effectiveness of medications." This intervention statement contained nursing tasks (evaluating symptoms and documenting) written as treatment interventions. "Gather clients with verbal prompts to actively to 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 schizophrenia." This statement contained nursing tasks (gathering patients to participate and offering groups) written as treatment interventions and failed to reflect the staff's intent to provide or deliver these groups. "Nursing staff to discuss patient knowledge about schizophrenia to identify opportunities for education to promote self-care, expected outcome, and relapse prevention." "Educate the client about the illness related symptoms of psychosis to identify and recognize when to call the physician for adjustments in medications and/or side effects." This intervention did not discuss how this information would be provided-individually or in a group.

(b) MD Interventions: "Dr. will discuss symptoms of psychosis and adjust medications as indicated; provide education on diagnosis of [left blank] related to psychosis and medication compliance and the importance of relapse prevention." This intervention did not discuss how this information would be provided-individually or in a group.

(c) Social Work Interventions: "Verbally invite client to actively participate in all groups and offer process groups to provide an opportunity for reality orientation, gain insight into the issues of psychosis relate to schizophrenia and help to build stress management and relaxation exercises to manage symptoms of psychosis." This statement contained social work tasks (inviting the patient's participation in all groups and offering groups) written as treatment interventions, failed to list specific SW groups scheduled, and did not reflect the staff's intent to provide or deliver these groups. "Case Management will provide education and appropriate follow-up referrals as indicated." This treatment intervention did not include an appropriate frequency of contact because "as indicated" was not an acceptable level of treatment intensity. It also did not state how the information would be provided to the patient.

(d) Activity Therapy (AT) Intervention: "Verbally prompt client to participate and offer diagnosis appropriate activity therapy groups to help with concentration, insight, and develop independent living skills." This statement contained activity tasks (prompting the patient's participation and offering groups) written as treatment interventions, failed to list the specific AT groups assigned and did not reflect the staff's intent to provide or deliver these groups.

3. Active sample patient C8's MTP dated 10/9/13 had as a problem, "Psychosis/Hallucinations as evidenced by: visual hallucinations, auditory hallucinations, paranoid thoughts. [There was no information describing the hallucination and paranoid thoughts]. The staff specific interventions chosen were:

(a) Registered Nurse (RN) Interventions: "RN to meet with client 1-1 for 10 minutes to evaluate presenting symptoms of psychosis and document mood, mental status, and effectiveness of medications." "Gather clients with verbal prompts to actively to participate in their treatment; offer goals and wrap-up groups to assist in identifying small steps towards discharge and healthy coping skills with productive goals for treatment." This statement contained nursing tasks (gathering patients with verbal prompts and offering groups) written as treatment interventions and failed to reflect the staff's intent to provide or deliver these groups. "Discuss with patient their [sic] knowledge about their [sic] illness (e.g.) MDD [with psychotic] fx [features] and symptoms to promote and identify understanding of mental illness to promote self-care, sustained stabilization and prevent relapse." "Educate the Pt (patient) about the illness related to symptoms of psychosis to identify and recognize when to call the physician for adjustments in medication and/or side effects." These interventions did not discuss how this information would be provided-individually or in a group.

(b) MD Intervention: "Dr. will discuss symptoms of psychosis and adjust medications as indicated; provide education on diagnosis of schizophrenia related to psychosis and medication compliance and the importance of relapse prevention."

(c) Social Work Interventions: "Verbally encourage patient to actively participate in all groups and specifically offer process groups to provide an opportunity for reality orientation and gain insight into the pt.'s (patient's) presenting problems of V/H (Visual Hallucinations) & A/H (Auditory Hallucination) and ways to manage symptoms, i.e., paranoid thoughts." This statement contained social work tasks (encouraging the patient's active participation in all groups and offering groups) written as treatment interventions, failed to list specific SW groups assigned, and did not reflect the staff's intent to provide or deliver these groups. "Social Services will provide education re: community services and follow-up referrals as indicated." This treatment intervention only stated "as indicated" and was not an appropriate frequency of contact.

(d) Activity Therapy (AT) Intervention: "Verbally prompt client to participate and offer diagnosis appropriate activity therapy groups to help with concentration, insight, and develop independent living skills." This statement contained activity therapy tasks (prompting client to participate and offering groups) written as treatment interventions, failed to identify the specific AT groups assigned, and did not reflect the staff's intent to provide or deliver these groups.

4. Active sample patient D5's MTP dated 10/16/13 had as a problem, "Delusional thinking as evidenced by: Talking to empty cars, jumping out car when moving, and appearing fearful of things that are visual." The staff specific interventions chosen were:

(a) Registered Nurse (RN) Interventions: "RN to meet with client 1-1 for 10 minutes to determine change in presenting symptoms of delusional thinking, ongoing suicidality, mood, mental status and Pt (patient) Perception of effectiveness of medications." This statement contained nursing tasks written as treatment interventions. "Verbally invite patient to participate in groups as a part of their [sic] treatment and offer goal and wrap up groups to assist Pt. (patient) in identifying 2 healthy coping skills and productive goals." This statement contained nursing tasks (inviting the patient's participation and offering groups) written as treatment interventions and failed to reflect the staff's intent to provide or deliver these groups. "Nursing staff to...provide education regarding medication route, time, dosage, expected use and expected outcome of Librium symptoms." "Nursing will teach patient with verbal and written materials the side effects of medication s for delusional thinking." These interventions did not discuss how this information would be provided-individually or in a group.

(b) Social Work (SW) Interventions: "Encourage participation and offer psychoeducational groups regarding psychosis and to provide an opportunity to share and gain insight [sic] the issues of delusional thinking." This statement contained social work tasks (encouraging and offering groups) written as treatment interventions. This statement also failed to list specific SW groups assigned and did not reflect the staff 's intent to provide or deliver these groups. "Social Services will provide education and appropriate follow as indicated." This treatment intervention only stated "as indicated" and was not an appropriate frequency of contact.

(c) Activity Therapy (AT) Intervention: "Verbally prompt client to attend groups as a way of their [sic] active participation in treatment and offer music, thought process groups activity therapy groups to help with concentration and insight." This statement contained generalized AT tasks (prompting client to attend group and offering groups) written treatment interventions and failed to reflect the staff's intent to provide or deliver these groups.

5. Active sample patient E1's Master Treatment Plan [MTP], dated 10/12/13, had as a problem "psychosis/hallucinations". The staff specific interventions chosen were:

(a) Registered Nurse (RN) Intervention: "Nursing to administer medication as dosage and schedule prescribed to decrease symptoms of blank space and document response to medication." This intervention statement contained nursing tasks (administering medication and documenting outcome) written as treatment interventions.

(b) MD Intervention: "Dr. will discuss symptoms of psychosis and adjust medications as indicated on diagnosis of blank space related to psychosis and medication compliance and the importance of related prevention." This intervention did not discuss how this information would be provided-individually or in a group.

(c) Social Work (SW) Intervention: "Social services will provide education re: community services and follow-up referrals as indicated." This intervention did not discuss how this information would be provided-individually or in a group. and did not include the frequency of the interventions.

6. Active sample patient E6, MTP dated 10/11/13, had as a problem "delusional thinking as evidenced by responding to internal stimuli, paranoid [sic], increased agitation." The staff specific interventions chosen were:

(a) Registered Nurse (RN) Interventions : "RN to meet with patient 1:1 for 10 - 15 minutes"...."pt. (patient) perception of effectiveness of medications." "Nursing to administer and provide education regarding medication route, time, dosage, expected use and expected outcome of schizophrenia." These intervention statements contained nursing tasks (assessing perception and administering medication) written as treatment interventions and did not discuss how education regarding medication would be provided-1:1 and/or group.

(b) Social Work (SW) Intervention: "Social services will provide education and appropriate follow-up referrals as indicated." This intervention did not discuss how this information would be provided-individually or in a group and did not include the frequency of the interventions.

(c) MD Intervention: "Dr. to meet with patient, discuss and provide evaluation on diagnosis related to delusional thinking and importance of medication compliance." This intervention did not discuss how this information would be provided-individually or in a group.

(d) Activity Therapy (AT) Intervention: "Verbally prompt patient to attend groups as a way of their active participation in treatment and offer [word illegible] exercise, relaxation, also activity therapies [sic] groups to help concentration and insight." These intervention statements contained AT tasks (prompting patients and offering groups) and did not include the specific AT groups assigned.

7. Active sample patient F1, MTP dated 10/12/13, had as a problem "alteration in mood depressive symptoms as evidenced by verbalizing depressed mood; [the rest was illegible]." The staff special interventions chosen were:

(a) Registered Nurse (RN) Intervention: "RN to meet 1:1 with patient for 15 minutes to determine change in mood, affect behavior and document outcome and level of depression, any suicidality, changes in mood, mental status and pt.'s (patient's) perception of effectiveness of medication." This intervention statement contained nursing tasks (assessing and documenting outcome) written as treatment interventions.

(b) Social Work (SW) Interventions: "Verbally invite patient to actively participate in all groups and offer process groups to provide opportunity to share and gain insight into the issues of depression related to personal stressors and help to build a good support system of self esteem." These intervention statements contained SW tasks (inviting patient participation and offering groups) written as treatment interventions.

(c) MD Intervention: "Dr. will discuss symptoms, adjust medications as indicated and provide education on medications to stabilize mood affect." This intervention did not discuss how this information would be provided-individually or in a group.

8. Active sample patient G2, MTP dated 10/11/13, included the following problems:

Problem: "Delusional thinking as evidenced by: pt. (patient) believing that [his/her] food is poisoned. Staff specific interventions were:

(a) Registered Nurse (RN) Interventions: "RN to meet with patient 1:1 for 10 - 15 minutes to determine change in presenting symptoms of delusional thinking on going suicidality, mood, mental status ant pt. (patient) perception of effectiveness of medications." "Nursing staff to administer and provide education regarding medication route, time, dosage, expected use and expected outcome of delusions symptoms." These intervention statements contained a nursing task (assessing and administering medication) written as a treatment intervention and did not discuss how education regarding medication would be provided-1:1 and/or group.

(b) Social Work (SW) Intervention: "Encourage participation and offer psychoeducation group regarding paranoia and to provide an opportunity to share and gain insight into the issue of delusional thinking." This intervention statement contained SW tasks (encouraging participation and offering groups) written as treatment interventions and did not reflect the staff's intent to provide or deliver group.

(c) MD Intervention: "Dr. to meet with patient, discuss symptoms of delusion and adjust thinking and importance of medication compliance." This intervention did not discuss how this information would be provided-individually or in a group.

(d) Activity Therapy (AT) Intervention: "Verbally prompt patient to attend groups as a way of their active participation treatment and offer art, music exercise, relaxation activity therapy groups to help with concentration and insight." This intervention statement contained AT tasks (prompting patients and offering groups) written as treatment interventions.

Problem: "Alternation in mood depressive symptoms as evidenced by pt isolative, very guarded." Staff specific interventions were:

(a) Registered Nurse (RN) Interventions: "RN to meet 1:1 with patient for 15 minutes to determine change in mood and document outcome and level of depression, any suicidality, changes in mood, mental status and pt.'s (patient's) perception of effectiveness of medication." These statements contained nursing tasks (determining mood changes, mental status and patient's perception of effectiveness of medication)) written as treatment interventions.

(b) Social Work (SW) Intervention: "Verbally invite patient to actively participate in all groups and offer process groups to provide opportunity to share and gain insight into the issues of depression related to mood disturbance and help to build a good support system and coping skills." This statement contained SW tasks (encouraging participation and offering groups) written as treatment interventions and did not reflect the staff 's intent to provide or deliver group.

(c) Activity Therapy (AT) Intervention: "Verbally prompt patient to attend groups as a way of their active participation in treatment and offer [word illegible] exercise, relaxation, also activity therapies [sic] groups to help concentration and insight depression." This intervention statement contained AT tasks (prompting patients and offering groups) written as treatment interventions and did not include the staff's intent to provide or deliver the AT groups.

B. Staff Interview

During interview on 10/16/13 at 1:30 p.m. with the Director of Nursing (DON), Director of Risk Management, and RN 4, the MTPs for Patient A3, B8, C8, and D5 were reviewed. The DON and RN4 confirmed that the treatment plans contained treatment interventions that did not state whether interventions would be delivered in group or individual sessions. They also acknowledged that the treatment plans contained discipline tasks written as treatment interventions.






07814

Based on record review and interview, the facility failed to identify the names of the registered nurse and/or physician responsible for various interventions on the Master Treatment plan for 3 of 8 active sample patients (E1, F1, and G2). This practice results in the facility's inability to clearly monitor staff responsibility for seeing specific interventions are carried out.

Findings include:

A. Record Review

1. Facility Policy, titled "Interdisciplinary Treatment Plan, last revised 1/12, section 600.17" stated, that the intervention includes the following components: - "Responsible staff: The name(s) and credentials/discipline of the specific staff members responsible for the provision of the intervention."

(The underline words and/or spaces below indicate spaces for staff to add information)

2. Active sample patient E1, MTP dated 10/12/13. For the problem "psychosis/hallucinations", the interventions were: (1) "nursing to administer medication for dosage and schedule prescribed to decrease symptoms of [blank space] and document response to medications." The space to list the name of "Discipline Responsible Staff" was left blank. (2) "Dr. (Doctor) will discuss symptoms of psychosis and adjust medications as indicated; provide education on diagnosis of [blank space] related to psychosis and medication compliance and the importance of relapse prevention." The Discipline Responsible Staff" space was left blank.

3. Active sample patient F1, MTP dated 10/12/13. For the problem of "alteration in mood depressive symptoms", the interventions were: (1) "RN to meet 1:1 with patient for 15 minutes to determine change in mood, affect behavior and document outcome and level of depression, any suicidality, changes in mood, mental status and pt's perception of effectiveness of medication." The "discipline responsible staff" space was left blank. (2) "Dr. will discuss symptoms, adjust medications as indicated, and provide education on medication to stabilize mood affect." The "discipline responsible staff " space was left blank.

4. Active sample patient G2, MTP dated 10/11/13. For the problem "delusional thinking", the interventions were: (1) "RN to meet with patient 1:1 for 10 - 15 minutes to determine change in presenting symptoms of schizophrenia ongoing suicidality, mood, mental status ant pt perception of effectiveness of medications." (2) "Nursing staff to administer and provide education regarding medication, route, time, dosage, expected use and expected outcome of schizophrenia symptoms." The "discipline responsible staff" space was left blank.

B. Staff Interview

In an interview on 10/16/13 at 10:00 a.m., the absence of names of responsible nursing staff on MTP was discussed with the Nursing Director. She did not dispute the findings. She promised to address the issue.

Based on observation, record review, and interview, the facility failed to provide active treatment, including alternative interventions, for 3 of 8 active sample patients (E6, F1, and G2) who were either not cognitively capable of participating in treatment or were not motivated to attend the groups offered on their respective units. Rather than providing individualized treatment to meet these patients' specific needs at present time, the patients were encouraged to attend any and all available groups held on the units. These patients spent most of their day either lying on their beds or wandering around the hallways. Failure to provide active and appropriate treatment for patients results in the patients being hospitalized without all intervention for recovery being provided to them, potentially delaying their improvement.

Findings include:

A. Active sample patient E6

1. Patient E6 was admitted on 10/8/13. The Psychiatric Evaluation, dated 10/9/13, stated that, "The patient, with a history of schizophrenia, apparently stopped taking [his/her] medication." "[S/he] tends to stop taking [his/her] medication and decompensates." "The patient speaks in tongues, which I do not understand." "The patient is responding to internal stimuli"---"Insight and judgment are poor. Impulse control is poor."

2. On 10/15/13 at 11:00 a.m., patient E6 was observed wandering up and down the hallway near the nurse's station during the time of a "Progress Group" being held in the Dayroom of Mariah West. RN #1 asked the patient if [s/he] would talk to the surveyor, but the patient refused. The patient was also asked if [s/he] wanted to attend the "Process Group," the patient shook [his/her] head in a negative way and walked off.

3. The three secured locked units (Mariah East, Mariah West and Cherokee) had identical unit group schedules. According to the Social Work Director and the Nursing Director, during an interview on 10/16/13 around 10:30 a.m., the identical schedules were because the patients on these 3 units have the same basic needs.

The group schedules provided 7 groups between 9:00 a.m and 4:00 p.m. Monday through Friday and 6 groups during this same period on the weekends. The groups were "Exercise", 11:15 a.m. - "Supportive Group Therapy", 1:00 p.m. - "Therapeutic Task," 2:00 p.m. - "Symptom Management," 3:00 p.m. - "Therapeutic Games," and 4:00 p.m. - "Life Skills." "Symptom Management" group was not offered on the weekend. Patients had "free time" during this period. None of the groups listed above were included on the Master Treatment plans. There were vague references to groups in general mentioned on the plans such as "psychoeducation by social work and "exercise, relaxation" groups by activities [sic] therapist.

4. "Mariah West daily group notes" sheets for the period of 10/9/13 to 10/15/13 documented patient E1 schedule attendance for a total of 37 groups offered during this time. The patient was listed as attending only 4 of the 37 groups and was documented for lack of attendance for various reasons such as "Pt. responding to internal stimuli", "pt. unable to process at this time."

5. Patient E1's Mater Treatment plan (MTP), dated 10/11/13, with a target date of 10/15/13 showed no revisions based on the patient's lack of attendance at most of the scheduled groups. The problem of the patient's lack of group attendance was not addressed in the MTP.

B. Active sample patient F1

1. Patient F1 was admitted on 10/8/13. The Psychiatric Evaluation, dated 10/9/13, stated that, "The patient was admitted into [name of hospital] because [s/he] was confused. [S/he] was depressed."---"[S/he] stated [s/he] had been drinking over a pint a day for a long time although [s/he] denies any history of severe withdrawal symptoms when [s/he] stops drinking, [s/he] states [s/he] would like some help detoxing off the alcohol. That is why [s/he] came in because of severe depression and alcohol withdrawal."---"[S/he] has poor cognitive and intermittent suicidal ideation with no plan"---"Affect is guarded and restricted. Thought process is disorganized and illogical."---"Insight and judgment are poor."

2. On 10/15/13 at 10:20 a.m., patient F1 was observed sitting on a couch in the Dayroom of Mariah East watching TV while an "Art and Craft group" was being conducted at a nearby table. RN #2, the charge nurse on the unit, was asked why patient F1 was not in the group. RN #2 stated that patient F1 was invited to join the group, but had refused.

3. As mentioned under patient E6 above, the unit group schedule on Mariah East was identical to Mariah West and Cherokee units.

4. "Mariah East daily group notes" sheets for the period of 10/11/13 to 10/15/13 documented patient F1 scheduled for attendance in 35 group sessions. The patient was listed as attending only 6 of the 35 group sessions. A "Symptom Management" group held on 10/12/13 at 2:00 p.m. did not check off whether the patient attended or not. The attendant choices were left blank. However, the patient's attendant behavior and/or results were as follows: "Pt. given handout on stress cycle." It did not state whether patient attended or not. Otherwise, patient F1 was documented as "did not attend", "pt. sleeping late" [Group on 10/11/13 at 9:00a.m.] or "pt was too tired to attend" [Therapeutic Task 10/14/13 at 1:00 p.m.].

5. Patient F1's Master Treatment plan, dated 10/11/13, did not mention the patient's poor attendance at groups, nor did it suggest any alternative activities for the patient. The only specific group listed on the MTP was "Process Group." Otherwise there were general references to the patient participating in "all groups."

6. In an interview on 10/17/13 at 9:00 a.m., MD #1 was asked if he was aware that patient F1 was not attending groups on the unit. MD #1 stated that he was aware of this, but due to the fact that the patient can get extremely agitated when pressured, wanted only staff who had established a good rapport with the patient to provide 1:1 intervention. MD #1 was informed that this information could not be found on the MTP. MD #1 stated that the information should be on the MTP.

C. Active sample patient G2

1. Patient G2 was admitted on 10/8/13. The Psychiatric/evaluation, dated 10/9/13, stated that the patient "was brought to the emergency room"---"for being totally nonfunctioning at home, not eating, not drinking, and extremely delusional believing that the food is poisoned and has been pacing at home. The patient was also almost nonverbal, very brief in [his/her] answer and appeared to be declining fast, losing weight." "The patient also reported that there has been a decline in [his/her] motivation, energy, and interest in things." The patient "spends most of [his/her] time in bed. According to [him/her] or pacing, or eating"---- "Insight is impaired, judgment is impaired, memory and concentration are impaired."

2. Patient G2 was observed in bed with eyes closed on 10/15/13 around 10:00 a.m., on Cherokee unit. During this time a "Process Group" was being held in the Dayroom of the unit. MHT [Mental Health Technician] #1 was asked at this time why patient G2 was not in the "Process group." MHT #1 stated, "[Name of patient] stays in bed most of the day. He'll come out for a bit to eat at times."

3. As with E6 and F1 above, the unit group schedules were identical to each other.

4. "Cherokee unit daily group notes" sheets for the period of 10/9/13 to 10/15/13 documented patient G2 scheduled attendance in 19 group sessions. The patient was listed as attending 8 of the 19 group sessions. For groups not attended, the patient was documented as "medicated and sleeping ["Mood Management on 10/8/13 at 3:30 p.m."], "SW [social work] provide handout & will provide support as needed" "["Psycho - ED Group" on 10/9/13 at 10:00 a.m.]", or "Pt. (patient) was non-responsive to any inquiries in group. Pt. (patient) pacing back & forth. Pt displays great levels of anxiety ["Process Group" on 10/14/13 at 3:00 p.m]."

5. The patient's Master Treatment plan, dated 10/13/13, did include in the weekly summary that the patient was not attending groups. However, up until 10/16/13, there were no alternative measures included in the Master Treatment plan suggesting the implementation of any alternative approaches in providing care to the patient.

6. In an interview on 10/16/13 at 9:20 a.m., the lack of active treatment being provided for active sample patients E6, F1, and G2 was discussed with the Medical Director. He did not dispute the findings. "The docs [sic] do as much as they can to help these patients."

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:

1. The development of Multidisciplinary Treatment Plans (MTP) that evidenced sufficient individualized planning of interventions with specific focus for 8 of 8 active sample patients (A3, B8, C8, D5, E1, E6, F1, and G2). These patients' treatment plans were developed from pre-printed forms that included lists of generalized psychiatric interventions for various identified problems. The generalized interventions were actually disciplines tasks written as treatment intervention selected from the available lists with a check mark to the left of the desired choice. All patients were expected to attend the groups listed on the activity schedule for their unit. However, the MTPs did not include all of the groups from the group schedule. In addition, many psychiatric treatment intervention statements did not state whether they would be delivered in group or individual sessions. Some interventions did not include frequency and/or duration. Failure to develop individualized comprehensive treatment plans impedes the provision of active treatment to meet specific treatment needs of patients.
Refer to B122)

2. The identifying names of the registered nurse and/or physician responsible for various interventions is on the Master Treatment plan for 3 of 8 active sample patients (E1, F1, and G2). This practice results in the facility's inability to clearly monitor staff responsibility for seeing specific interventions are carried out. (Refer to B123)

3. Active treatment, including alternative interventions, is provided for 3 of 8 active sample patients (E6, F1, and G2) who were either not cognitively capable of participating in treatment or were not motivated to attend the groups offered on their respective units. Rather than providing individualized treatment to meet these patients' specific needs at present time, the patients were encouraged to attend any and all available groups held on the units. These patients spent most of their day either lying on their beds or wandering around the hallways. Failure to provide active and appropriate treatment for patients results in the patients being hospitalized without all intervention for recovery being provided to them, potentially delaying their improvement. (Refer to B125)

In an interview on 10/16/13 at 9:20 A.M., the various issues with the Master Treatment Plans and active treatment were discussed with the Medical Director. He did not dispute the findings.

Based on record review and interview, the Nursing Director failed to develop Multidisciplinary Treatment Plans [MTP] that evidenced sufficient individualized planning of nursing interventions with specific focus for 8 of 8 active sample patients (A3, B8, C8, D5, E1, E6, F1 and G2). These patients' treatment plans were developed from pre-printed forms that included lists of generalized goals and interventions for various identified problems. The interventions from the available list were chosen by putting a check mark next to the left of the desired choice. The nursing interventions on the MTP's were generic functions expected of the discipline regardless of a patient's problems and/or need. The Nursing Director also failed to ensure that the names of the discipline designated for being responsible for seeing that each nursing intervention on the Master Treatment plan is carried out was included on the plans for 3 of 8 active sample patients (E1, E6 and G2). This practice results in the facility staff inability to clearly monitor staff responsibility for specific interventions. Failure to develop individualized comprehensive treatment plans impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

I. Generalized nursing interventions

A. Record Review

1. Active sample patient A3's MTP dated 10/15/13 had as a problem, "Excessive Anxiety as evidenced by: patient will stabilize on medication and experience [sic] anxiety." The staff specific nursing interventions chosen were:

Registered Nurse (RN) Interventions: "RN to meet with patient 1-1 for individual assessment to evaluate mood, mental status and effectiveness of medications." "RN to administer anxiety med (medication) at dosage and schedule prescribed to decrease anxiety and panic attacks, document outcome of medication." These intervention statements contained nursing tasks (assessing, evaluating, administering medication and documenting outcome) written as treatment interventions. "Pt. (Patient) Education related to Mania for recognition of side effects and expected outcome." "Pt. Education regarding illness to promote self-care of anxiety and panic feelings." This intervention did not discuss how this information would be provided-individually or in a group.

2. Active sample patient B8's MTP dated 10/12/13 had as a problem, "Psychosis/Hallucinations as evidenced by: auditory hallucinations, disorganized thoughts." [There was no information describing the hallucination and disorganized thoughts]. The staff specific nursing interventions chosen were:

Registered Nurse (RN) Interventions: "RN to meet with client 1-1 for 10 minutes to evaluate presenting symptoms of psychosis and document mood, mental status, and effectiveness of medications." This intervention statement contained nursing tasks (evaluating symptoms and documenting) written as treatment interventions. "Gather clients with verbal prompts to actively to 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 schizophrenia." This statement contained nursing tasks (gathering patients to participate and offering groups) written as treatment interventions and failed to reflect the staff's intent to provide or deliver these groups. "Nursing staff to discuss patient knowledge about schizophrenia to identify opportunities for education to promote self-care, expected outcome, and relapse prevention." "Educate the client about the illness related symptoms of psychosis to identify and recognize when to call the physician for adjustments in medications and/or side effects." This intervention did not discuss how this information would be provided-individually or in a group.

3. Active sample patient C8's MTP dated 10/9/13 had as a problem, "Psychosis/Hallucinations as evidenced by: visual hallucinations, auditory hallucinations, paranoid thoughts." [There was no information describing the hallucination and paranoid thoughts]. The staff specific nursing interventions chosen were:

Registered Nurse (RN) Interventions: "RN to meet with client 1-1 for 10 minutes to evaluate presenting symptoms of psychosis and document mood, mental status, and effectiveness of medications." "Gather clients with verbal prompts to actively to participate in their treatment; offer goals and wrap-up groups to assist in identifying small steps towards discharge and healthy coping skills with productive goals for treatment." This statement contained nursing tasks (gathering patients with verbal prompts and offering groups) written as treatment interventions and failed to reflect the staff's intent to provide or deliver these groups. "Discuss with patient their [sic] knowledge about their [sic] illness (e.g.) MDD [with psychotic] fx [features] and symptoms to promote and identify understanding of mental illness to promote self-care, sustained stabilization and prevent relapse." "Educate the Pt (patient) about the illness related to symptoms of psychosis to identify and recognize when to call the physician for adjustments in medication and/or side effects." These interventions did not discuss how this information would be provided-individually or in a group.

4. Active sample patient D5's MTP dated 10/16/13 had as a problem, "Delusional thinking as evidenced by: Talking to empty cars, jumping out car when moving, and appearing fearful of things that are visual." The staff specific nursing interventions chosen were:

Registered Nurse (RN) Interventions: "RN to meet with client 1-1 for 10 minutes to determine change in presenting symptoms of delusional thinking, ongoing suicidality, mood, mental status and Pt (patient) Perception of effectiveness of medications." This statement contained nursing tasks written as treatment interventions. "Verbally invite patient to participate in groups as a part of their [sic] treatment and offer goal and wrap up groups to assist Pt. (patient) in identifying 2 healthy coping skills and productive goals." This statement contained nursing tasks (inviting the patient's participation and offering groups) written as treatment interventions and failed to reflect the staff's intent to provide or deliver these groups. "Nursing staff to...provide education regarding medication route, time, dosage, expected use and expected outcome of Librium symptoms." "Nursing will teach patient with verbal and written materials the side effects of medication s for delusional thinking." These interventions did not discuss how this information would be provided-individually or in a group.

5. Active sample patient E1's Master Treatment Plan [MTP], dated 10/12/13, had as a problem "psychosis/hallucinations." The staff specific nursing interventions chosen were:

Registered Nurse (RN) Intervention: "Nursing to administer medication as dosage and schedule prescribed to decrease symptoms of blank space and document response to medication." This intervention statement contained nursing tasks (administering medication and documenting outcome) written as treatment interventions.

6. Active sample patient E6, MTP dated 10/11/13, had as a problem "delusional thinking as evidenced by responding to internal stimuli, paranoid [sic], increased agitation." The staff specific nursing interventions chosen were:

Registered Nurse (RN) Interventions : "RN to meet with patient 1:1 for 10 - 15 minutes".... "pt (patient) perception of effectiveness of medications." "Nursing to administer and provide education regarding medication route, time, dosage, expected use and expected outcome of schizophrenia." These intervention statements contained nursing tasks (assessing perception and administering medication) written as treatment interventions and did not discuss how education regarding medication would be provided-1:1 and/or group.

7. Active sample patient F1, MTP dated 10/12/13, had as a problem "alteration in mood depressive symptoms as evidenced by verbalizing depressed mood; [the rest was illegible]." The staff special nursing interventions chosen were:

Registered Nurse (RN) Interventions: "RN to meet with patient 1:1 for 10 - 15 minutes to determine change in presenting symptoms of delusional thinking on going suicidality, mood, mental status ant pt perception of effectiveness of medications." "Nursing staff to administer and provide education regarding medication route, time, dosage, expected use and expected outcome of delusions symptoms." These intervention statements contained a nursing task (assessing and administering medication) written as a treatment intervention and did not discuss how education regarding medication would be provided-1:1 and/or group.

Problem: "Alteration in mood depressive symptoms as evidenced by pt isolative, very guarded." Staff specific nursing interventions were:

Registered Nurse (RN) Interventions: "RN to meet 1:1 with patient for 15 minutes to determine change in mood and document outcome and level of depression, any suicidality, changes in mood, mental status and pt.'s (patient's) perception of effectiveness of medication." "Nursing staff to meet with patient individually to build a relationship by working with the pt.'s (patient's) strengths, support from family and utilize compliments as a positive reinforcement and allow them to ventilate their feelings." These statements contained nursing tasks (assessing, documenting outcome, and building a relationship) written as treatment interventions.

8. Active sample patient G2, MTP dated 10/11/13, included the following problems:

Problem: "Delusional thinking as evidenced by: pt. (patient) believing that [his/her] food is poisoned." RN staff specific interventions were:

(Registered Nurse (RN) Interventions: "RN to meet with patient 1:1 for 10 - 15 minutes to determine change in presenting symptoms of delusional thinking on going suicidality, mood, mental status ant pt. (patient) perception of effectiveness of medications." "Nursing staff to administer and provide education regarding medication route, time, dosage, expected use and expected outcome of delusions symptoms." These intervention statements contained a nursing task (assessing and administering medication) written as a treatment intervention and did not discuss how education regarding medication would be provided-1:1 and/or group.

Problem: "Alternation in mood depressive symptoms as evidenced by pt. isolative, very guarded." Staff specific interventions were:

(Registered Nurse (RN) Intervention: "RN to meet 1:1 with patient for 15 minutes to determine change in mood and document outcome and level of depression, any suicidality, changes in mood, mental status and pt.'s (patient's) perception of effectiveness of medication." These statements contained nursing tasks (determining mood changes, mental status and patient's perception of effectiveness of medication)) written as treatment interventions.


B. Staff Interviews


During interview on 10/16/13 at 1:30 p.m. with the Director of Nursing (DON), Director of Risk Management, and RN 4, the MTPs for Patient A3, B8, C8, and D5 were reviewed. The DON and RN4 confirmed that the treatment plans contained treatment interventions that did not state whether interventions would be delivered in group or individual sessions. They also acknowledged that the treatment plans contained discipline tasks written as treatment interventions.


II. Absence of the names of nursing staff on Master Treatment plan who were designated as responsible person for carrying out nursing intervention.


Findings include:


A. Record Review


1. Active sample patient E1, MTP dated 10/12/13. For the problem "psychosis/hallucinations", the intervention was:
"Nursing to administer medication for dosage and schedule prescribed to decrease symptoms of [blank space] and document response to medications." The space to list the name of "Discipline Responsible Staff" was blank.

2. Active sample patient F1, MTP dated 10/12/13. For the problem of "alteration in mood depressive symptoms", the intervention was: (1) "RN to meet 1:1 with patient for 15 minutes to determine change in mood, affect behavior and document outcome and level of depression, any suicidality, changes in mood, mental status and pt's perception of effectiveness of medication." The "discipline responsible staff" space was blank.

3. Active sample patient G2, MTP dated 10/11/13. For the problem "delusional thinking", the interventions were:
"RN to meet with patient 1:1 for 10 - 15 minutes to determine change in presenting symptoms of schizophrenia ongoing suicidality, mood, mental status ant pt perception of effectiveness of medications."
"Nursing staff to administer and provide education regarding medication, route, time, dosage, expected use and expected outcome of schizophrenia symptoms." The "discipline responsible staff" space was blank. (Refer to B123)

B. Staff Interview


In an interview on 10/16/13 at 10:00 a.m., the absence of names of responsible nursing staff on MTP was discussed with the Nursing Director. She did not dispute the findings, but promised to address the issue.