HospitalInspections.org

Based on record reviews and interviews, the facility failed to ensure that the comprehensive treatment plans of 9 of 9 active sample patients (1, 2, 3, 4, 5, 6, 7, 8 and 9) included treatment interventions that were individualized and that specified the focus of treatment. The interventions were generic and did not document specific treatment interventions based on individual patient needs. This failure results in the failure to guide treatment staff to provide consistent and effective treatment related to presenting problems and goals identified on the master treatment plans.


Findings include:


A. Record Review


1. Patient 1 (Master Treatment Plan dated 7/13/12):


For the problem of "Disturbed Thought Process," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," " Order medical consults for H&P (history and physical) and management of medical problems," "Monitor effectiveness of treatment," and "Monitor labs." The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with reality based interactions," and "Provide prescribed medication as ordered." The social work interventions were "Contact out patient provider," "Will contact family within 24 hours of admission. Verify living situation," "Work with patient on developing a post-discharge safety crisis intervention plan," "Arrange aftercare appointment with provider. Fax continuation of care packet," and "Groups daily for 60-90 min. to assist patient with identify [sic] coping skills and increase reality based orientation." The activities therapy interventions were "Groups daily for 30-60 min. to assist patient with reality orientation relating to disturbed thought process" and "CTRS (certified therapeutic recreation specialist) will redirect and confront distorted thinking." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


2. Patient 2 (Master Treatment Plan dated 7/11/12):


For the problem of "Danger to Others (Aggressive)," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," "Order medical consults for H&P (history and physical) and management of medical problems," "Monitor effectiveness of treatment," and "Monitor labs." The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with positive coping skills to help manage aggressive behaviors and what triggers it," and "Administer prescribed medication as ordered." The social work interventions were "Contact out patient provider," "Will contact family within 24 hours of admission. Verify living situation," "Work with patient on developing a post-discharge safety crisis intervention plan," "Groups daily for 60-90 min. to assist patient with self care deficits, responsibility for behavior, self monitoring," "Arrange aftercare appointment with provider. Fax continuation of care packet," and "Clarify reasons for readmission, develop plan to avoid readmission." The activities therapy interventions were "Will encourage daily expression of emotions through positive outlets" and "Groups daily for 30-60 min. to assist patient with anger management related to impulsivity and aggression." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


3. Patient 3 (Master Treatment Plan dated 7/9/12):


For the problem of "Mood Instability," the psychiatrist interventions were "Assess level of functioning as it relates to behaviors and risk factors," "Access blood level of mood stabilizer," and "Order medical consults for H&P (history and physical) and management of medical problem." The nursing interventions were "Monitor patient every 15 minutes for safety for duration of hospital stay," "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with positive coping skills to help manage m and what triggers mood instability and help identify what triggers it." and "Nursing staff will administer medications as prescribed." The social work interventions were "Contact out patient provider," "Will contact family within 24 hours of admission. Verify living situation," "Work with patient on developing a post-discharge safety crisis intervention plan," and "Arrange aftercare appointment with provider. Fax continuation of care packet." The activities therapy interventions were "Groups daily for 30-60 min. to assist patient with coping skills education relating to unstable mood" and "CTRS will provide healthy coping skills to utilize to help stabilize mood." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


For the problem of "Substance Abuse," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," and "Order medical consults for H&P (history and physical) and management of medical problems." The nursing interventions were "Groups daily for 30-60 min. to assist patient with chemical-free coping skills to help manage substance abuse," and "Will provide substance abuse didactic three times weekly." The social work interventions were "Work with patient on developing a post-discharge safety plan" and "Groups daily for 60 min. to assist patient with processing related to cocaine abuse and separation with wife." The activities therapy interventions were "Will provide 30-90 minute group sessions daily to assist with coping skills education" and "CTRS will provide chemical free coping skills to utilize when urges arise." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


4. Patient 4 (Master Treatment Plan dated 7/9/12):


For the problem of "Manic Behavior," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," and "Assesses medication response, side effects and make adjustments as indicated." The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with identifying triggers for manic behavior," "Nursing staff will administer medications as prescribed," and "Monitor patient every 15 min for GSP (general suicide precaution)." The social work intervention was "Work with patient on developing a post-discharge safety crisis intervention plan," "Groups daily 60-90 min. to assist patient with identify pattern suppressing emotional reactions leading to impulsive behavior and educate on recognizing early signs of decompensation and behaviors to avoid a crisis," and "Contact guardian/family for additional data." The activities therapy interventions were "CTRS will help patient explore healthy ways to manage mood swings" and "Group therapy sessions provided 30-90 mins daily to assist with mood stability." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


5. Patient 5 (Master Treatment Plan dated 7/11/12):


For the problem of "Danger to Others (Aggression)," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," "Order medical consults for H&P (history and physical) and management of medical problems," "Monitor effectiveness of treatment," and "Monitor labs." The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Nursing staff will administer medications as prescribed," and "Staff will provide general suicidal precaution every 15 min while in hospital." The social work interventions were "Contact out patient provider," "Will contact family within 24 hours of admission. Verify living situation," "Work with patient on developing a post-discharge safety crisis intervention plan," "Groups daily for 60-90 min. to assist patient with reality testing, educate signs/symptoms of decompensation, coping skills," and "Arrange aftercare appointment with provider. Fax continuation of care packet." The activities therapy interventions were "Groups daily for 30-90 minutes to assist with coping skills education related to management of aggressive behavior" and "CTRS will encourage appropriate venting of emotions through leisure outlets." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


For the problem of "Substance Abuse," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," and "Order medical consults for H&P (history and physical) and management of medical problems." The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with identify 3 positive coping skills." The social work interventions were "Work with the patient on developing a post-discharge safety plan" and "Groups daily for 60-90 min. to assist patient with identify triggers for and develop relapse prevention plan." The activities therapy interventions were "Groups daily for 30-90 minutes to assist with coping skills education related to substance abuse" and "CTRS will encourage patient to identify benefits of abstaining from chemical abuse and utilization of leisure outlet." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


6. Patient 6 (Master Treatment Plan dated 7/11/12):


For the problem of "Danger to Self," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," and "Order medical consults for H&P (history and physical) and management of medical problems." The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with identifying 3 possible coping skills for thoughts of self harm for 3 consecutive days," and "Monitor for sleep nightly." The social work interventions were "Contact out patient provider," "Will contact family within 24 hours of admission. Verify living situation," "Work with patient on developing a post-discharge safety crisis intervention plan," and "Groups daily for 60-90 min. to assist patient with learning alternative behaviors to reduce suicidality," and "Arrange aftercare appointment with provider. Fax continuation of care packet." The activities therapy interventions were "CTRS will provide positive leisure outlets to utilize upon feelings of hopeless and helpless" and "Groups daily for 30-90 min. to assist patient with coping skills education." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


For the problem of "Substance Abuse," the psychiatrist interventions were identical to the problem of "Danger to Self." The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Provide substance abuse didactic 3 times a weekly [sic]," and "Monitor patient for sign and symptoms of withdrawal." The social work interventions were "Work with patient on developing a post-discharge safety crisis intervention plan," and "Groups daily for 60-90 min. to assist patient with learning healthy alternatives to substance use." The activities therapy interventions were "CTRS will provide chemical free outlets to utilize upon urges" and "Will provide 30-90 minute group sessions daily to assist with coping skills education." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


7. Patient 7 (Master Treatment Plan dated 7/9/12):


For the problem of "Disturbed Thought Process," the psychiatrist interventions were
"Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," "Order medical consults for H&P (history and physical) and management of medical problems," "Monitor effectiveness of treatment," and "Monitor labs." The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with reality based conversations," and "Nursing staff will administer medications as prescribed." The social work interventions were "Contact out patient provider," "Will contact family within 24 hours of admission. Verify living situation," "Work with patient on developing a post-discharge safety crisis intervention plan," "Arrange aftercare appointment with provider. Fax continuation of care packet," and "Groups daily for 60-90 min. to assist patient with reality oriented conversation." The activities therapy interventions were "Groups daily for 30-90 min. to assist patient with reality orientation related to disturbed thought" and "CTRS will confront distorted thinking and redirect." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


8. Patient 8 (Master Treatment Plan dated 7/9/12):


For the problem of "Danger to Self," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," and "Order medical consults for H&P (history and physical) and management of medical problems." The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with positive coping skills to help manage self injurious behaviors," "Staff will provide general suicide precautions (monitor patient every fifteen (15) minutes while hospitalized," and "Administer prescribed medications as ordered." The social work interventions were "Contact out patient provider," "Will contact family within 24 hours of admission. Verify living situation," "Work with patient on developing a post-discharge safety crisis intervention plan," and "Groups daily for 60-90 min. to assist patient with increasing coping skills re: suicidal thoughts," and "Arrange aftercare appointment with provider. Fax continuation of care packet." The activities therapy interventions were "CTRS will provide healthy outlets daily to help appropriately vent emotions" and "Groups daily for 30-90 min. to assist patient with coping skills education related to recent cutting self." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


For the problem of "Mood Instability," the psychiatrist interventions were "Assess level of functioning as it relates to behaviors and risk factors," "Access blood level of mood stabilizer," and "Order medical consults for H&P (history and physical) and management of medical problem." The nursing interventions were The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with positive coping skills to help manage unstable mood and identify what triggers it," and "Administer medications as prescribed." The social work interventions were "Contact out patient provider," "Will contact family within 24 hours of admission. Verify living situation," "Work with patient on developing a post-discharge safety crisis intervention plan," and "Groups daily for 60-90 min. to assist patient with reducing mood instability," and "Arrange aftercare appointment with provider. Fax continuation of care packet." The activities therapy interventions were "Groups daily for 30-90 min. to assist patient with coping skills education relating to unstable mood" and "CTRS will provide relaxation techniques to utilize to help stabilize mood." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


9. Patient 9 (Master Treatment Plan dated 7/9/12):


For the problem of "Danger to Self," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," and "Order medical consults for H&P (history and physical) and management of medical problems." The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with identifying at least 2 healthy coping skills for feelings of self harm," "Staff will provide general suicide precautions (monitor patient every fifteen (15) minutes while hospitalized," and "Administer medications as prescribed until discharged." The social work interventions were "Contact out patient provider," "Will contact family within 24 hours of admission. Verify living situation," "Work with patient on developing a post-discharge safety crisis intervention plan," and "Groups daily for 60-90 min. to assist patient with processing grief and loss," and "Arrange aftercare appointment with provider. Fax continuation of care packet." The activities therapy interventions were "CTRS will provide positive leisure outlets to utilize when in crisis" and "Groups daily for 30-90 min. to assist patient with coping skills education relating to suicide attempt." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


For the problem of "Mood Instability," the psychiatrist interventions were "Assess level of functioning as it relates to behaviors and risk factors," "Access blood level of mood stabilizer," and "Order medical consults for H&P (history and physical) and management of medical problem." The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with identify healthy coping skills to help manage mood instability," and "Nursing staff will administer medications as ordered." The social work interventions were identical to the social working interventions for "Danger to Self." The activities therapy interventions were "Group daily for 30-90 min. to assist patient with coping skills education related to unstable mood" and "CTRS will provide chemical free leisure outlets to utilize to increase relaxation and stabilize mood." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


For the problem of "Substance Abuse," the psychiatrist interventions were identical to the problem of "Danger to Self." The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min. to assist patient with identifying triggers to substance abuse," "Provide substance abuse didactic 3 times weekly," and "Monitor patient for sign and symptoms of substance withdrawal." The social work interventions were "Work with patient on developing a post-discharge safety crisis intervention plan," and "Groups daily for 60-90 min. to assist patient with identifying healthy non-chemical coping skills." The activities therapy interventions were "CTRS will help patient identify strengths and accomplishments to focus on urges [illegible]" and "Will provide 30-90 minute group sessions daily to assist with coping skills education." These interventions were generic, not individualized to patient needs, and did not specify a focus for treatment.


B. Interviews


1. During an interview with the treatment team on 7/11/12 at 1:30p.m., MD 1, Director of Nursing (DON), Director of Social Work, Director of Activities Therapy, RN1, and SW1 agreed that the interventions on the treatment plans for all patients on the unit were generic and did not document specific treatment interventions based on individual patient needs.


2. An interview with the DON was made on 7/12/12 at 9:25a.m. regarding the pre-printed Treatment Plans and the section of the plans indicating interventions titled "Focus/Purpose.The content for this section for nursing stated "Provide education via visual/auditory for prescribed medications" for 9 out of 9 patient treatment plans reviewed. The DON stated, "I clearly agree it [the intervention] lacks specificity. The section needs to be expanded to allow more area to write. We have met about this and it was recommended by the consultant that this be revised."


3. An interview with the Director of Social Work was made on 7/12/12 at 11:15a.m. regarding the pre-printed Treatment Plans and the section of the plans indicating interventions titled "Focus/Purpose." The content for this section for social work stated "Contact outpatient provider," "Will contact family within 24 hours of admission. Verify living situation," "Work with patient on developing a post - discharge safety crisis intervention plan," and "Arrange aftercare appointment with provider. Fax continuation of care packet" for 9 out of 9 treatment plans reviewed. The Director of Social Work stated, "We have talked about this and I agree we need to be more specific."


4. During an interview with the Medical Director on 7/12/12 at 4:00p.m., he acknowledged that the interventions for all disciplines on the treatment plans were generic interventions and did not indicate specific interventions to guide treatment staff to provide consistent and effective treatment related to presenting problems and goals identified on the master treatment plans.

Based on interview and document review, the Medical Director failed to ensure that the comprehensive treatment plans of 9 of 9 active sample patients (1, 2, 3, 4, 5, 6, 7, 8, and 9) included physician treatment interventions that were individualized and that specified the focus of treatment. Instead, interventions were listed as generic assessment and consultation functions. This results in the facility not delineating the role of the physician in the treatment of patients.

Findings include:

A. Record Review

1. Patient 1 (Master Treatment Plan dated 7/13/12):

For the problem of "Disturbed Thought Process," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," "Order medical consults for H&P (history and physical) and management of medical problems," "Monitor effectiveness of treatment," and "Monitor labs."

2. Patient 2 (Master Treatment Plan dated 7/11/12):

For the problem of "Danger to Others (Aggressive)," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," "Order medical consults for H&P (history and physical) and management of medical problems," "Monitor effectiveness of treatment," and "Monitor labs."

3. Patient 3 (Master Treatment Plan dated 7/9/12):

For the problem of "Mood Instability," the psychiatrist interventions were "Assess level of functioning as it relates to behaviors and risk factors," "Access blood level of mood stabilizer," and "Order medical consults for H&P (history and physical) and management of medical problem."

For the problem of "Substance Abuse," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," and "Order medical consults for H&P (history and physical) and management of medical problems."

4. Patient 4 (Master Treatment Plan dated 7/9/12):

For the problem of "Manic Behavior," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," and "Assesses medication response, side effects and make adjustments as indicated."

5. Patient 5 (Master Treatment Plan dated 7/11/12):

For the problem of "Danger to Others (Aggression)," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," "Order medical consults for H&P (history and physical) and management of medical problems," "Monitor effectiveness of treatment," and "Monitor labs."

For the problem of "Substance Abuse," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," and "Order medical consults for H&P (history and physical) and management of medical problems."

6. Patient 6 (Master Treatment Plan dated 7/11/12):

For the problem of "Danger to Self," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," and "Order medical consults for H&P (history and physical) and management of medical problems."

For the problem of "Substance Abuse," the psychiatrist interventions were identical to the problem of "Danger to Self."

7. Patient 7 (Master Treatment Plan dated 7/9/12):

For the problem of "Disturbed Thought Process," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," "Order medical consults for H&P (history and physical) and management of medical problems," "Monitor effectiveness of treatment," and "Monitor labs."

8. Patient 8 (Master Treatment Plan dated 7/9/12):

For the problem of "Danger to Self," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," and "Order medical consults for H&P (history and physical) and management of medical problems."

For the problem of "Mood Instability," the psychiatrist interventions were "Assess level of functioning as it relates to behaviors and risk factors," "Access blood level of mood stabilizer," and "Order medical consults for H&P (history and physical) and management of medical problem."

9. Patient 9 (Master Treatment Plan dated 7/9/12):

For the problem of "Danger to Self," the psychiatrist interventions were "Assesses level of functioning as it relates to behaviors and risk factors," "Assesses medication response, side effects and make adjustments as indicated," and "Order medical consults for H&P (history and physical) and management of medical problems."

For the problem of "Mood Instability," the psychiatrist interventions were "Assess level of functioning as it relates to behaviors and risk factors," "Access blood level of mood stabilizer," and "Order medical consults for H&P (history and physical) and management of medical problem."

For the problem of "Substance Abuse," the psychiatrist interventions were identical to the problem of "Danger to Self."

B. Interviews

1. During an interview with the treatment team on 7/11/12 at 1:30p.m., MD 1, Director of Nursing (DON) Director of Social Work, Director of Activities Therapy, RN1, and SW1 agreed that the interventions on the treatment plans for all patients on the unit were generic and did not document specific treatment interventions based on individual patient needs.

2. During an interview with the Medical Director on 7/12/12 at 4:00p.m., he acknowledged that the interventions for psychiatrists on the treatment plans were generic interventions and did not indicate specific interventions for the psychiatrist to provide for each patient based on the needs of the individual patients.

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

I. Ensure that the comprehensive treatment plans of 9 of 9 active sample patients (1, 2, 3, 4, 5, 6, 7, 8, and 9) included nursing treatment interventions that were individualized and that specified the focus of treatment. This failure results in the failure to guide nursing staff to provide consistent and effective treatment related to presenting problems and goals identified on the Master Treatment Plans.

Findings include:

A. Record Review

1. Patient 1 (Master Treatment Plan dated 7/13/12):

For the problem of "Disturbed Thought Process," the nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with reality based interactions," and "Provide prescribed medication as ordered."

2. Patient 2 (Master Treatment Plan dated 7/11/12):

For the problem of "Danger to Others (Aggressive)," the nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with positive coping skills to help manage aggressive behaviors and what triggers it," and "Administer prescribed medication as ordered."

3. Patient 3 (Master Treatment Plan dated 7/9/12):

For the problem of "Mood Instability," the nursing interventions were "Monitor patient every 15 minutes for safety for duration of hospital stay," "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with positive coping skills to help manage m and what triggers mood instability and help identify what triggers it." and "Nursing staff will administer medications as prescribed."

For the problem of "Substance Abuse," the nursing interventions were "Groups daily for 30-60 min. to assist patient with chemical-free coping skills to help manage substance abuse," and "Will provide substance abuse didactic three times weekly."

4. Patient 4 (Master Treatment Plan dated 7/9/12):

For the problem of "Manic Behavior," the nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with identifying triggers for manic behavior," "Nursing staff will administer medications as prescribed," and "Monitor patient every 15 min for GSP (general suicide precaution)."

5. Patient 5 (Master Treatment Plan dated 7/11/12):

For the problem of "Danger to Others (Aggression)," the nursing interventions were "Provide education via visual/auditory for prescribed medication," "Nursing staff will administer medications as prescribed," and "Staff will provide general suicidal precaution every 15 min while in hospital."

For the problem of "Substance Abuse," the nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with identify 3 positive coping skills."

6. Patient 6 (Master Treatment Plan dated 7/11/12):

For the problem of "Danger to Self," the nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with identifying 3 possible coping skills for thoughts of self harm for 3 consecutive days," and "Monitor for sleep nightly."

For the problem of "Substance Abuse," the nursing interventions were "Provide education via visual/auditory for prescribed medication," "Provide substance abuse didactic 3 times a weekly [sic]," and "Monitor patient for sign and symptoms of withdrawal."

7. Patient 7 (Master Treatment Plan dated 7/9/12):

For the problem of "Disturbed Thought Process," the nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with reality based conversations," and "Nursing staff will administer medications as prescribed."

8. Patient 8 (Master Treatment Plan dated 7/9/12):

For the problem of "Danger to Self," the nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with positive coping skills to help manage self injurious behaviors," "Staff will provide general suicide precautions (monitor patient every fifteen (15) minutes while hospitalized," and "Administer prescribed medications as ordered."

For the problem of "Mood Instability," the nursing interventions were The nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with positive coping skills to help manage unstable mood and identify what triggers it," and "Administer medications as prescribed."

9. Patient 9 (Master Treatment Plan dated 7/9/12):

For the problem of "Danger to Self," the nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with identifying at least 2 healthy coping skills for feelings of self harm," "Staff will provide general suicide precautions (monitor patient every fifteen (15) minutes while hospitalized," and "Administer medications as prescribed until discharged."

For the problem of "Mood Instability," the nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min, to assist patient with identify healthy coping skills to help manage mood instability," and "Nursing staff will administer medications as ordered."

For the problem of "Substance Abuse," the nursing interventions were "Provide education via visual/auditory for prescribed medication," "Groups daily for 30-60 min. to assist patient with identifying triggers to substance abuse," "Provide substance abuse didactic 3 times weekly," and "Monitor patient for sign and symptoms of substance withdrawal."

B. Interviews

1. An interview with the DON was held on 7/12/12 at 9:25a.m. regarding the pre-printed Treatment Plans and the section of the plans indicating interventions titled "Focus/Purpose." The content for this section for nursing stated "Provide education via visual/auditory for prescribed medications" for the 9 active sample patients. The DON stated, "I clearly agree it [the intervention] lacks specificity. The section needs to be expanded to allow more area to write. We have met about this and it was recommended by the consultant that this be revised."

2. In an interview on 7/12/12 at 2:15p.m. with the Director of Nursing and Nurse Manager, the medical record for Patient 21 was reviewed. The Nurse Manager acknowledged that short term goals and interventions for the problem related to use of restraints were not included on the master treatment plan. The Director of Nursing confirmed that the interventions were generic clinical tasks and instructions for staff instead of interventions to assist the patient with employing non-harmful behaviors.

II. Provide adequate training of registered nurses (RNs) assigned to conduct the 1-hour face-to-face assessments of 3 of 3 non-sample patients (19, 20, and 21) placed in physical restraints. Specifically, RNs received basic training regarding seclusion and restraint and an outline of what was included in a face-to-face assessment instead of comprehensive training with detailed information and return demonstrations regarding how to conduct behavioral and physical assessments including a review of systems, assessing medications, reviewing recent labs, and evaluating the appropriateness of the restraint or seclusion procedure. Additionally, the RN who initiated the restrictive procedure also performed the 1-hour face-to-face assessment, preventing a credible evaluation of the procedure used. The lack of an adequate RN training program potentially results in a failure to conduct a comprehensive review of the patient's condition and failure to determine whether other factors such as medication side effects and/or medical problems may have led to the patient's behavior. In addition, inadequate training may potentially lead to a failure to document appropriate information needed for the treatment team decisions about appropriate interventions to minimize the use of restrictive procedures.

A. Document Review

1. A review of incidents of seclusion and restraints from October 2011 through June 2012 revealed the following findings:

a. Patient 19 was placed in a physical restraint on 5/4/12 at 2:24p.m. for 2 minutes. According to the "Seclusion/Restraint Documentation Form," the "Patient is observed pacing halls, screaming at staff. Patient is threatened staff being verbally aggressive... Received order to give Ativan 2 mg with Haldol 5 mg intramuscular x1 now for severe agitation with verbal order to physically restrain patient." The one hour face-to-face assessment section of the "Seclusion/Restraint Documentation Form" was completed by the same registered nurse that initiated the restraint. There was no documentation regarding an assessment of body systems and no documentation regarding a review for possible side effects and drug interactions. In addition, the RN provided no documentation on the section of the form requiring an assessment of "Reaction to Intervention" and "Behavioral condition" at all. Therefore, there was no assessment of mental status or description of contributing factors to the patient's aggressive behavior and did not provide any assessment reflecting whether the intervention was appropriate to handle the behavior.

b. Patient 20 was placed in a physical restraint on 11/30/11 at 2:00a.m. for "4 minutes." According to the "Seclusion/Restraint Documentation Form," the "Patient was very agitated, refusing to do body check [try] to elope when [try] to redirect patient became very agitated and hostile to staff... Ativan 2mg and Haldol 5mg intramuscular given... Physical [hold] patient to give medication for safety. The one hour face-to-face assessment section of the "Seclusion/Restraint Documentation Form" was completed by the same registered nurse that initiated the restraint. There was no documentation regarding an assessment of body systems and no documentation regarding a review for possible side effects and drug interactions. In addition, the RN provided no documentation on the section of the form requiring an assessment of the "Behavioral condition" at all. Therefore, there was no assessment of mental status or description of contributing factors to the patient's aggressive behavior and did not provide any assessment reflecting whether the intervention was appropriate to handle the behavior.

c. Patient 21 was placed in a physical restraint on 10/15/11 at 3:10p.m. for "30 seconds." A progress note dated 10/15/11 at 3:10 stated, "Patient was given "Ativan 1 mg IM and Haldol 5mg IM for agitation of kicking wall... will beat any staff's [sic] that try to give [sic] medication ..." According to the "Seclusion/Restraint Documentation Form," "...patient became severely agitated when [MD's name] informed [him/her] [he/she] wasn't being discharged today. Patient became verbally and physically aggressive by pushing desk,..." The one hour face-to-face assessment section of the "Seclusion/Restraint Documentation Form" was completed by the same registered nurse that initiated the restraint. There was no documentation regarding an assessment of body systems and no documentation regarding a review for possible side effects and drug interactions. In addition, the RN provided no documentation on the section of the form requiring an assessment of "Patient's immediate situation, Reaction to Intervention, and Behavioral condition" at all. Therefore, there was no assessment of mental status or description of contributing factors to the patient's aggressive behavior and did not provide any assessment reflecting whether the intervention was appropriate to handle the behavior(s).

2. A review of the "Patient Management Form" used to document modifications of the Master Treatment Plan after an episode of seclusion or restraint revealed that all interventions listed on the preprinted form contained the following instructions for staff, and generic clinical tasks rather than treatment interventions to assist Patients 19 and 20 with using non-harmful behaviors: "Maintain a low level of stimuli in patient's environment, observe patient's behavior every 15minutes; Remove all dangerous objects from patients' environment; Staff to maintain and convey a calm attitude to patient; Administer medication at [sic] ordered by a physician and monitor for effectiveness; and If medication not effective, notify physician, use of seclusion or restraint may be necessary following hospital policy." A review of medical record for Patient 21 revealed a problem for "Restraints" was added to the Master Treatment Plan with no short term goal(s) or treatment intervention(s) provided to address the aggressive behaviors.

3. A review of the facility's "Policy Number: 2.4, Restraints" revealed the following stipulation: "The following will also be documented in the medical record:... Face to face medical and behavioral examination by the physician or RN documented on the Seclusion/Restraint Nursing Documentation Form. The practitioner must evaluate... the patient's medical and behavioral conditions..."

4. A review of the facility's 1-hour face-to-face assessment training program revealed that there was no comprehensive program to train registered nurses to complete the required 1-hour face-to-face assessment for episodes of seclusion and restraint. The program entitled "Face-to-Face Assessment: Seclusion and Restraint Competency Validation" contained a PowerPoint presentation with general information concerning face-to-face assessment included and how the RN can meet the competency requirement to do the one hour face-to-face assessment. The training program failed to include detailed content regarding physical and behavioral assessments. In addition, the training records reviewed failed to provide documented training and evidence regarding registered nurses competency in conducting physical and behavior assessments.

B. Staff Interview

In an interview on 7/12/12 at 3:10p.m., with the Director of Nursing, the face-to-face assessment training program for registered nurses was discussed. The Director of Nursing confirmed that the facility's training program did not include detailed content or documented competency for RNs to conduct the medical and behavior assessments required for the 1-hour face-to-face assessment for episodes of seclusion and restraint

Based on record review and interviews, the Director of Social Services failed to ensure the quality and appropriateness of social service interventions on the treatment plans, specifically that the social work interventions were individualized and contained the specified focus of treatment for 9 of 9 active sample patients (1, 2, 3, 4, 5, 6, 7, 8 and 9). Instead, interventions were listed as generic procedures. This results in the facility not providing specific comprehensive social service interventions to patients relative to their individual therapeutic needs.

Findings include:

A. Record Review

1. Patient 1 (Master Treatment Plan dated 7/13/12):
The social work interventions were, "Contact outpatient provider", "Will contact family within 24 hours of admission. Verify living situation", "Work with patient on developing a post-discharge safety crisis intervention plan", "Arrange aftercare appointment with provider. Fax continuation of care packet."

2. Patient 2 (Master Treatment Plan dated 7/11/12):
The social work interventions were, "Contact outpatient provider", "Will contact family within 24 hours of admission. Verify living situation", "Work with patient on developing a post-discharge safety crisis intervention plan", "Arrange aftercare appointment with provider. Fax continuation of care packet", "Clarify reasons for readmission, develop plan to avoid readmission."

3. Patient 3 (Master Treatment Plan dated 7/9/12):
The social work interventions were, "Contact outpatient provider," "Will contact family within 24 hours of admission. Verify living situation", "Work with patient on developing a post-discharge safety crisis intervention plan", "Arrange aftercare appointment with provider. Fax continuation of care packet", "Work with patient on developing a post-discharge safety plan."

4. Patient 4 (Master Treatment Plan dated 7/9/12):
The social work intervention was, "Work with patient on developing a post-discharge safety crisis intervention plan."

5. Patient 5 (Master Treatment Plan dated 7/11/12):
The social work interventions were, "Contact outpatient provider", "Will contact family within 24 hours of admission. Verify living situation", "Work with patient on developing a post-discharge safety crisis intervention plan", "Arrange aftercare appointment with provider. Fax continuation of care packet."

6. Patient 6 (Master Treatment Plan dated 7/11/12):
The social work interventions were, "Contact outpatient provider", "Will contact family within 24 hours of admission. Verify living situation", "Work with patient on developing a post-discharge safety crisis intervention plan", "Arrange aftercare appointment with provider. Fax continuation of care packet."

7. Patient 7 (Master Treatment Plan dated 7/9/12):
The social work interventions were, "Contact outpatient provider," "Will contact family within 24 hours of admission. Verify living situation", "Work with patient on developing a post-discharge safety crisis intervention plan", "Arrange aftercare appointment with provider. Fax continuation of care packet."

8. Patient 8 (Master Treatment Plan dated 7/9/12):
The social work interventions were, "Contact outpatient provider", "Will contact family within 24 hours of admission. Verify living situation", "Work with patient on developing a post-discharge safety crisis intervention plan", "Arrange aftercare appointment with provider. Fax continuation of care packet."

9. Patient 9 (Master Treatment Plan dated 7/9/12):
The social work interventions were, "Contact outpatient provider", "Will contact family within 24 hours of admission. Verify living situation", "Work with patient on developing a post-discharge safety crisis intervention plan", "Arrange aftercare appointment with provider. Fax continuation of care packet."

B. Interviews

1. During an interview with the treatment team on 7/11/12 at 1:30p.m., MD 1, Director of Nursing (DON) Director of Social Work, Director of Activities Therapy, RN1, and SW1 agreed that the interventions on the treatment plans for all patients on the unit were generic and did not document specific treatment interventions based on individual patient needs.

2. During an interview with the Director of Social Work on 7/12/12 at 11:15a.m. regarding the pre-printed Treatment Plans and the section of the plans indicating interventions titled [Focus/Purpose] for social work, the Director of Social Work stated, "We have talked about this and I agree we need to be more specific."

Based on record review and interviews, the Director of Activity Services failed to ensure the quality and appropriateness of therapeutic activities on the treatment plans, specifically that the interventions were focused for 9 of 9 active sample patients (1, 2, 3, 4, 5, 6, 7, 8 and 9). Instead, interventions listed were generic. This failure results in the facility not providing individualized therapeutic activities to address the specific needs of the patients.

Findings include:

A. Record Review

1. Patient 1 (Master Treatment Plan dated 7/13/12):
The activities therapy interventions were, "Groups daily for 30-60 min. to assist patient with reality orientation relating to disturbed thought process" and "CTRS (certified therapeutic recreation specialist) will redirect and confront distorted thinking."

2. Patient 2 (Master Treatment Plan dated 7/11/12):
The activities therapy interventions were "Will encourage daily expression of emotions through positive outlets" and "Groups daily for 30-60 min. to assist patient with anger management related to impulsivity and aggression."

3. Patient 3 (Master Treatment Plan dated 7/9/12):
The activities therapy interventions were "Groups daily for 30-60 min. to assist patient with coping skills education relating to unstable mood" and "CTRS will provide healthy coping skills to utilize to help stabilize mood."

4. Patient 4 (Master Treatment Plan dated 7/9/12):
The activities therapy interventions were "CTRS will help patient explore healthy ways to manage mood swings" and "Group therapy sessions provided 30-90 min [sic] daily to assist with mood stability."

5. Patient 5 (Master Treatment Plan dated 7/11/12):
The activities therapy interventions were "Groups daily for 30-90 minutes to assist with coping skills education related to management of aggressive behavior" and "CTRS will encourage appropriate venting of emotions through leisure outlets."

6. Patient 6 (Master Treatment Plan dated 7/11/12):
The activities therapy interventions were "CTRS will provide positive leisure outlets to utilize upon feelings of hopeless and helpless" and "Groups daily for 30-90 min. to assist patient with coping skills education."

7. Patient 7 (Master Treatment Plan dated 7/9/12):
The activities therapy interventions were "Groups daily for 30-90 min. to assist patient with reality orientation related to disturbed thought" and "TRS will confront distorted thinking and redirect."

8. Patient 8 (Master Treatment Plan dated 7/9/12):
The activities therapy interventions were "CTRS will provide healthy outlets daily to help appropriately vent emotions" and "Groups daily for 30-90 min. to assist patient with coping skills education related to recent cutting self."

9. Patient 9 (Master Treatment Plan dated 7/9/12):
The activities therapy interventions were "CTRS will provide positive leisure outlets to utilize when in crisis" and "Groups daily for 30-90 min. to assist patient with coping skills education relating to suicide attempt."

B. Interviews

1. During an interview with the treatment team on 7/11/12 at 1:30p.m., MD 1, the Director of Nursing (DON), the Director of Social Work, the Director of Activities Therapy, RN1, and SW1 agreed that the interventions on the treatment plans for all patients on the unit were generic and did not document specific treatment interventions based on individual patient needs.

2. During an interview on 7/13/12 at 9:10 a.m., the Director of Activities Therapy acknowledged that the interventions for all disciplines on the treatment plans were "nonspecific" and referenced a meeting that took place with Department Supervisors and a consultant that recommended the need to revise the treatment plans to be more specifically defined. She stated that the treatment interventions need to be more specific to the patients.