HospitalInspections.org

Based on record review, observations and interviews, the facility failed to:

I. Provide comprehensive Master Treatment Plans (MTPs) that included treatment interventions by all members of the interdisciplinary team for 9 of 9 active sample patients ((A4, A6, A7, B2, B11, C2, C9, D6 and E3). None of the MTPs included interventions by psychiatrists. Failure to clearly specify interventions by all members of the interdisciplinary team on the MTP hampers staff's ability to provide coordinated treatment and potentially results in patients not receiving all needed treatment to address their problems. (Refer to B118)

II. Provide treatment plans for 9 of 9 active sample patients (A4, A6, A7, B2, B11, C2, C9, D6, and E3) that consistently included active treatment interventions with a specific focus. Interventions were either generic monitoring and discipline functions to be performed by a nurse, social worker/therapist and recreation therapy staff, or just the name of groups being offered to patients. Frequently many interventions had either one discipline assigned as the responsible person to see that the intervention was carried out. Many of the interventions did not include a frequency or duration. Because the Master Treatment plans (MTPs) were pre-printed and based on specific problems [i.e. psychotic behavior or Post Traumatic Stress Disorder], patients with identical problems had identical or similarly worded interventions. These deficiencies results in treatment plans that fail to reflect an individualized approach to multi-disciplinary treatment and fail to provide guidance to staff regarding the specific modalities needed and/or the purpose for each. These failures potentially result in inconsistent and/or ineffective treatment. (Refer to B122)

III. Use or follow proper release criteria for seclusion for 1 of 6 patients (A4) whose records were reviewed for facility compliance on seclusion/restraint policy and procedure protocol. Record documentation revealed that patient A4 was kept secluded longer than necessary on one occasion. This deficient practice results in failure to ensure patient's right to be free from restriction of movement. (Refer to B125I)

IV. Provide active treatment, including alternative intervention, for 1 of 3 active sample patients (A4) on the Crisis Stabilization Unit. Patient A4 was either not emotionally stable enough to participate in treatment at times or was not motivated to attend all groups s/he was supposed to attend as listed on the unit activity schedule. Although the treatment plan for this patient included several group therapies, the patient regularly and repeated did not attend groups. According to unit nursing staff, A4 spent many hours isolated in his/her room without any structured activities. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patient's treatment goals and objectives, potentially delaying the patient's improvement. (Refer to B125II)

Based on record review and staff interview, the facility failed to include discharge planning by the social workers in psychosocial assessments for 8 of 9 active sample patients (A6, A7, B2, B11, C2, C9, D6 and E3). This deficiency potentially prolongs hospital stay and prevents patients from having all available community resources utilized.

Findings include:

A. Record review

1. The Psychosocial Assessment for patient A6 (dated 1/7/14) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

2. The Psychosocial Assessment for patient A7 (dated 1/8/14) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

3. The Psychosocial Assessment for patient B2 (dated 1/9/14) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

4. The Psychosocial Assessment for patient B11 (dated 1/10/14) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

5. The Psychosocial Assessment for patient C2 (dated 12/5/13) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

6. The Psychosocial Assessment for patient C9 (dated 12/26/13) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

7. The Psychosocial Assessment for patient D6 (dated 1/9/14) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

8. The Psychosocial Assessment for patient E3 (dated 1/7/14) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.


B. Interviews

1. in an interview on 1/14/14 at 10:30 a.m. The Director of Social Work agreed with the findings and stated, "We used to have that as a part of our psychosocial assessment form but then our forms were changed and it was no longer there. I find that deficiency often when I do my reviews. We need to provide additional training."

Based on record review and interview, the facility failed to provide comprehensive Master Treatment Plans (MTPs) that included treatment interventions by all members of the interdisciplinary team for 9 of 9 active sample patients A4, A6, A7, B2, B11, C2, C9, D6 and E3). None of the MTPs included interventions by psychiatrists. Failure to clearly specify interventions by all members of the interdisciplinary team on the MTP hampers staff's ability to provide coordinated treatment and potentially results in patients not receiving all needed treatment to address their problems.

Findings include:

A. Record review

1. MTP for patient A4 (last reviewed 1/14/14) did not include any interventions by a psychiatrist.

2. MTP for patient A6 (dated 1/7/14) did not include any interventions by psychiatrist.

3. MTP for patient A7 (dated 1/12/14) did not include any interventions by psychiatrist.

4. MTP for patient B2 (dated 1/9/14) did not include any interventions by psychiatrist.

5. MTP for patient B11 (dated 1/10/14) did not include any interventions by psychiatrist.

6. MTP for patient C2 (dated 12/8/13) did not include any interventions by psychiatrist.

7. MTP for patient C9 (dated 12/25/13) did not include any interventions by psychiatrist.

8. MTP for patient D6 (dated 1/10/14) did not include any interventions by psychiatrist.

9. MTP for patient E3 (dated 1/7/14) did not include any interventions by psychiatrist.


B. Interviews

1. in an interview on 1/14/14 at 1:30 p.m. The Medical Director agreed with the findings and stated, "We used to have many interventions that psychiatrists included in the plan but the Joint Commission recommended against that stating that we only needed psychiatrists to sign the plans."

Based on record review and interview, the facility failed to provide Master Treatment plans that identified patient related short and/or long term goals in observable, measurable, behavioral terms for 9 of 9 active sample patients (A4, A6, A7, B2, B11, C2, C9, D6 and E3). In some instances, the Master Treatment Plans of patients A7, B11 and D6 did not have long term goals for some of the psychiatric problems. This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, as well as to patients stays beyond the resolution of the behaviors requiring admission.

Findings include:

A. Record Reviews

1. Patient A4: The Master Treatment plan (MTP), last reviewed 1/14/14, had as a problem - "Psychotic behavior with aggression/agitation." The non-measurable long-term goal (LTG) was: "Stabilize psychosis, mood, and decrease delusions and aggression." The non-measurable short-term goal (STG) was: "Patient will demonstrate decreased reaction to internal stimuli and decreased psychotic behavior."
For the problem of "seclusion/restraints episode secondary to imminent danger to others," the non-measurable short-term goal was: "Patient will demonstrate ability to control impulses."

2. Patient A6: The MTP, dated 1/7/14, had as a problem - "Psychotic behavior." The non-measurable STP was: "Patient will demonstrate decreased reaction to internal stimuli and decreased psychotic behavior."

3. Patient A7: The MTP, dated 1/12/14, had as a problem - "Psychotic behavior." There was no LTG for this problem. The STG was: "Patient will demonstrate decreased reaction to internal stimuli and decreased psychotic behavior."

4. Patient B2: The MTP, dated 1/9/14, had as a problem - "Depression with suicidality." The non-measurable LTG was: "Patient will remain safe while hospitalized." For the problem of PTSD (Post Traumatic Stress Disorder), the non-measurable LTG was: "Patient will be able to effectively manage awareness of traumatic crisis with decreased anxiety." The non-measurable STG was: "Patient will increase insight and trauma response by verbalizing feelings and experiences."

5. Patient B11: The MTP, dated 1/10/14, had as a problem - "Psychotic behavior." There was no LTG. The non-measurable STG was: "Patient will demonstrate decreased reaction to internal stimuli and decreased psychotic behavior."

6. Patient C2: The MTP, dated 12/18/13, had as a problem - "Psychotic behavior." The non-measurable LTG was: "Pt [patient] will stabilize mood upon discharge." The non-measurable STG was: "Patient will demonstrate decreased reaction to internal stimuli and decreased psychotic behavior."

7. Patient C9: The MTP, dated 12/25/13, had as a problem - "Assaultive behavior and aggression towards others." A non-measurable STG was: "Patient will demonstrate decreased reaction to internal stimuli and decreased psychotic behavior." For the problem of "Psychotic behavior", the non-measurable LTG was: "Improve, stabilize mood, thinking and behavior."

8. Patient D6: The MTP, dated 1/10/14, had as a problem - "Depression without suicidality." There was no LTG.

9. Patient E3: The MTP, dated 1/10/14, had as a problem - "PTSD[Post Traumatic Stress Disorder]". The non-measurable LTGs were: "Patient will be able to effectively manage awareness of traumatic events with decreased anxiety" and "Gain insight into effects of trauma." The non-measurable STG was: "Gain insight into effects of trauma/decrease minimization."


B. Interviews

1. In an interview on 1/14/14 at 9:45 a.m., the non-measurable long-term and/or short-term goals on the Master Treatment plans were discussed with the Nursing Director. She did not dispute the findings. "I will start working on this problem immediately."

2. In an interview on 1/14/14 at 1:30 p.m., the non-measurable long-term and short-term goals were discussed with the Medical Director. "These were directions from the head office [meaning corporate] to write short and simple goals and interventions on the treatment plans, but I will get working on this problem with the staff."

Based on record review and interview, the facility failed consistently provide treatment plans for 9 of 9 active sample patients (A4, A6, A7, B2, B11, C2, C9, D6, and E3) that included active treatment interventions with a specific focus. Interventions were either generic monitoring and discipline functions to be performed by a nurse, social worker/therapist or recreation staff, or just simply the name of a particular group to be offered to a patient. Frequently many interventions had one discipline assigned as the responsible person to see that the intervention is carried out. Few of the interventions provided a focus. Many of the interventions did not include a frequency or duration. Because the Master Treatment plans (MTP) were pre-printed and based on specific problems [i.e. psychotic behavior or Post Traumatic Stress Disorder], patients with identical problems had identical or similarly worded interventions.
These deficiencies result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and fail to provide guidance to staff regarding the specific modalities needed and/or the purpose for each. This failure potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Patient A4: The MTP, last reviewed 1/14/14, stated the following generic and routine discipline functions for the identified problem of "Psychotic behavior with aggression/agitation:" Therapist/ provider [in this facility, a provider could be anyone administering treatment to a patient] - "group and psycho-educational group daily." Nursing - "Provide concise and direct instructions and redirect topic of conversation daily." Rec [recreation] therapy - " activity therapy groups daily." The focus and duration for these interventions were absent.
For problem - "seclusion/restraint episode secondary to imminent danger to others:" Nursing - "licensed staff to administer prn [as needed] or emergency medications as ordered. Give i/m [intramuscular] Ativan at pt's [patient's] request." The RN [registered nurse] was the only discipline listed as a responsible person for this intervention.

2. Patient A6: The MTP, dated 1/7/14, stated the following generic and routine discipline functions for the identified problem of "Psychotic behavior:" Therapist - "process group and psycho-educational group therapy daily." Rec. therapy - "activity therapy groups [illegible symbol] coping - 2 daily [sic]." These interventions contained no duration or focus.
For the problem of aggression, the generic discipline function was: Therapist - " therapist will provide group therapy and psycho-educational groups daily." A focus or duration was not listed for the group. No other discipline was assigned.

3. Patient A7: The MTP, dated 1/12/14, stated the following generic discipline function for the problem "Psychotic behavior:" Therapist - "process group and psycho-educational group therapy." No focus, duration or frequency was listed.

4. Patient B2: The MTP, dated 1/9/14, stated the following generic and routine discipline function for the identified problem of "Depression with suicidality:" Therapist - "training and/or group therapy and psycho-educational groups 2x daily." No other discipline was assigned to provide treatment for this problem.

5. Patient B11: The MTP, dated 1/10/14, stated the following generic discipline functions for the problem "Psychotic behaviors:" Rec. therapy - "Activity therapy groups - [illegible symbol] coping x2 daily." No focus or duration was listed, nor were other disciplines included to address this problem.

6. Patient C2: The MTP, dated 12/18/13, stated the following generic discipline function for the identified problem of "Psychotic behavior:" Rec therapy - "activity therapy groups daily." The intervention lacked a focus and duration. This is the only discipline and intervention for the problem.
For the problem of "Danger to others:" the generic and routine discipline functions were: Therapy - "therapist will provide group therapy and psycho-educational groups." There was no duration or focus listed. Nursing - "licensed staff will administer routine/comfort medications as ordered." Nursing - "RN to assess patient's behavior q [every] shift prn [as needed]." These are generic discipline functions.

7. Patient C9: The MTP, dated 12/25/13, stated the following generic discipline functions for the identified problem of "Assaultive behavior and aggression towards others:" Nursing, therapist, provider - "Process group and psycho-educational group therapy daily." Rec therapy - "activity therapy groups daily." The groups did not include focus or duration.
For the problem of "Psychotic behavior" the generic discipline functions were: Nursing, provider - "Order medications and monitor dosage daily." Therapist - "process group and psycho-educational group therapy daily." Rec. therapy - "activity therapy groups." The interventions did not include focus or durations.

8. Patient D6: The MTP, dated 1/10/14, stated the following generic functions for the identified problem of "Depression without suicidality:" Nursing- "RN to assess patient's depression level daily." Nursing - "administer routine and prn medications as ordered daily." Therapist - "family and/or group therapy and psycho-educational groups daily." The interventions lacked focus and duration.

9. Patient E3: The MTP, dated 1/7/14, stated the following generic functions for the problem of "PTS:" provider - "licensed staff will administer medications as ordered." Nursing - "RN to assess mood, effectiveness of medication, response and behaviors related to self-control." Therapist - "individual therapy, group therapy, family therapy." Rec therapy - "AT [activity therapy] groups to promote [illegible symbol] coping." The RN and therapy interventions lacked focus, duration and frequency. The Activity intervention lacked only duration and frequency.


B. Interviews

1. In an interview on 1/14/14 at 9:45 a.m., the non-measurable interventions on the Master Treatment plans were discussed with the Nursing Director. She did not dispute the findings. "I will start working on this problem immediately."

2. In an interview on 1/14/14 at 1:30 p.m., the non-measurable interventions on the Master Treatment Plans were discussed with the Medical Director. "These were directions from the head office [meaning corporate] to write short and simple goals and interventions on the treatment plans, but I will get working on this problem with the staff."

Based on record review, observation and interviews, the facility failed to:

I. Use or follow proper release criteria for seclusion for 1 of 6 patients (A4) whose records were reviewed for facility compliance on seclusion/restraint policy and procedure protocol. Record documentation revealed that patient A4 was kept secluded longer than necessary on one occasion. This deficient practice results in failure to ensure patient ' s right to be free from restriction of movement.

II. Provide active treatment, including alternative interventions, for 1 of 3 active sample patients (A4) on the Crisis Stabilization Unit. Patient A4 was either not emotionally stable to participate in treatment at times or was not motivated to attend all groups s/he was supposed to attend as listed on the unit activity schedule. Although the treatment plan for this patient included several group therapies, the patient regularly and repeated did not attend group. According to unit nursing staff, A4 spent many hours isolated in his/her room without any structured activities. A4's non-participation in assigned treatment modalities negates the clinical effectiveness of the patient ' s treatment goals and objectives, potentially delaying the patient's improvement.

Findings include:

I. Failure to keep patient A4 in seclusion without justifiable cause

A. Record Review

1. Facility policy and procedure, titled "Use of Seclusion", number PC03.05.01 - 03.05.19, dated 7/29/13, states: "Seclusion is to be terminated as soon as possible. Seclusion should be maintained only as long as a patient is exhibiting behavior that present imminent probability of harm to self or others. If the patient falls asleep in seclusion, the door will be unlocked and the patient's comfort will be assured."

2. According to the facility's "Seclusion/Restraint Observation Log" sheet, dated 12/5/13, the patient was placed in seclusion on 12/5/13 at 2:10 a.m. for "aggressive [sic] swinging and kicking at staff." The patient continued on and off for the next two and a half hours the behavior of "yelling, screaming, banging on the seclusion room door and urinating on the floor of the seclusion room" until 4:30 a.m. At 4:30 a.m., the patient was described as "lying calm". At 4:45 a.m., the patient was described as "appeared sleeping." At 5:15 a.m., the "pt [patient] moved bed mattress to floor, knocked on door lightly 2 times", and "was" quiet" until 6:00 a.m. When patient was released from the locked seclusion room.

3. A review of the "Physician/Provider order" sheet, dated 12/5/13 (no time), the seclusion/restraint order was written for up to 4 hours, which expired at 6:00 a.m.

B. Interviews

1. In an interview on 1/14/14 at 12:30 p.m., RN #2 was asked why the staff had not opened the door after the patient quieted down and fell asleep, per seclusion/restraint policy/procedure. RN #2 stated, "It [meaning door] should have been opened."

2. In an interview on 1/14/14 at 9:45 a.m., the lack of nursing staff releasing patient after patient quieted down and fell asleep at 4:30 a.m., was discussed with the Nursing Director. She confirmed the accuracy of the facility policy on seclusion/restraint. "I guess I need to provide nursing staff with more education on the policy."


II. Lack of Active Treatment for Patient A4

A. Record Review

1. Patient A4 was admitted on 11/30/13. According to the Psychiatric Evaluation, dated 11/30/13, the patient was admitted from an acute care emergency room in Wyoming where patient was "initially seen for an agitated psychosis with paranoia, delusions, combativeness"..."The patient" is not able to talk currently, because she is choosing to remain mute and is somewhat groggy from having had a Geodon i/m [intramuscular] 20 mg [milligrams][sic] that apparently assisted in her transport. [Patient] came by ambulance. Police were also associated with this...."Patient is apparently having auditory hallucinations, certainly is delusional, acutely psychotic and very agitated."

2. The Master Treatment plan, last reviewed 1/14/14, listed the following interventions for the problem of "Psychotic behavior with aggression/agitation:" "Process group and psycho-educational group," and "activity therapy groups." These interventions were not specific, lacked focus, and therefore did not address A4's specific problems.

3. A review of the Crisis Stabilization Unit's activity schedule showed "Rec Therapy" being offered twice/day for 7 days at 11:45 a.m. - 12:15 p.m. and 2:15 p.m. to 3:00 p.m. A specific name of "process group" and "psycho-educational group" were not found on the unit schedule, but per SW #1, in an interview on 1/14/14 at 1:05 p.m., the "therapy" group listed on the treatment plans included all those groups provided by social workers and other "therapist."

4. A review of "Recreational Therapy Daily Documentation" sheets for the period of 1/6/14 to 1/13/14 revealed the following lack of group attendance by patient A4 as follows:

- 1/6/14 - for 11:30 a.m. to 12:30 p.m. group - "not present for group" - for 2:15 p.m. to 3:00 p.m. group - "did not attend"

- 1/7/14 - for 11:00 a.m. to 11:30 a.m. - "not appropriate for group" - for 2:15 p.m to 3:00 p.m. - " did not attend "

- 1/8/14 - for 11:30 a.m. to 12:30 p.m. - "[Name of patient] was in her room during group" - for 2:15 p.m to 3:00 p.m. - "Did not attend group."

- 1/9/14 - for 11:45 a.m. to 12:30 p.m. - "Group cancelled" - for 2:15 p.m. to 3:00 p.m. - "not congruent with group"

- 1/10/14 - for 11:30 a.m. to 12:30 p.m. Music group - "[Name of patient] attended group late. She was quiet and had a depressed affect. She did not respond to redirection. Treatment included relaxation and art therapy" - for 2:15 p.m. to 3:00 p.m. - "not present"

- 1/11/14 - for 11:30 a.m. to 12:30 p.m. - "not present for group" - for 2:00 p.m. to 3:00 p.m. - "refused"

- 1/12/14 - for 11:30 a.m. to 12:30 p.m. - "refused" - for 2:00 p.m. to 3:00 p.m. - "refused "

- 1/13/14 - for 11:30 a.m. to 12:30 p.m. - "did not participate" - for 2:15 p.m. to 3:00 p.m. - "not appropriate for group by recreation staff"

Summary - Of a total of 15 recreational therapy groups (one cancellation) offered between 1/6/14 and 1/13/14, the patient attended 1 group.

5. A review of the "Patient Rounds" sheet for the same period of time (1/6/14 - 1/13/14) validated that A4 spent most of day time either sitting in dayroom or bedroom or lying in bed.

6. A review of "Daily Nursing Flow Sheet/Progress Note" sheet for the period of 1/6/14 - 1/13/14, showed that the staff documented primarily on A4's mental and physical condition. Staff made no mention of patient's isolation behavior and/or lack of group attendance.


B. Observation

On 1/15/14 at 9:30 a.m., patient A4 was observed in room in bed with linen covering most of head and face. RN #1 stated that the patient had been in bed all morning and had not participated in any offered groups so far that morning. Several other patients were in the Day room. The unit schedule listed the scheduled group at this time to be "Crisis Stabilization workbook", supervised by a Mental Health Technician.


C. Interviews

1. In an interview on 1/14/14 at 10:55 a.m. About what patient A4 does on the unit, RN #2 stated, "[Patient] stays in room most of the time."

2. In an interview on 1/14/14 at 12:55 p.m., RN #1, in a reference to patient A4's lack of group attendance stated, "[Name of patient] isolates in room. When out, s/he interacts very minimally with others." RN#1 also stated that all patients were expected to attend all groups listed on the unit schedule.

3. In an interview on 1/14/14 at 1:05 p.m., the lack of A4's participation in groups was discussed with MD #1. He stated that the patient is often too agitated to attend groups, but felt that 1:1 {one to one} interventions with specific staff would be appropriate. MD #1 agreed that alternative treatment such as 1:1 interventions should be included on the treatment plan.

Based on record review and interview, it was determined that the Medical Director failed to adequately monitor the care provided patients at the facility. Specifically, the Medical Director failed to ensure that:

1. Master Treatment Plans (MTPs) included treatment interventions by all members of the interdisciplinary team for 9 of 9 active sample patients (A4, A6, A7, B2, B11, C2, C9, D6 and E3). None of the MTPs included interventions by psychiatrists. Failure to clearly specify interventions by all members of the interdisciplinary team on the MTP hampers staff's ability to provide coordinated treatment and potentially results in patients not receiving all needed treatment to address their problems. (Refer to B118)

2. Master Treatment plans identified patient related short and long term goals in observable, measurable, behavioral terms for 9 of 9 active sample patients (A4, A6, A7, B2, B11, C2, C9, D6 and E3). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, as well as to patients stays beyond the resolution of the behaviors requiring admission. (Refer to B121)

3.Master Treatment Plans for 9 of 9 active sample patients (A4, A6, A7, B2, B11, C2, C9, D6, and E3 consistently included active treatment interventions with a specific focus. Interventions were either generic monitoring and discipline functions to be performed by a nurse, social worker/therapist, or recreation staff or just simply the name of a particular group to be offered to a patient. Frequently many interventions had one discipline assigned as the responsible person to see that the intervention is carried out. Few of the interventions provided a focus. Many of the interventions did not include a frequency or duration. Because the Master Treatment plans (MTP) were pre-printed and based on specific problems [i.e. psychotic behavior or Post Traumatic Stress Disorder], patients with identical problems had identical or similarly worded interventions.

These deficiencies result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and fail to provide guidance to staff regarding the specific modalities needed and/or the purpose for each. This failure potentially results in inconsistent and/or ineffective treatment. (Refer to B122)

4. The proper release criteria for seclusion for 1 of 6 patients (A4) whose records were reviewed for facility compliance on seclusion/restraint policy and procedure protocol were followed. Record documentation revealed that patient A4 was kept secluded longer than necessary on one occasion. This deficient practice results in failure to ensure A4's right to be free from restriction of movement. (Refer to B125I)

5. Active treatment, including alternative intervention, was provided for 1 of 3 active sample patients (A4) on the Crisis Stabilization Unit. Patient A4 was either not emotionally stable to participate in treatment at times or was not motivated to attend all groups s/he was supposed to attend as listed on the unit activity schedule. Although the treatment plan for this patient included several group therapies, the patient regularly and repeated did not attend groups. According to unit staff, A4 spent many hours isolated in his/her room without any structured activities. A4's non-participation in assigned treatment modalities negates the clinical effectiveness of the patient ' s treatment goals and objectives, potentially delaying the patient's improvement. (Refer to B125II)


Interviews

In an interview on 1/14/14 at 1:30 p.m., the Medical Director agreed with the findings and stated, "We used to have many interventions that psychiatrists included in the plan but the Joint Commission recommended against that stating that we only needed psychiatrists to sign the plans."

In a discussion with the Medical Director on 1/14/14 at 1:05 p.m. and during the exit conference on 1/15/2014 at 10:20 a.m., the non-measurable long-term and short-term goals were discussed. "These were directions from the head office [meaning corporate] to write short and simple goals and interventions on the treatment plans, but I will get working on this problem with the staff."

Based on record review and interview, the Nursing Director failed to ensure the quality and appropriateness of patient care provided by nursing staff. Specifically the Nursing Director failed to ensure that nursing staff:

I. Provided nursing interventions on Master Treatment Plans for 5 of 9 active sample patients (A4, C2, C9, D6 and D9) that were individualized and based on specific patient needs. Nursing interventions were generic monitoring and discipline functions to be performed by a nurse. None of the nursing interventions provided a focus. Many of the interventions did not include a frequency or duration. Because the Master Treatment plans (MTs) were pre-printed and based on specific problems [i.e. psychotic behavior or PTSD], patients with identical problems had identical or similarly worded interventions.
These deficiencies result in treatment plans that fail to reflect an individualized approach to multi-disciplinary treatment and fail to provide guidance to staff regarding the specific modalities needed and/or the purpose for each. This failure potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Patient A4: The MTP, last reviewed 1/14/14, stated the following generic and routine discipline function for the identified problem of "seclusion/restraint episode secondary to imminent danger to others:" Nursing- "licensed staff to administer prn [as needed] or emergency medications as ordered. Give i/m [intramuscular] Ativan at pt.'s [patient's] request." The RN [registered nurse] was the only discipline listed as a responsible person for this intervention.

2. Patient C2: The MTP, dated 12/18/13, stated the following generic discipline functions for the identified problem of "Danger to others:" - Nursing - "licensed staff will administer routine/comfort medications as ordered." Nursing - "RN to assess patient's behavior q [every] shift prn [as needed]."

3. Patient C9: The MTP, dated 12/25/13, stated the following generic discipline functions for the identified problem of "Assaultive behavior and aggression towards others:" Nursing - "Process group and psycho-educational group therapy daily." The groups did not include focus or duration.
For the problem of "Psychotic behavior" the generic function was: "Nursing- - Order medications and monitor dosage daily." The interventions did not include focus or durations.

4. Patient D6: The MTP, dated 1/10/14, stated the following generic functions for the identified problem of "Depression without suicidality:" Nursing - "RN to assess patient's depression level daily." Nursing - "administer routine and prn medications as ordered daily." The interventions lacked focus and duration.

5. Patient E3: The MTP, dated 1/7/14, stated the following generic functions for the problem of PTSD: nursing - "licensed staff will administer medications as ordered." Nursing "RN to assess mood, effectiveness of medication, response and behaviors related to self-control." The interventions lacked focus, duration and frequency.

B. Interview

In an interview on 1/14/14 at 9:45 a.m., the non-measurable nursing interventions on the Master Treatment plans were discussed with the Nursing Director. She did not dispute the findings. "I will start working on this problem immediately."




II. Use or follow proper release criteria for seclusion for 1 of 6 patients (A4) whose record was reviewed for facility compliance on seclusion/restraint policy and procedure protocol. Record documentation revealed that patient A4 was kept secluded longer than necessary on one occasion. This deficient practice results in failure to ensure patient's right to be free from restriction of movement.

Findings include:

I. Failure to keep patient A4 in seclusion without justifiable cause

A. Record Review

1. Facility policy and procedure, titled "Use of Seclusion" number PC03.05.01 - 03.05.19, dated 7/29/13, states: "Seclusion is to be terminated as soon as possible. Seclusion should be maintained only as long as a patient is exhibiting behavior that present imminent probability of harm to self or others. If the patient falls asleep in seclusion, the door will be unlocked and the patient's comfort will be assured."

2. According to the facility's "Seclusion/restraint observation log" sheet, dated 12/5/13, the patient was placed in seclusion on 12/5/13 at 2:10 a.m. for "aggressive [sic] swinging and kicking at staff." The patient continued on and off for the next two and a half hours the behavior of "yelling, screaming, banging on the seclusion room door and urinating on the floor of the seclusion room" until 4:30 a.m. At 4:30 a.m., the patient was described as "lying calm". At 4:45 a.m., the patient was described as "appeared sleeping." At 5:15 a.m., the "pt [patient] moved bed mattress to floor, knocked on door lightly 2 times," and was "quiet" until 6:00 a.m. When patient was released from a locked seclusion room.

3. A review of the "Physician/Provider order" sheet, dated 12/5/13 (no time), the seclusion/restraint order was written for up to 4 hours, which expired at 6:00 a.m.

B. Interviews

1. In an interview on 1/14/14 at 12:30 p.m., RN #2 was asked why the staff had not opened the door after the patient fell asleep, per seclusion/restraint policy/procedure form. RN #2 stated, "It [meaning door] should have been opened."

2. In an interview on 1/15/14 at 9:45 a.m., the lack of nursing staff releasing patient after patient quieted down and fell asleep at 4:30 a.m. was discussed. The Nursing Director confirmed the accuracy of the facility policy on seclusion/restraint. "I guess I need to provide nursing staff with more education on the policy."

Based on record review and staff interview, the Director of Social Work failed to evaluate and monitor psychosocial assessments for 8 of 8 active sample patients. Those assessments failed to include discharge planning by social workers (A6, A7, B2, B11, C2, C9, D6 and E3). This deficiency potentially prolongs hospital stay and prevents patients from having all available community resources utilized. (Refer to B108)

Findings include:

A. Record review

1. The Psychosocial Assessment for patient A6 (dated 1/7/14) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

2. The Psychosocial Assessment for patient A7 (dated 1/8/14) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

3. The Psychosocial Assessment for patient B2 (dated 1/9/14) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

4. The Psychosocial Assessment for patient B11 (dated 1/10/14) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

5. The Psychosocial Assessment for patient C2 (dated 12/8/13) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

6. The Psychosocial Assessment for patient C9 (dated 12/26/13) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

7. The Psychosocial Assessment for patient D6 (dated 1/9/14) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.

8. The Psychosocial Assessment for patient E3 (dated 1/7/14) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. No social work plan was mentioned.