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Based on record review and interview the hospital failed to implement a monitoring process for identified problems related to physical assessments, updated nursing care plans and psychiatric evaluations which included individualized patient assets as evidenced by continued non-compliance. Findings:

Review of the data submitted by the hospital as QA /PI for 01/26/11 through 02/20/11 revealed 41 indicators were developed for review of the medical record which included Psychiatric Evaluations, but no review of the identified problem of individualized assets. Further review revealed no documented evidence physical assessments or care plans had been included in the monitoring process.

In a face to face interview on 02/28/11 at 2:00pm FFS1 Administrator indicated the hospital had hired a Quality Assurance/Performance Improvement Consultant, RN FFS7, at the time of the last survey. S1 indicated that due to the termination of the Director of Nursing (DON) RN FFS7 was named as DON on 01/14/11 in addition to her role as QA/PI Director. RN FFS7 was terminated on 02/17/11 and two chart auditing consultants (LPN FFS5 and FFS6 a retired Registered Nurse) were hired to perform chart audits on 100% of the medical records. Further S1 indicated that according to the information submitted by the chart auditors (LPN FFS5 and FFS6) documented via graphs, the hospital was making improvements in the problems identified during the last survey.

In a face to face interview on 02/28/11 at 3:00pm LPN FFS5, Chart Auditor, indicated she went through the medical record and chose the indicators from the forms that were in the chart. Further she indicated that during the first week of data collection "Deficiency Sheets" were utilized to trend the nursing staff as to who was not documenting appropriately; however this was changed before the second week of data collection began. FFS5 indicated graphs were then used to illustrate results of the chart audits and verified the data indicating improvement did not include individualized assets, physical assessments, or care plan revisions because these were not included as indicators.

In a face to face interview on 03/01/11 at 3:`3pm FFS8 Consultant indicated he requested the the Chart Auditors use graphs to show the improvements noted in the medical record reviews.
When the surveyor asked FFS8 to show the survey team the improvement noted in the identified problems from the last survey of individualized assets, physical assessments and care plans FFS8 was unable and verified these had not been monitored.

See findings at Tag B0117, A0395 and A0396 for continued non-compliance.

Based on record review and interviews, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the care of each patient as evidenced by: 1) failure to perform physical assessments of patients after the RN received reports of a physical altercation between peers on 3 separate occasions for 2 of 7 sampled patients (#FF1, #FF5); 2) failure to assess the intake and output (I&O) for 3 of 3 patients reviewed with orders for I&O from a total sample of 7 patients (#FF1, #FF2, #FF3); and 3) failure to perform a complete physical assessment with a complaint by the patient of not feeling well for 1 of 1 patients reviewed with complaints of not feeling well from a total sample of 7 patients (#FF5). Findings:

1) Failure of the RN to perform physical assessments of patients who had been involved in physical altercations with peers:
Patient #FF1
Review of Patient #FF1's "Physician's Admit Orders" revealed she was admitted on 02/23/11 at 1814 (6:14pm) with a provisional diagnosis of psychosis. Review of the "Psychiatric Evaluation" performed by Physician FFS9 on 02/24/11 revealed diagnoses of psychotic disorder, impulse control disorder, oppositional defiant disorder, and a history of traumatic brain injury.

Review of the narrative portion of the "Interdisciplinary Progress Note" written by RN Charge Nurse FFS11 for Patient #FF1 on 02/26/11 at 1400 (2:00pm) revealed "Pt (patient) returned from gym. MHT (mental health tech) reports she was in altercation with pt # FF5. She was hit with the basketball & (and) threw the ball back at peer & hit L (left) side of her face. Pt's then began slapping one another & were separated by MHT. On assessment no injury noted. Medical Director FFS10 notified...".

Review of the "narrative summary" of the "Tech Notes/Observation Sheet" written by MHT FFS12 on 02/26/11, with no documented evidence of the time the note was written, revealed, in part, "Pt observed in the gym at CRH (Crossroads Regional Hospital). Pt was hit in the upper body with a basketball thrown by a peer. Both pt and peer were redirected and separated. Pt and peer began hitting and slapping each other. Pt and peer were separated and taken to the unit. RN was notified...".

Review of the entire medical record revealed no documented evidence that a physical assessment had been performed by RN Charge Nurse FFS11 to assess Patient # FF1 for possible injury.

In a face-to-face interview on 02/28/11 at 4:20pm, DON (director of nursing) FFS2 confirmed there was no documented evidence that RN Charge Nurse FFS11 had performed a physical assessment after the altercation with a peer on 02/26/11.

Patient #FF5
Review of Patient #FF5's medical record revealed she was admitted on 02/18/11 at 2025 (8:25pm) with a diagnosis of Intermittent Explosive Disorder. Review of the "Psychiatric Evaluation" performed on 02/19/11 by Physician FFS9 revealed diagnoses of mood disorder and oppositional defiant disorder.

Review of the narrative portion of the "Interdisciplinary Progress Note" written by FFS13 RN on 02/20/11 at 1800 (6:00pm) revealed "Pt hit in face with ball by another pt. States was hurting for a few minutes but not hurting at this time. Will continue to monitor for safety". Further review revealed no documented evidence FFS13 had performed a complete physical assessment to assess for injury. Review of the "Quality/Risk Management Report of Event" completed by FFS13 on 02/20/11 revealed no documented evidence that the"Quality/Risk Management Report of Event" had been reviewed by someone in leadership as required by hospital policy.

Review of the narrative portion of the "Interdisciplinary Progress Note" written by FFS14 LPN (licensed practical nurse) on 02/26/11 at 1400 (2:00pm) revealed "returned to unit tearful holding left side of face. Stated a peer had hit her with basketball. Reported by staff that an altercation involving slapping started shortly afterwards. Returned to unit. Ice pack applied to affected area @ (at) this time". Further review revealed no documented evidence FFS14 had reported the injury to the RN in charge and that a RN had performed a complete physical assessment.

In a face-to-face interview on 02/28/11 at 4:20pm, FFS2 DON confirmed a complete physical assessment of Patient #FF5 had not been performed by a RN after the physical altercation between peers on 02/20/11 and 02/26/11.

In a face-to-face interview on 02/28/11 at 4:55pm, FFS2 DON confirmed the "Quality/Risk Management Report of Event" had no evidence that it had been reviewed by leadership.

In a face to face interview on 02/28/11 at 4:00pm S1 Administrator indicated the assessment policy needed revisions to include an assessment of systems every shift by the RN, after a change in patient condition and/or physical altercations. Further S1 indicated the policy had not been approved as yet by the Medical Executive Committee; however the meeting was scheduled for 7:00pm tonight (02/28/11).

In a face-to-face interview on 03/01/11 at 10:50am, FFS1 Administrator indicated he and FFS2 DON were responsible for reviewing the incident reports at the operational meeting that was held each morning. He could offer no explanation for the incident report from the altercation between peers on 02/20/11 not having been reviewed by himself or FFS2.

Review of the hospital policy titled "Reporting and Analysis of Events", revised 11/09/10, revealed, in part, "...In order to accurately document information relative to possible variations in patient care or untoward events, a Risk Management/Quality management Confidential Report of Event is to be completed. ...Reports on all unusual events/occurrences involving patients will be reviewed and investigated by the Charge Nurse and Director of Nursing/designee. The Risk management/Quality Management Confidential Report of Event Forms are to be dated and timed by the persons completing the form. ... Procedure: ... D. The appropriate department manager or Director of Nursing should review the QM/RM (quality manager/risk manager) Report of Event. If the event occurs after hours or on weekends or holidays the Charge Nurse should complete the review. E. The QM/RM Report of Event form will be forwarded to the office of the Quality/Risk Management Coordinator within 24 hours of the occurrence or event (Reports from patient care units may be placed in the designated QM/RM box on the unit). Reports completed on weekends and holidays will be picked up by QM/RM staff on the next business day. ...All QM/RM forms involving patients will be forwarded to the Quality/Risk Management Coordinator and the original report or a copy will be forwarded to the Director of Nursing by a Risk Management staff member, for review and documentation of corrective action plan as indicated ...".

2) Failure to assess the I&O of patients as ordered by the physician:
Patient #FF1
Review of Patient #FF1's "Physician's Admit Orders" revealed she was admitted on 02/23/11 at 1814 (6:14pm) with a provisional diagnosis of psychosis. Review of the "Psychiatric Evaluation" performed by Physician FFS9 on 02/24/11 revealed diagnoses of psychotic disorder, impulse control disorder, oppositional defiant disorder, and a history of traumatic brain injury.

Review of Patient #FF1's "Physician's Orders" revealed an order on 02/24/11 at 0955 (9:55am) for nursing to monitor intake and output and help with ADL (activities of daily living) skills. Further review revealed an order on 02/28/11 at 10:20am to discontinue I&Os.

Review of the "Daily Intake/Output Record" revealed the following:
02/24/11 - 7am to 3pm shift: 120 cc (cubic centimeters) juice, 360 cc juice, 360 cc juice, 240 cc ensure; no documented evidence of the total intake for the shift and no documented evidence of output;
02/24/11 - 3pm to 11pm shift: no documented evidence of intake or output;
02/24/11 - 11pm to 7am shift: no documented evidence of intake; 100 cc output;
02/25/11 - 7am to 3pm shift: no documented evidence of totals for intake and output;
02/25/11 - 3pm to 11pm shift: no documented evidence of any recorded intake and output;
02/25/11 - 11pm to 7am shift: no documented evidence of any recorded intake and output;
02/26/11 - 7am to 3pm shift: no documented evidence of totals for intake and output;
02/26/11 - 3pm to 11pm shift: no documented evidence of any recorded output;
02/26/11 - 11pm to 7am: 120 water (no means of measurement documented), unmeasured at 6:20am; voided x (times) 1 at 6:15am "(not measured)";
02/27/11 - 7am to 3pm shift: no documented evidence of totals for intake and output;
02/27/11 - 3pm to 11pm shift: no documented evidence of totals for intake and output;
02/27/11 - 11pm to 7am shift: no measured voiding at 6:00am;
02/28/11 - 7am to 3pm shift: no documented evidence of intake or output from 7:00am to 10:20am when order was given to discontinue I&Os.
Further review revealed no documented evidence the totals of the intake per shift and/or per 24-hour period had been calculated.

Patient #FF2
Review of the medical record for Patient #FF2 revealed a 17 year old female admitted to the Child/Adolescent Unit of the hospital via Physician's Emergency Certificate on 02/14/11 for psychotic disorder with bizarre behavior.

Review of the Physician's Orders for Patient #FF2 dated/timed 02/19/11 at 0800 (8:00am) revealed an order for, "Strict I&Os (Intake and Output) and chart".

Review of the "Daily Intake/Output Record" dated 02/19/11 through 02/27/11 revealed no documented evidence the totals of the intake or output per shift and/or per 24-hour period had been calculated.

Review of the "Interdisciplinary Progress Notes" (utilized by the nursing staff for assessment and documentation of the patient) dated 02/19/11 through 02/27/11 revealed no documented evidence the intake and output for Patient #FF2 had been assessed and charted as ordered by the physician.

Patient #FF3
Review of the medical record for Patient #FF3 revealed a 22 year old female admitted to the Adult Unit of the hospital via Physician's Emergency Certificate on 01/18/11 for psychotic disorder and to rule out Schizophreniform Disorder and Cannabis Disorder.

Review of the Physicians' Orders dated/timed 01/29/11 at 1445 (2:45pm) for Patient #FF3 revealed an order to, "make sure patient is eating well, monitor food and fluid intake" .

Review of the "Daily Intake/Output Record" dated -1/29/11 through 02/27/11 revealed no documented evidence the fluid intake had been monitored for the following dates and shifts: 01/30/11 11p-7a; 02/02/11 11p-7a; 02/05/11 11p-7a; 02/06/11 11p-7a; 02/07/11 11p-7a; 02/08/11 11p-7a; 02/10/11 11p-7a; 02/11/11 11p-7a; 02/12/11 11p-7a; 02/13/11 11p-7a; 02/14/11 11p-7a; 02/15/11 11p-7a; 02/21/11 7a-3p, 3p-11p, and 11p-7a; 02/22/11 11p-7a; 02/23/11 11p-7a; 02/24/11 11p-7a; 02/25/11 11p-7a; 02/26/11 11p-7a; and 02/27/11 11p-7a. Further review revealed no documented evidence the totals of the intake per shift and/or per 24-hour period had been calculated.

In a face-to-face interview on 02/28/11 at 3:10pm, FF1 Administrator, FF2 DON, FF15, Staff Development RN, and FFS16, ADON (assistant director of nursing) could offer no explanation for I&Os not being assessed by the RN as ordered by the physician. FF1 Administrator indicated the hospital did not have an I&O policy prior to the start of this survey.

3) Failure to perform a complete physical assessment with a complaint by the patient of not feeling well:
Review of Patient #FF5's medical record revealed she was admitted on 02/18/11 at 2025 (8:25pm) with a diagnosis of Intermittent Explosive Disorder. Review of the "Psychiatric Evaluation" performed on 02/19/11 by Physician FFS9 revealed diagnoses of mood disorder and oppositional defiant disorder.

Review of the narrative portion of the "Interdisciplinary Progress Note" written by FFS11 RN on 02/21/11 at 1345 (1:45pm) revealed, in part, "HR (heart rate) 112. Pt states "I don't feel good". Call placed to Physician FFS9...". Further review revealed no documented evidence FFS11 performed a complete physical assessment to include blood pressure, respirations, temperature, auscultation of breath sounds, and neurological status. WHAT DID THE PHYSICIAN ORDER? WHY SHOULD THEY PERFORM THE ASSESSMENT AS LISTED ABOVE BECAUSE THE PATIENT "WAS NOT FEELING WELL".

In a face-to-face interview on 02/28/11 at 4:55pm, FFS2 DON confirmed the assessment of Patient #FF5 by FFS11 did not include all elements of a physical assessment. PLEASE LIST THE ELEMENTS OF PHYSICAL ASSESSMENT REQUIRED IN THE HOSPITAL'S POLICY.

Review of the hospital policy titled "Assessments, Initial Screening and Other", revised 06/03/10 and submitted by Consultant FFS7 as the hospital's current policy for assessment and reassessment, revealed, in part, "...Nursing Reassessment Post admission re-assessment of a patient's physical status will be accomplished by the RN charge nurse in the event of an injury, return form therapeutic assignment (pass), at the time of discharge or any other time physical impairments may be identified by staff...". THIS DOES NOT LIST WHAT ELEMENTS ARE REQUIRED IN THE ASSESSMENT. OUR REGULATION DOES NOT LIST REQUIRED COMPONENTS OF AN ASSESSMENT; ONLY STATES "IN ACCORDANCE WITH HOSPITAL POLICY.

In a face to face interview on 02/28/11 at 4:00pm FFS1 Administrator indicated the assessment policy needed revisions to include physical assessment and had not been approved as yet by the Medical Executive Committee. Further FFS1 added that the meeting was scheduled for 7:00pm tonight (02/28/11).

In a face-to-face interview on 03/01/11 at 11:25am with FFS1 Administrator and FFS3 Consultant present, FFS3 indicated she was aware that plans for correcting nursing services that had been identified on the last survey had not been implemented. She further indicated FFS7 former DON/QAPI (quality assurance performance improvement) Coordinator would not attend the morning operational meetings. FFS1 Administrator indicated he would meet after the operational meetings with FFS7 former DON/QAPI in her office. FFS3 Consultant indicated in a meeting on 02/01/11 with FFS18 Physician owner and member of the governing body, FFS1 Administrator, FFS7 former DON/QAPI, FFS3 Consultant, and the CFO (chief financial officer) present, FFS7 former DON/QAPI said she would not report to FFS3 Consultant, and FFS18 Physician owner and member of the governing body accepted FFS7's request.

In a face-to-face interview on 03/01/11 at 12:25pm with FFS18 Physician owner and member of the governing body and FFS1 Administrator present, FFS18 confirmed FFS7 former DON/QAPI told him she could not report to FFS3 Consultant, but she (FFS7) could report to FFS1 Administrator. FFS1 indicated at the time he (FFS1) would accept FFS7 reporting directly to him. FFS1 Administrator indicated he was responsible to follow-up on FFS7 to ensure she was implementing the action plan to correct the identified problems with nursing services. FFS1 further indicated he relied on the expectation that FFS7 was doing what she was directed to do, and he did not check to see what was being done. FFS1 Administrator indicated he had no evidence to provide the surveyors that the in-services that were supposed to be held with the nursing staff on January 28, 29, 30, and 31, 2011 had been conducted. FFS1 further could offer no explanation for the continued practice of the failure of the RN to physically assess patients for injury following physical altercations, to assess the intake and output of patients as ordered by the physician, and to assess patients who report a change in condition other than it was his responsibility to follow-up and he didn't do it.

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Based on record review and interviews, the hospital failed to ensure: 1) the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failure to have patients' medical problems addressed in the care plan for 3 of 3 patient reviewed with medical problems (#FF2, #FF3, #FF6) and have the care plan updated with changes in the patient's condition (#FF1, #FF5) for 2 of 2 patients reviewed with a change in condition from a total of 7 sampled patients and 2) the nursing staff implemented physician orders for lab work for 1 of 7 sampled patients (#1). Findings:

1) Nursing staff developed and kept current the nursing care plan:
Patient #FF1
Review of Patient #FF1's "Physician's Admit Orders" revealed she was admitted on 02/23/11 at 1814 (6:14pm) with a provisional diagnosis of psychosis. Review of the "Psychiatric Evaluation" performed by Physician FFS9 on 02/24/11 revealed diagnoses of psychotic disorder, impulse control disorder, oppositional defiant disorder, and a history of traumatic brain injury.

Review of Patient #FF1's "Physician's Orders" revealed an order on 02/24/11 at 9:55am for nursing to monitor intake and output and help with ADL (activities of daily living) skills.

Review of the narrative of the "Interdisciplinary Progress Note" for 02/24/11 at 1:20pm revealed "Nutrition Therapy: During group, pt stated "I don't ever eat at home". When asked what she eats... she states "When I go to the store, I get some chips". ... PO (by mouth) intake being monitored closely...".

Review of Patient #FF1's "Master Treatment Plan" revealed no documented evidence Patient #FF1's care plan had been updated to include monitoring of intake and output and assistance with ADL skills.

Review of the "Interdisciplinary Progress Note" for Patient #FF1 on 02/26/11 at 1400 (2:00pm) revealed Patient #FF1 was in a physical altercation with a peer in the gym.

Review of Patient #FF1's "Master Treatment Plan" revealed a nursing short-term goal of "pt (patient) will not show any aggressive or combative behavior for 3 consecutive days after admission" with a target date of 02/26/11. Further review revealed no documented evidence the treatment plan had been changed/updated following the physical altercation on 02/26/11.

Patient #FF2
Review of the medical record for Patient #FF2 revealed a 17 year old female admitted to the Child/Adolescent Unit of the hospital via Physician's Emergency Certificate on 02/14/11 for psychotic disorder with bizarre behavior.

Review of the Diet section of Nurses' Notes for Patient #FF2 revealed daily intake was as follows: 02/15/11 Breakfast 5%, Lunch 0%, Supper 15% and Snack 30%; 02/16/11 Breakfast 50%, Lunch 40%, Supper 75% and Snack 100%; and 02/17/11 Breakfast 40%, Lunch 40%.

Review of the Physician's Orders for Patient #FF2 revealed the following: 02/17/11 (no time documented) a telephone order for "House supplement if patient eats less than 75% (after meals and offer again at 10, 2 an 7 if patient does not accept after meals), push fluids QID (four times a day), and 4 ounces cranberry juice a day. 02/19/11 at 0800 (8:00am) Strict I&Os (Intake and Output)".

Review of the "Daily Vital Signs, BM (Bowel Movement) & WT (Weight) Flow Sheet" for Patient #FF2 revealed the following: 02/17/11 at 6:30 (am or pm not documented) heart rate 112; 02/18/11 at 0600 (6:00am) heart rate 110; 02/20/11 at 0700 (7:00am) heart rate 122; and 02/21/11 at 0600 (6:00am) heart rate 120.

Review of the Physician's Orders for Patient #FF2 dated 02/21/11 at 0905 (9:05am) revealed a telephone order for, "Medical consult for increased heart rate. 02/21/11 at 1020 (no am or pm documented) Vital signs every 2 hours while awake".

Review of the master Treatment Plan for Patient #FF2 dated 02/17/11 through the present revealed no documented evidence any medical problems had been identified or care planned.

Patient #FF3
Review of the medical record for Patient #FF3 revealed a 22 year old female admitted to the Adult Unit of the hospital via Physician's Emergency Certificate on 01/18/11 for psychotic disorder and to rule out Schizopherniform Disorder and Cannibus Disorder.

Review of the Physician's Orders for Patient #FF3 revealed the following: 01/29/11 an order, "Make sure patient is eating well. Monitor food and fluid intake. House supplements before/with meals and at 10am, 2pm and 7pm".

Review of the Master Treatment Plan For Patient #FF3 dated 01/19/11 through the present revealed no documented evidence any medical problems had been identified or care planned.

Patient #FF5
Review of Patient #FF5's medical record revealed she was admitted on 02/18/11 at 2025 (8:25pm) with a diagnosis of Intermittent Explosive Disorder. Review of the "Psychiatric Evaluation" performed on 02/19/11 by Physician FFS9 revealed diagnoses of mood disorder and oppositional defiant disorder.

Review of the "Interdisciplinary Progress Note" for 02/20/11 at 1800 (6:00pm) revealed "Pt hit in face with ball by another pt. States was hurting for a few minutes but not hurting at this time...".

Review of the "Interdisciplinary Progress Note" for 02/26/11 at 1400 (2:00pm) revealed Patient #FF5 was involved in a physical altercation with a peer that involved slapping one another.

Review of Patient #FF5's "Master Treatment Plan" revealed a nursing short-term goal of "pt will have no thoughts of harming others for 3 consecutive days" with a target date of 02/25/11. Further review revealed no documented evidence the care plan had been changed/updated following the injury on 02/20/11 and the physical altercation with a peer on 02/26/11.

Patient #FF6
Review of Patient #FF6's medical record revealed he was admitted on 02/18/11 per a formal voluntary legal status with diagnoses of bipolar disorder, depression, panic disorder without agoraphobia, cannabis abuse, alcohol disorder, superficial cuts to the chest and wrist, epididymitis, and a history of Tourette's.

Review of Patient #FF6's "Master Treatment Plan" revealed no documented evidence of nursing goals to address the medical problems of superficial cuts to the chest and wrist and epididymitis.

In a face-to-face interview on 02/28/11 at 3:10pm with FFS1 Administrator, FFS15 Staff Development, FFS2 DON (director of nursing), and FFS16 ADON (assistant director of nursing) present, when informed by the surveyors that the nursing care plans continued to not have patients' medical problems and updates with changes in condition addressed, no explanation was offered by any of the hospital leadership present.

In a face to face interview on 03/01/11 at 9:00am FFS1 Administrator and FFS8 Consultant indicated the former Director of Nursing FFS7 was delegated the responsibility for inservicing the nursing staff and correcting the care plan problem. FFS1 verified the problem with medical problems being care planned was still occurring.

In a face-to-face interview on 03/01/11 at 11:25am with FFS1 Administrator and FFS3 Consultant present, FFS3 indicated she was aware that plans for correcting nursing services that had been identified on the last survey had not been implemented. She further indicated FFS7 former DON/QAPI (quality assurance performance improvement) Coordinator would not attend the morning operational meetings. FFS1 Administrator indicated he would meet after the operational meetings with FFS7 former DON/QAPI in her office. FFS3 Consultant indicated in a meeting on 02/01/11 with FFS18 Physician owner and member of the governing body, FFS1 Administrator, FFS7 former DON/QAPI, FFS3 Consultant, and the CFO (chief financial officer) present, FFS7 former DON/QAPI said she would not report to FFS3 Consultant, and FFS18 Physician owner and member of the governing body accepted FFS7's request.

In a face-to-face interview on 03/01/11 at 12:25pm with FFS18 Physician owner and member of the governing body and FFS1 Administrator present, FFS18 confirmed FFS7 former DON/QAPI told him she could not report to FFS3 Consultant, but she (FFS7) could report to FFS1 Administrator. FFS1 indicated at the time he (FFS1) would accept FFS7 reporting directly to him. FFS1 Administrator indicated he was responsible to follow-up on FFS7 to ensure she was implementing the action plan to correct the identified problems with nursing services. FFS1 further indicated he relied on the expectation that FFS7 was doing what she was directed to do, and he did not check to see what was being done. FFS1 Administrator indicated he had no evidence to provide the surveyors that the in-services that were supposed to be held with the nursing staff on January 28, 29, 30, and 31, 2011 had been conducted. FFS1 further could offer no explanation for the continued practice of the failure of the RN to include patients' medical problems in their care plans and to update the care plans with changes in patient condition other than it was his responsibility to follow-up, and he didn't do it.

Review of the hospital policy titled "Treatment Planning and Review Process", policy number AS-00-011 and submitted by FFS1 Administrator as their current policy for the treatment plan process, revealed, in part, "...Any significant medical issues requiring an interdisciplinary approach to address the identified problem shall have a plan of care (Problem Identification Form) to address this problem initiated by the nurse completing the nursing care section of the initial treatment plan...The interdisciplinary team conducts a treatment plan review conference on every patient at least every 7 days during the inpatient stay after the Master Treatment Plan has been initiated. ... The treatment team may meet more frequently to review the patient's status and progress when major clinical changes occur, whether positive or negative. ... When indicated, the plan of care and treatment goals may be revised...".

2) Nursing staff implemented physician orders for lab work:
Review of Patient #FF1's "Physician's Admit Orders" revealed she was admitted on 02/23/11 at 1814 (6:14pm) with a provisional diagnosis of psychosis. Further review revealed an order for a CMP (comprehensive metabolic panel), CBC (complete blood count), Free T4 (thyroid), TSH (thyroid stimulating hormone), RPR (rapid plasma reagin), UDS (urine drug screen), UCG (urine pregnancy), and Fasting Lipids. Review of the "Physician's Orders" revealed an order on 02/27/11 at 1715 (5:15pm), 3 days after the lab work was due to be drawn, to obtain the UDS result.

Review of the lab requisitions for Patient #FF1 revealed the urine for the drug screen and pregnancy tests was collected on 02/24/11 at 6:00am. Further review of the requisition for the CBC, CMP, lipid profile, TSH, T4, and RPR revealed the collection date was 02/24/11 with no documented evidence of the time of the collection.

Review of the lab results revealed the CMP, lipid profile, TSH, T4, and CBC were collected on 02/25/11 at 6:25am, reported on 02/25/11 at 3:00pm, and faxed to the hospital on 02/25/11 at 3:14pm. Further review revealed no documented evidence the RPR had been collected and reported as ordered. Further review revealed the UDS and UCG were collected 02/24/11 at 6:00am, the report printed on 02/27/11 at 5:10pm, and faxed to the hospital on 02/27/11 at 5:03pm, 3 days after it had been collected.

Review of the "narrative" of the "Interdisciplinary Progress Note" for 02/24/11 at 6:40am revealed, in part, "Pt (patient) up this AM; lab tech here to draw her blood for routine lab work. Lab tech tried 3 times but pt was uncooperative; refused to have it done. Will try again sometime...". Further review revealed no documented evidence the physician was notified of the unsuccessful attempt to draw Patient #FF1's blood.

Review of the policy titled "Laboratory Values: Reporting of Critical Lab Values to the Physician", policy number TX-00-025, revised 10/20/09, and submitted by FFS2 DON (director of nursing) as the hospital's policy for lab services, revealed the policy only addressed the process for notifying the physician of critical lab values and did not address the process of drawing labs, reporting the unsuccessful attempts to the physician, the obtaining of results, and the reporting of results to the physician.

Review of the "Data Collection Worksheet" presented along with policy # TX-00-025 by FFS2 DON revealed the "indicator/measure: appropriateness of contract services - lab and x-ray" included the following data elements: labs will be performed within 24 hours of order, results of routine labs will be on chart within 24 hours of draw, documentation of patient refusal for lab draw by nursing staff, and physician notified of patient refusal to have labs drawn.

In a face-to-face interview on 03/01/11 at 10:30am, FFS1 Administrator gave no explanation when told the lab policy presented by FFS2 DON did not address the lab process of drawing, resulting, and notification of the physician of refusal by the patient. FFS1 indicated the hospital did not have a policy that included the lab drawing process.

In a face-to-face interview on 03/01/11 at 10:45am, FFS2 DON indicated the lab audit was not being performed.

Based on record review and interview, the hospital failed to ensure the psychiatric evaluation included an inventory of the patient's assets in descriptive terms as evidenced by failure to have patient-specific personal attributes documented that could be used to develop a meaningful treatment plan and therapeutic groups for 6 of 7 sampled medical records reviewed for psychiatric evaluations from a total of 7 sampled patients (#FF1, #FF2, #FF3, #FF5, #FF6, #FF7). Findings:

Patient #FF1
Review of the medical record for Patient #FF1 revealed a 15 year old female admitted to the Child/Adolescent Unit of the hospital per a formal voluntary legal status on 02/23/11 for psychosis.

Review of the Psychiatric Evaluation performed by Psychiatrist FFS9 dated 02/24/11 revealed Patient #FF1 had the following assets: supportive family, adequate housing. Further review revealed no documented evidence of patient-specific personal attributes that could be used to develop a meaningful treatment plan and therapeutic groups.

Patient #FF2
Review of the medical record for Patient #FF2 revealed a 17 year old female admitted to the Child/Adolescent Unit of the hospital via Physician's Emergency Certificate on 02/14/11 for psychotic disorder with bizarre behavior.

Review of the Psychiatric Evaluation performed by Psychiatrist FFS9 dated 02/15/11 revealed Patient #FF2 had the following assets: supportive family, adequate housing, good health, hobbies, physically intact and ambition. Further review revealed no documented evidence of patient-specific personal attributes that could be used to develop a meaningful treatment plan and therapeutic groups.

Patient #FF3
Review of the medical record for Patient #FF3 revealed a 22 year old female admitted to the Adult Unit of the hospital via Physician's Emergency Certificate on 01/18/11 for psychotic disorder and to rule out Schizophreniform Disorder and Cannabis Disorder.

Review of the Psychiatric Evaluation performed by Psychiatrist FFS9 dated 01/20/11 revealed Patient #FF3 had the following assets: supportive family, hobbies, physically intact and average IQ. Further review revealed no documented evidence of patient-specific personal attributes that could be used to develop a meaningful treatment plan and therapeutic groups.

Patient #FF5
Review of the medical record for Patient #FF5 revealed an 11 year old female admitted to the Child/Adolescent Unit of the hospital per a formal voluntary legal status for Intermittent Explosive Disorder.

Review of the Psychiatric Evaluation performed by Psychiatrist FFS9 dated 02/19/11 revealed Patient #FF5 had the following assets: hobbies, physically intact, accepts need for treatment, sports, low average IQ, ambition, and capable of insight. Further review revealed no documented evidence of patient-specific personal attributes that could be used to develop a meaningful treatment plan and therapeutic groups.

Patient #FF6
Review of the medical record of Patient #FF6 performed by Psychiatrist FFS9 dated 02/19/11 revealed a 17 year old male admitted to the Child/Adolescent Unit of the hospital per a formal voluntary legal status for bipolar disorder, panic disorder, cannabis abuse, and alcohol use disorder.

Review of the Psychiatric Evaluation performed by Psychiatrist FFS9 dated 02/19/11 revealed Patient #FF6 had the following assets: hobbies, physically intact, accepts need for treatment, sports, average IQ, capable of insight, and supportive family. Further review revealed no documented evidence of patient-specific personal attributes that could be used to develop a meaningful treatment plan and therapeutic groups.

Patient #FF7
Review of the medical record for Patient #FF7 revealed a 14 year old male admitted to the Child/Adolescent Unit of the hospital via Formal Voluntary Legal Status on 02/10/11 for Intermittent Explosive Disorder.

Review of the Psychiatric Evaluation performed by Psychiatrist FFS9 dated 02/11/11 revealed Patient #FF7 had the following assets: supportive family, hobbies, physically intact, low average IQ, ambition, and capable of insight. Further review revealed no documented evidence of patient-specific personal attributes that could be used to develop a meaningful treatment plan and therapeutic groups.

In a face-to-face interview on 03/01/11 at 9:05am, Medical Director and Psychiatrist FFS10 indicated he documented patient assets in the narrative section under social history. After review of psychiatric evaluations performed by Psychiatrist FFS9, FFS10 indicated he would have to address the appropriate documentation of patient assets with Psychiatrist FFS9. Medical Director and Psychiatrist FFS10 could not explain why the patient assets documented in the psychiatric evaluations were often the same for each patient and not patient-specific.




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Based on record review and interview, the hospital failed to ensure the treatment plan included measurable goals that were written in a manner to allow them to be measured by observation of patient behaviors and/or the target date for completion of the goals for 7 of 7 patients reviewed for treatment plans (#FF1, #FF2, #FF3, #FF4, #FF5, #FF6, #FF7) from a total of 7 sampled medical records. Findings:

Patient #FF1
Review of the medical record for Patient #FF1 revealed a 15 year old female admitted to the Child/Adolescent Unit of the hospital per a formal voluntary legal status on 02/23/11 for psychosis.

Review of the Master Treatment Plan, with no documented evidence of the date the treatment plan was developed, revealed Patient #FF1 had the following short-term goals: physician - patient will deny any thoughts to harm self, others times 3 consecutive days with no documented evidence of the target date for completion and patient will deny having auditory hallucinations times 3 consecutive days with no documented evidence of the target date for completion; nursing - patient will not have any thoughts of wanting to hurt self for 3 successive days with a target date of 02/26/11, patient will not hurt self while hospitalized with a target date of 02/26/11, patient will not show any aggressive or combative behavior for 3 consecutive days after admission with a target date of 02/26/11, patient will comply with medicine per doctor's orders daily with no documented evidence of a target date for completion, and patient will take less meds daily per doctor's orders with no documented evidence of a target date for completion; social services - patient will verbalize feelings of sadness, anger, hopelessness related to a conflicted relationship with others with a target date of 02/25/11 and patient will identify successful strategies to assist her with controlling her temper; recreation - patient will display thought processes that reflect an accurate interpretation of the environment by day 5. Further review revealed no documented evidence the goals were written in a manner to allow them to be measured by observation of patient behaviors and no documented evidence the goal had been achieved by the target date.

Patient #FF2
Review of the medical record for Patient #FF2 revealed a 17 year old female admitted to the Child/Adolescent Unit of the hospital via Physician's Emergency Certificate on 02/14/11 for psychotic disorder with bizarre behavior.

Review of the Master Treatment Plan dated 02/21/11 revealed Patient #FF2 had the following short-term goals developed by Social Services: The patient will begin to participate minimally during daily group therapy and learn positive ways to interact with others and Recreational Services: patient will have thought processes that reflect accurate interpretation of environment by day six per group notes. Further review revealed no documented evidence the goals were written in a manner to allow them to be measured by observation of patient behaviors or documented evidence the goal had been achieved by the target date of 02/21/11.

Patient #FF3
Review of the medical record for Patient #FF3 revealed a 22 year old female admitted to the Adult Unit of the hospital via Physician's Emergency Certificate on 01/18/11 for psychotic disorder and to rule out Schizophreniform Disorder and Cannabis Disorder.

Review of the Master Treatment Plan dated 01/20/11 revealed Patient #FF3 had the following short term goals developed by Social Services: patient will show a decrease in paranoia and delusional behavior by 01/20/11; patient will participate in daily group therapy and discuss reasons for hospitalization by 01/21/11; and patient will discuss the necessity of medication and aftercare compliance by 01/22/11. Further review revealed no documented evidence the goals had been achieved by the target date of 02/21/11.

Patient #FF4
Review of the medical record for Patient #FF4 revealed a 30 year old male admitted to the Adult Psychiatric Unit of the hospital per a PEC (physician's emergency certificate) on 02/22/11 for gravely disabled.

Review of the Master Treatment Plan, with no documented evidence of the date the treatment plan was developed, revealed Patient #FF4 had the following short-term goals: nursing - patient will identify situations that precede hallucinations/delusions by 02/25/11, patient will show reduction in paranoid delusion and be able to interact with peers and staff with reality-based conversations by 03/01/11, and patient will report a decrease in fatigue and changes in behavior by 02/22/11; social services - patient will demonstrate a decrease and/or disappearance of delusions and hallucinations by the time of discharge, patient will acknowledge the importance of medication compliance by the time of discharge, and patient will agree to and is motivated for outpatient treatment by the time of discharge; recreation - patient will have thought process that reflect accurate interpretation of environment by 02/28/11. Further review revealed no documented evidence the goals were written in a manner to allow them to be measured by observation of patient behaviors or documented evidence the goal had been achieved by the target date.

Patient #FF5
Review of the medical record for Patient #FF5 revealed an 11 year old female admitted to the Child/Adolescent Unit of the hospital per a formal voluntary legal status for Intermittent Explosive Disorder.

Review of the Master Treatment Plan developed 02/19/11 for Patient #FF5 revealed the following short-term goals: nursing - patient will not have any thoughts of self-harm or harming others times 3 consecutive days after admission with a target date of 02/25/11; social services - patient will identify 3 coping skills to deal with depression for 7 days with a target date of 02/25/11 and patient will identify 3 positive coping skills to cope with anger with a target date of 02/25/11; recreation - patient will develop alternative methods of expressing angry feelings with a target date of 02/20/11 and a completion date of 02/18/11 (day of admit). Further review revealed no documented evidence the goals were written in a manner to allow them to be measured by observation of patient behaviors or documented evidence the goal had been achieved by the target date.

Patient #FF6
Review of the medical record of Patient #FF6 performed by Psychiatrist FFS9 dated 02/19/11 revealed a 17 year old male admitted to the Child/Adolescent Unit of the hospital per a formal voluntary legal status for bipolar disorder, panic disorder, cannabis abuse, and alcohol use disorder.

Review of the Master Treatment Plan developed 02/19/11 for Patient #FF6 revealed the following short-term goals: physician - patient will verbalize a need to continue to abstain from use of alcohol or marijuana and develop appropriate coping skills times 3 consecutive days with no documented evidence of a target date for completion; nursing - patient will not have any thoughts of self-harm or do anything to hurt self times 3 days after admission with a target date of 02/20/11 (patient admitted 02/18/11 and target date before third day after admission), patient will not crave for any alcohol or marijuana times 3 days after admission (patient admitted 02/18/11 and target date before third day after admission), and patient will develop positive coping skills to deal with problems in 3 days; social services - patient will identify 5 positive coping skills for depression by 02/25/11 and patient will identify 5 positive coping skills that will assist him in remaining abstinent by 02/25/11. Further review revealed no documented evidence the goals were written in a manner to allow them to be measured by observation of patient behaviors or documented evidence the goal had been achieved by the target date.

Patient #FF7
Review of the medical record for Patient #FF7 revealed a 14 year old male admitted to the Child/Adolescent Unit of the hospital via Formal Voluntary Legal Status on 02/10/11 for Intermittent Explosive Disorder.

Review of the the Master Treatment Plan for Patient #FF7 revealed the following short-term goals by Social Services: in three days patient will begin to discuss triggers to anger during daily group therapy by 02/13/11; in five days patient will have shown lessened frequency of aggression by 02/15/11; and in seven days patient will have shown zero aggressive behaviors in last three days prior to discharge by 02/17/11. Further review revealed no documented evidence the goals had been achieved by the specific target date.

Review of the "Staff Development Sign In Sheet" dated 01/26/11 revealed an in-service had been conducted by FFS17 LCSW (licensed clinical social worker). Further review revealed the topic of the presentation was "appropriate documentation that can be utilized by multidisciplinary staff to address problems a patient is dealing with and measure the degree to which the patient has reached their treatment goals... addressed the need for s.s. (social service) to document short and long term goals that are patient specific, measurable, and time sensitive... reported to s.s. staff that charts will be monitored by RN/LPN (registered nurse/licensed practical nurse) on a nightly basis in order to ensure that long and short term goals are measurable, patient specific, and have a target date noted". Further review revealed the attendants were members of the social service department.

The hospital could not submit a policy and procedure for the revised Master Treatment Plan due to the continued revisions being made.

In a face to face interview on 01/28/11 at 3:15pm FFS8 Consultant working with the Social Service Department indicated a new Social Service Director was hired and in the process of assessing the department. Further FFS8 indicated problems were identified and Psychiatrist FFS10, Medical Director, was included in reviewing the documentation presently being used for the treatment plan including the "Initial Treatment Plan" (initiated within 24 hours of admit), the "Master Treatment Plan Problem List", the Master Treatment Plan" and the "Master Treatment Plan of Care". FFS8 indicated correcting the master treatment plan is a work in progress and continues to be revised.

In a face-to-face interview on 03/01/11 at 9:05am, Medical Director and Psychiatrist FFS10 indicated that nurses should not be auditing the patients' social service goals for appropriateness, and this should be performed by a qualified social worker.





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