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Based on observation, interview and record review, staff failed to provide a safe, secure environment free from ligature risks.

Findings:

Staff failed to ensure that the inpatient psychiatric environment was free from all potential ligature risks in 1 of 2 hallways on the inpatient unit (shower hallway) See Tag 0144.

Based on observation, interview and record review, staff failed to ensure that the inpatient psychiatric environment was free from all potential ligature risks in 1 of 2 hallways on the inpatient unit (shower room hallway).

Findings include:

The facility policy titled, "Ligature Risk Assessment," #5331515, dated 10/2018, revealed in part, "Ligature Risk: Anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes, and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures....The Consumer Risk Assessment Committee will meet yearly and as needed to review our Ligature Risk Assessment and perform a physical walk-through of the unit in order to identify any possible ligature or other safety risks and make modifications in a timely manner."

An observation of external door hinges was made on 1/27/2020 at 10:33 AM accompanied by Director of Nursing B who confirmed this finding. The hinges, which were not "piano hinge" type, were on the corridor side of the door, on both the women's shower room and the men's shower room down one of the 2 inpatient hallways. These external hinges had exposed open spaces where a hand could easily fit through and that could potentially be a ligature risk.

In an interview with Director B on 1/27/2020 at 10:33 AM regarding the hinges, Director B stated that the hallways are monitored by staff frequently. There were no staff members in the hallway at the time of the observation, which Director B acknowledged as being a true statement.

A review of the facility's Mental Health Environment of Care Checklist, which was an internal environmental safety review of the unit, conducted August 1, 2019 revealed that the criteria for door hinges on the inpatient unit had been met. In an interview with Director B on 1/29/2020 at 9:10 AM regarding the finding in the report, Director B stated, "You're correct, it wasn't identified."

Based on record review and interview, staff failed to document appropriate and ongoing wound care in 3 of 3 records reviewed of patients with wounds/ulcers out of a total of 31 records reviewed (Patient #2, 5 and 30).

Findings:

Nursing staff failed to document wound care, characteristics and/or measurements of identified skin integrity issues. See Tag 0395

Based on record review and interview, nursing staff failed to document wound care, characteristics and/or measurements in 3 of 3 records reviewed of patients with wounds/ulcers out of a total of 31 records reviewed (Patient #2, 5 and 30).

Findings include:

An interview with Director of Nursing B was conducted on 1/29/2020 at 8:30 AM regarding wound care documentation and a policy was requested. Director B stated that any wound care/wound characteristics documentation would be within the narrative of the progress notes for the Registered Nurses and the facility had no policy on wound care or wound assessments.

A record review on Patient #2's open medical record revealed that Patient #2 was admitted on 1/24/2020 and discharged on 1/28/2020. The medical history and physical indicated Patient #2 had a right below the knee amputation (BKA) and a left transmetatarsal foot amputation (partial removal of the foot). The history and physical also indicated that Patient #2 had open areas on the left amputation site that #2 had been caring for for over a year. The treatment plan indicated, "RN (Registered Nurse) will clean wounds and apply dressing to wounds on right BKA as ordered by NP (Nurse Practitioner)."

Nursing documentation in the progress notes revealed on 1/25/2020 that the dressing was changed to the left leg stump. There were no wound characteristics or measurements documented. On 1/26/2020 nursing documentation in the progress notes revealed the dressing was changed to the left leg stump, drainage was described, no wound measurements. On 1/27/2020 nursing documentation in the progress notes revealed dressings were changed to the left lower stump, described the wounds as scabbed, no measurements were documented.

These findings were discussed with and confirmed by interview with Director of Nursing B on 1/29/2020 at 10:00 AM.

A record review on Patient #5's open medical record revealed that Patient #5 was admitted on 1/10/2020. The medical history and physical revealed multiple skin rashes and tears, Patient #5 has a history of scratching self and biting fingers until they bleed. Patient #5 was intermittently incontinent of urine and stool. Patient #5's treatment plan and provider orders indicated to "clean abrasion to coccyx and apply mepilex dressing as needed."

On 1/10/2020 nursing documentation in the progress notes revealed "wounds were dressed." There was no documentation of wound characteristics or measurements. On 1/13/2020 nursing documentation in the progress notes revealed the mepilex dressing was applied to an abrasion near the coccyx. There was no documentation of wound characteristics or measurements. On 1/18/2020 nursing documentation in the progress notes revealed, "Old bandaids and mepilex removed and new dressings applied. Coccyx opened when old mepilex was removed." There was no documentation of wound characteristics or measurements. There was no other documentation regarding the wounds.

These findings were discussed with and confirmed by interview with Director of Nursing B on 1/29/2020 at 10:00 AM.

A record review on Patient #30's closed medical record revealed Patient #30 was admitted on 1/2/2020 and discharged on 1/9/2020. The medical history and physical indicated "ulcers on heels due to improper fitting shoes." On 1/3/2020 at 9:30 AM the provider orders indicated to cleanse, apply gel, and change dressings to both heels daily.

On 1/3/2020 at 2:30 PM, nursing documentation in the progress notes revealed dressing changes were completed as ordered. There was no documentation of wound characteristics or measurements. There was no documentation found in the medical record that dressing changes were completed as ordered on 1/4/20 or 1/5/20. On 1/6/2020 at 7:01 AM, "Nurses Notes" revealed "...Both heels are red and moderate about (sic) of serous drainage to both affected areas. No order noted." Dressing changes were completed as ordered, no documentation of wound measurements. There was no documentation found in the medical record that dressing changes were completed as ordered on 1/7/20. On 1/8/2020 at 10:23 PM, "Nurses Notes revealed, "...Dressing was changed to right heel, no c/o (complaint of) pain to the area. Scant amount of yellow/clear drainage noted on old dressing." There was no documentation of measurements and no mention of the left heel. There was no provider order to discontinue wound care to the left heel. On 1/9/2020, "Nurses Notes" revealed, "...Right heel dressing changed before discharge. No s/s (signs or symptoms of) infection to heel and scant amount of serous fluid. Left heel OTA (open to air)." There was no documentation of measurements. There was no provider order to discontinue wound care to the left heel.

These findings were discussed with and confirmed by interview with Director of Nursing B on 1/29/2020 at 10:00 AM.

Based on observation, interview and record review, staff failed to develop a tracking system for sample medications in the event of a medication recall in 1 of 1 medication room observed.

Findings include:

The facility policy titled, "Use of Pharmaceutical Samples on NPC (abbreviation for the name of the inpatient psychiatric unit)," #5983972, dated 2/2019, revealed in part, "When medication samples arrive on the unit, a Proof of Use Record must be filled out by the receiving RN (Registered Nurse). The form is used to track when the samples arrived on the unit and to which client they were administered."

An observation of sample medications, locked in the medication room, was made on 1/27/2020 at 10:25 AM accompanied by Director of Nursing B. A review of the sample medication logs revealed staff did not record lot numbers of sample medications when they were received.

In an interview with Director B on 1/27/2020 at 10:25 AM, B stated that the staff did not track the lot numbers of the medications when they came in. In response to how the facility would be able to track patients who received these medications in the event of a recall, Director B stated, "That's a very good question."

Based on observation, record review and interview staff failed to maintain the integrity of intravenous sodium chloride in 1 of 1 emergency medication cart observed.

Findings include:

Manufacturer recommendations for Baxter intravenous products, May 24, 2017: "Baxter recommends removing products packaged in VIAFLEX plastic containers from the overwrap immediately prior to product use. If a product in a VIAFLEX container is removed from its overwrap and is not used immediately, the product should be used as soon as possible and the following data related to
out of overwrap storage must be followed:
25 mL (milliliters) to 1000 mL Products in VIAFLEX Containers stored at room temperature* must not be stored out of overwrap for longer than the following time periods: Container Size <50 mL 15 days out of overwrap; >100 mL and <1000 mL 30 days out of overwrap."

An observation of the emergency medication cart was made on 1/27/2020 at 10:45 AM accompanied by Director of Nursing B who confirmed the following finding: A 500 mL bag of sodium chloride was found in one of the drawers with the protective outer wrap removed and was not dated. Per interview with Director B on 1/27/2020 at 10:45 AM, Director B stated B did not know the intravenous bags came with an outer wrap and did not know when it was removed.

Based on observation, staff interviews, and review of maintenance records on January 27, 2020, revealed that the facility did not construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 482.41 Condition of Participation: Physical Environment is NOT MET

Findings include:

The facility was found to contain the following deficiencies.
Hospital

K 0271 Discharge From Exits
K 0345 Fire Alarm System - Testing and Maintenance
K 0374 Subdivision of Building Spaces - Smoke Barrier Doors
K 0521 Building Services - HVAC
K 0914 Electrical Systems - Maintenance and Testing

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interviews, and review of maintenance records on January 27, 2020, revealed that the facility did not construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 482.41(b) Standard: Life Safety from Fire was NOT MET

Findings include:

The facility was found to contain the following deficiencies.
Hospital

K 0271 Discharge From Exits
K 0345 Fire Alarm System - Testing and Maintenance
K 0374 Subdivision of Building Spaces - Smoke Barrier Doors
K 0521 Building Services - HVAC
K 0914 Electrical Systems - Maintenance and Testing

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on record review and interview, staff failed to monitor medication and food refrigerator temperatures per facility expectation in 1 of 1 medication refrigerator and 1 of 1 food refrigerator on the inpatient psychiatric unit and in 1 refrigerator/freezer unit designated for storage of laboratory samples and 1 refrigerator/freezer unit designated for food and drink in a total of 2 refrigerator/freezer units located in the laboratory.

Findings include:

A review of facility policy titled, "Refrigeration of Foods and Medications," #6453060, dated 6/2019, revealed in part, "The night shift CNA (certified nursing assistant) is to audit and record the temperature of refrigerator on the unit daily using the attached temperature log...The Director of Nursing or designee will audit the medication refrigerator monthly and as needed."

Review of facility policy titled, "Storage and Use of Food and Beverage Brought in by Visitors for Residents," #6896360, dated 9/2019, revealed in part, "Refrigerator and freezer temperatures of refrigerators located in the dietary support and household dining areas will be recorded once daily by staff of the Food and Nutrition Services department."

Review of the temperature logs for the inpatient psychiatric unit revealed temperatures for both medication refrigerator and food refrigerator are to be monitored and recorded two times per day.

For October 2019 (31 days) there were 16 missing medication and food refrigerator temperature entries.
For November 2019 (30 days) there were 14 missing medication and food refrigerator temperature entries.
For December 2019 (31 days) there were 10 missing medication and food refrigerator temperature entries.
For January 2020 (1st-25th) there were 7 missing medication and food refrigerator temperature entries.

These findings were discussed per interview with Administrator A on 1/27/2020 at 4:30 PM. Administrator A stated that the medication refrigerator was replaced in November 2019 and is now electronically monitored. A request for the electronic logs was made at this time.

In an interview on 1/28/2020 at 4:00 PM with Administrator A, A stated that an electronic log for the medication refrigerator was unable to be obtained.




41127


During a tour of the laboratory on 1/28/20 at 7:31 AM, 2 refrigerator/freezer units were noted in the laboratory space. 1 was labeled with a biohazard sticker and the other labeled as "Clean."

When asked about the use of the refrigerator/freezers, Lab Staff H opened the refrigerator labeled with a biohazard sticker and stated that was used for storing any temperature-sensitive laboratory samples "like urine" prior to pick up by the courier for transport to the resulting lab. No laboratory samples were noted to be in the refrigerator/freezer at the time of the interview. Thermometers were noted to be located in the refrigerator and the freezer.

When asked about the refrigerator/freezer labeled "Clean," Lab Staff H opened the refrigerator and stated that was used to keep juice and crackers from the kitchen for patients who may become lightheaded. No food or drink was noted to be in the refrigerator/freezer at the time of the interview. Lab Staff H stated, "I'll have to run to the kitchen to get some. I like to make individual bags up with a juice and crackers and keep it all together in the refrigerator." Thermometers were noted to be located in the refrigerator and the freezer.

When asked how the temperature was monitored, Lab Staff H stated, "I check the temps every day. The freezer temp should be within the black line and the refrigerator should be within the blue line, the 32 (degrees) to 35 (degrees) range. Both refrigerators have the same temperature ranges."

When asked about action steps if the temperatures were found to be out of range, Lab Staff H stated, "I would change the temperature settings."

When asked about logs for documenting the termperatures, Lab Staff H stated, "There is no log. There used to be one, but when the other lady left she took it and I haven't been able to find one."

During an interview on 1/29/20 at 8:47 AM with Director of Nursing (DON) B, when asked about expectations for monitoring the 2 refrigerator/freezer temperatures in the laboratory, DON B stated, "I would expect those to be monitored; there should be a log. I will get [Lab Staff H] one."

Based on observation and interview, staff failed to maintain a clean and sanitary environment free from potential sources of contamination on 1 of 1 nursing unit observed (inpatient psychiatric unit).

Findings include:

A tour of the inpatient psychiatric unit was conducted on 1/27/2020 between 10:20 AM and 10:45 AM accompanied by Director of Nursing B who confirmed the following findings at the time of discovery:

*Observation in seclusion room 2 of a dark colored substance on the ceiling in the corner by the door that opens to the corridor. Per interview with Director B on 1/27/2020 at 10:20 AM regarding the substance, Director B stated, "Oh, that needs to be cleaned!"
*Observation of numerous breaches in the integrity of the dry wall by the phones provided for patient use. Breaches exposed porous areas underneath rendering the areas non-cleanable.
*Observation of exposed porous areas of dry wall around soap dispenser in room 130. Director B stated in an interview on 1/27/2020 at 10:37 AM, "We just put the dispensers in last week and must have missed this."
*Observation of exposed porous areas of dry wall on the outside wall to the corridor outside of room 129. Director B stated in an interview on 1/27/2020 at 10:38 AM, "That was a white board that got ripped off the wall on Friday (referring to the date of 1/24/2020)."
*Observation of a white substance covering the face of the ceiling sprinkler head and on the ceiling adjacent to the sprinkler in the bathroom of room 126. Director B stated in an interview on 1/27/2020 at 11:43 AM, "That needs to be cleaned off of there."


41127


Based on observation and interview, the facility failed to maintain an environment free from potential contamination in 2 of 2 storage areas observed.

During a tour on 1/27/20 at 1:46 PM with Staff I, the room labeled, "Clean Utility" was observed to contain solid shelving with uncovered clean linen. A red blanket was observed to be lying directly on the floor. Exposed drywall and chipped areas observed in the wall surrounding the upper areas of the interior door frame. Plastic totes and cardboard boxes were observed on the floor stored under the shelving units.

When asked about the red blanket, Staff I stated, "I'm not sure why that is there. We don't use them much at all. It shouldn't be on the floor."

When asked about the exposed drywall around the door frame, Staff I stated, "Yes, I see that too."

When asked how the floors are ensured to be cleaned when totes and boxes are on the floor, Staff I stated, "I guess I don't know if they move those when they clean the floor. I guess we don't know for sure."

During a tour on 1/28/20 at 10:09 AM with Director of Nursing (DON) B, the supply storage room 281 was observed to contain 13 cardboard boxes stacked in various locations on the floor. The boxes were stacked in a manner that supplies located on shelving near the back of the room were unable to be accessed.

When asked about the boxes, DON B stated, "It looks like those are gloves and scrubs. Someone must have just put those in here. They weren't here yesterday. I know they shouldn't be there."

Based on record review and interview, staff failed to follow provider orders for therapy evaluations in 1 of 1 medical record with therapy services ordered out of a total of 32 medical records reviewed (Patient #5).

Findings include:

A record review on Patient #5's open medical record revealed that in the provider orders on 1/10/2020 there was a provider order for physical, occupational, and speech therapy to evaluate and treat. In an interview with Director B on 1/29/2020 at 10:10 AM regarding the therapy evaluations, Director B stated the therapy evaluations were not done. Director B stated that the orders were faxed to therapy but no evaluations were completed as of 1/29/2020.

Based on medical record review and interview, the facility failed to ensure that active treatment measures, such as group and individual treatment, were provided for two (2) of eight (8) active sample patients (A2 and A8) and one non-sample patient added to evaluate active treatment (C1). Specifically, Patients A2, A8, and C1 were unable or unwilling to attend their scheduled treatment groups and failed to have specific therapeutic alternatives listed in their Master Treatment Plans (MTPs). Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to A1650/B125)

Based on medical record review and interview, the facility failed to provide psychosocial assessments that met professional social work standards. These assessments failed to include conclusions and recommendations that described anticipated social work roles in inpatient treatment and discharge planning for six (6) of eight (8) active sample patients (A1, A2, A3, A4, A6, and A8). This failure results in a lack of professional social work treatment services and a lack of input to the treatment team to assist in the care of the patient during hospitalization.

Findings include:

A. Medical Records

1. Patient A1's Psychosocial Evaluation, dated 01/12/2020, listed the following generic non-individualized social work inpatient recommendations for treatment:

"The client will remain on the unit for 3 - 7 days while [s/he] stabilizes thought process and safety. The need for court will be assessed. The client will discharge home and will continue to work with [his/her] outpatient providers. The client is encouraged to follow up with [his/her] PCP [Primary Care Provider] regarding this admission, as to connect with the ADRC [Aging and Disability Resource Center] for in home supports if needed."

2. Patient A2's Psychosocial Evaluation, dated 01/11/2020, failed to include individualized social work recommendations for inpatient treatment and instead listed the following generic recommendations:

"The client will remain on the unit while [sic] for 5 - 7 days for psychiatric stabilization and while the need for court continues to be assessed. The client will return to [his/her] group home and will continue outpatient services with Berlin and BCTC [Brown County Community Treatment Center]. The client and treatment team will work [sic] MCO [Medical Care Organization] Inclusa and the Professional Guardian for all follow up care, needs and appointments."

3. Patient A3's Psychosocial Evaluation dated, 11/01/2019, listed the following generic social work treatment recommendations:

"The client will remain on the unit for further mental health stabilization and safety. The client will discharge back to Morning Glory if possible (However, at this point [his/her] return is questionable). Lakeland and the client's guardian will continue to explore other options for placement. Client will continue to work with [his/her] Care team and outpatient providers and CM [Case Manager] for additional support."

4. Patient A4's Psychosocial Evaluation, dated 01/07/2020, listed the following generalized, non-individualized inpatient treatment recommendation:

"Client will discharge home to a lower level of care if necessary. Client will likely be on a mental health commitment and will continue to work with [his/her] outpatient providers as well as [his/her] newly arranged case manager post discharge."

5. Patient A6's Psychosocial Evaluation, dated 01/11/2020, listed the following generalized, non-individualized inpatient treatment recommendations:

"Client will remain on the unit while [s/he] waits for [his/her] 10-day hearing due to TX [Treatment] condition violations. The client will discharge to [his/her] son's home when [s/he] is stable. Social worker will work with [his/her] case manager to confirm upcoming appointments and discharge plans. Social work will also encourage [him/her] to utilize community resources like NAMI [National Alliance for the Mentally Ill], The Gathering Place and Wellsprings for Women for additional support."

6. Patient A8's Psychosocial Evaluation, dated 01/08/2020, listed the following generalized non-individualized inpatient treatment recommendations:

"The client will remain on the unit for psychiatric stability and safety. The client will remain on the unit for 3-7 days while [his/her] mental health needs continue to be assessed and monitored. The client will return to [his/her] group home with a medication order. The client will need to be discharged to a supervised living situation where [his/her] medication and physical wellbeing can be monitored and attended to."

B. Interview

In an interview on 01/28/2020 at 1:00 p.m., the Director of Social Work concurred with the findings of the lack of individualized treatment recommendations within the reviewed Psychosocial Evaluations.

Based on medical record review and interview, the facility failed to perform and document physical examinations, including a descriptive neurological examination for one (1) of eight (8) active sample patients (A5). The absence of this patient information limits the clinician's ability to diagnose the patient's condition accurately and to provide a measure of baseline functioning, thereby potentially adversely affecting patient care. The incompleteness of the examination has the potential to impair the patient receiving adequate care for primary neurological illnesses or secondary medical and psychiatric problems.

Findings include:

A. Medical Records

1. Patient A5 was admitted on 01/05/2020. The Admission Psychiatric Evaluation, dated 01/05/2020, documented the patient's lack of cooperation, being emotionally distraught, lying in the fetal position, and being none to minimally verbal on admission. His/her admitting diagnoses were "Psychotic disorder, not otherwise specified; History of bipolar disorder, History of post-traumatic stress disorder, History of borderline personality disorder, and History of attention deficit hyperactivity disorder."

2. The Physical Examination, dated 01/05/2020, documented the patient's refusal of most of the required elements of the exam, which were listed as "declined." The following sections, however, were listed as WNL [Within Normal Limits]: "palpation of Bladder, Anus, Perineum, and Rectum, Groin, and Other."

B. Interviews

1. In an interview on 01/29/2020 at 8:45 a.m., NP2 (Nurse Practitioner) concurred with the findings that the physical examination had not been completed since the initial documentation on 01/05/2020. [S/he] indicated there had been difficulties with communication with the part-time NPs and the permanent staff. (S/he) indicated a meeting was planned to make sure there was better communication.

2. In a telephone interview on 01/29/2020 at 9:00 a.m., NP1 indicated that the computer automatically populates WNL unless it is changed manually. NP1 stated the listed WNL on this physical examination probably indicated that deleting WNL was just "missed" and not changed to decline. NP1 said the nursing staff was informed of the inability to complete the examination. She admitted that there was no documentation of that fact.

3. In an interview on 01/29/2020 at 9:30 a.m., the Associate Medical Director concurred that Patient A5's Physical Examination was incomplete and problematic.

Based on medical records review, policy review, and interview, the facility failed to provide Master Treatment Plans (MTPs) that identified patient-related short-term goals (STGs) and long-term goals (LTGs) stated in observable, measurable, behavioral terms or STGs that were related to the patient's problem for five (5) of eight (8) active sampled patients (A1, A3, A4, A5, and A8). This failure hinders the ability of the treatment team to measure the change in the patient as a result of treatment interventions. It may contribute to the failure of the team to modify plans in response to patient needs, as well as to increase patient stays beyond the resolution of the behaviors requiring admission.

Findings include:

A. Record Review

1. Patient A1's MTP, dated 01/26/2020, listed for the Problem, "Ineffective health maintenance," the non-measurable STG goal of, "[Patient] will take prescribed medications and demonstrate administration independence each shift by 1/31/20."

2. Patient A3's MTP, dated 01/27/2020, listed for the Problem, "At risk for violence directed towards self or others," the non-measurable STG of, "[Patient] will verbalize [his/her] needs and process through [his/her] feelings in a clear & concise way without any verbal outbursts when communicating with staff/peers by 1/30/20."

3. Patient A4's MTP, dated 01/27/2020, listed for the Problem, "Altered thought processes," the non-measurable STG of, "[Patient] will use effective communication while discussing concrete things happening in life with an absence of delusions for at least 5 minutes by 2/3/20."

4. Patient A5's MTP, dated 01/27/2020, listed for the Problem, "Ineffective health maintenance," the non-measurable STG of, "[Patient] will verbalize a decrease in racing thoughts by 1/31/20."

5. Patient A8's MTP dated 1/27/20 listed for the Problem, "Altered Thought Processes," the non- measurable STG of, "Patient will report a decrease in frequency and intensity in altered thought process with the aid of medication and nursing interventions by 1/29/20."

B. Policy Review

The facility policy titled, "Treatment Plan, Master Treatment Plan, and Treatment Plan Review," last revised, 03/2018, stated, "Goals should be attainable and measurable."

C. Interviews

1. In an interview on 01/28/2020 at 10:45 a.m., the Director of Nursing agreed that the presented MTP goals were not measurable and, at times, not related to the listed problems.

2. In an interview on 01/28/2020 at 1:00 p.m., the Director of Social Work concurred with the lack of observable, measurable behavioral short-term goals.

Based on medical record review and interview, the hospital failed to develop treatment interventions based on the individual needs of the patients for eight of eight active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Treatment interventions in the Master Treatment Plan (MTP) listed only routine/generic discipline functions rather than individualized treatment options. This practice has the potential to lead to the failure of individualized treatment interventions and to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings include:

A. Record Review

1. Patient A1's MTP, dated 01/26/2020, listed the Short Term Goal (STG), "[Patient] will take prescribed medications and demonstrate administration independence each shift by 1/31/20." The generic nursing interventions for this goal included, "Nursing staff will reorientate [sic] [patient] to time/place/person, as needed," and "Nursing staff will provide adequate supervision of [patient] by maintaining observation as ordered." The generic social work intervention listed for this goal was, "SW [Social Work] will provide [patient] and [his/her] [wife/husband] with a list of community resources such as the ADRC [Aging and Disability Resource Center] for support upon discharge."

2. Patient A2's MTP, dated 01/24/2020, listed the STG, "[Patient] will take prescribed medications each shift by 01/31/2020." The generic nursing intervention for this goal was, "RN [Registered Nurse] will administer risperidone (d/c) [discontinued], Zyprexa Zydis, Invega, Invega Sustenna, and fluoxetine (d/c) as prescribed and monitor for effectiveness, updating MD [Medical Doctor] as needed."

3. Patient A3's MTP, dated 01/27/2020, listed the STG, "[Patient] will verbalize [his/her] needs and process through [his/her] feelings in a clear & concise way without any verbal outbursts when communicating with staff/peers by 1/30/20." The generic nursing intervention for this goal was, "RN will administer Navane [antipsychotic medication] as prescribed (after guardian verbal consent) and assess each shift while awake for any objective s/s [signs/symptoms] of side effects such as EPS [Extrapyramidal Symptoms." For the STG, "[Patient] will be accepting of placement options whether it includes a return to Morning Glory, or other options for placement by 1/30/20," the generic, job responsibility intervention for social work was, "SW will work with [patient], Guardian Stacey, Lakeland worker Chrissy, and CM [Case Manager] Abbie to arrange discharge plans while securing housing for [patient]."

4. Patient A4's MTP, dated 01/27/2020, listed the STG, "[Patient] will allow [his/her] family to be involved in [his/her] treatment by 2/3/20." The generic social work intervention for this goal was, "SW will request [patient] signs [sic] ROIs [Release of Information] for supports in [his/her] life to obtain collateral information." For the STG, "[Patient] will use effective communication while discussing concrete things happening in life with an absence of delusions for at least 5 minutes by 2/3/20," the generic nursing intervention was, "Nursing staff will orient [patient] to time/place/person, as needed."

5. Patent A5's MTP, dated 01/27/2020, listed the STG, "[Patient] will verbalize a decrease in racing thoughts by 1/31/20." The generic nursing intervention for this goal was, "RN will administer Abilify as prescribed and assess each shift while awake for any further c/o [complaint of] racing thoughts or SI [suicidal ideation]."

6. Patient A6's MTP, dated 01/27/2020, listed the STG, "[Patient] will take all prescribed medications each shift they are scheduled by 1/18/20. (GOAL MET as of 01/24/2020, Goal will be continued to 01/31/2020 per SW ]Social worker]." The generic nursing intervention for this goal was, "Nursing staff will monitor [Patient] every 15 minutes and PRN [as needed] due to [Patient] decompensating because [s/he] has not been taking [his/her]medication as prescribed ...."

7. Patient A7's MTP, dated 01/27/2020, listed the STG, "[Patient] will be free of self harm each shift by 1/29/20." The generic nursing intervention for this goal was, "Nursing staff will monitor [Patient] every 15 minutes for the duration of [his/her] stay due to recent past hanging attempts and significant legal issues."

8. Patient A8's MTP, dated 1/27/2020, listed the STG, "Patient will report a decrease in frequency and intensity in altered thought process with the aid of medication and nursing interventions by 1/29/20." The generic nursing intervention for this goal was, "RN will administer psychotropic medications Zyprexa, Ativan, Invega Sustenna as ordered, and report effectiveness to the MD."

B. Interviews

1. In an interview on 01/28/2020 at 10:45 a.m., the Director of Nursing agreed that the nursing interventions presented were generic and not individualized to the patient's needs.

2. In an interview on 01/28/2020 at 1:00 p.m., the Director of Social Work concurred that the presented interventions were not individualized and were generic in nature.

Based on record review, observation, and interview, the facility failed to ensure that active treatment measures, such as group and individual treatment, were provided for two (2) of eight (8) sample patients (A2 and A8) and one non-sample patient added to evaluate active treatment (C1). Specifically, Patients A2, A8, and C1 were unable or unwilling to attend their scheduled treatment groups and failed to have specific therapeutic alternatives listed in their Master Treatment Plans (MTPs). Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement.

Findings include:

I Specific Patient Findings: Patient A2

A. Record Review

1. Patient A2 was admitted on 01/10/2020. The "Initial Psychiatric Evaluation," dated 01/12/2020, stated that the reasons for hospitalization from a group home included, " ...not eating well and not drinking well ...screaming and scratching [his/her] fingers ... [and] decompensating significantly."

2. The Nurses' Progress Notes on admission (01/10/2020) stated that the patient was unable to contribute to the admission process due to "confusion, yelling, and agitation." The note further said that the patient became disruptive in the dayroom and had to be taken to his/her room where s/he picked at finger wounds and rubbed blood on the walls and bed. The patient was placed on 1:1 observation on 01/11/2020 and was still on 1:1 on 01/27/2020.

3. The MTP, updated 01/24/2020, revealed the Short-Term Goal (STG), "[Patient] will demonstrate improved thought processes/controlled moods AEB [As Evidence By] being able to tolerate and attend at least 10 minutes of a functional task (group task, conversation, meal) by 01/31/2020." This goal was set on the initial MTP dated 01/10/2020 and was still not met on 1/24/2020. The goal was not modified except for the target date.

4. Review of "Progress Notes" from 01/10/2020 to 01/27/2020 revealed that Patient A2 remained in his/her room all day with a Certified Nursing Assistant (CNA) assigned as 1:1 staff. The Patient did not attend groups, regularly refused food and medication, and rarely came out of his/her room. The Progress Notes also revealed that Patient A2 either refused, was excused from, or not considered appropriate for 50 groups during this time. Although there were times when a CNA offered a 1:1 interaction with Patient A2 following non-attendance at the "CNA Goals" group, the patient always refused. The only alternatives offered for the other groups were to either give the patient a handout (which s/he regularly refused) or to write "N/A" (Not Applicable) in the "Alternatives" section of the group progress note. Patient A2 was noted to attend three groups during the 01/10/2020 to 01/27/2020 time period. The activities consisted of (1) a leisure group on 01/13/2020 where s/he "rested" and did not participate; (2) a movie on 01/18/2020 where s/he participated "50%", and (3) a televised "Packers" football game where s/he participated "25%."

B. Observations

1. During observations on the unit on 01/27/2020 from 11:15 a.m. to 12:00 p.m., Patient A2 was observed sitting on his/her bed. CNA3 was sitting next to the bed providing 1:1 staff intervention.

2. During observations on the unit on 01/27/2020 from 1:00 p.m. to 2:20 p.m., Patient A2 was observed in his/her room with the door closed. The patient was sitting on the bed, repeating an unintelligible phrase over and over. During this time, two groups were being held on the unit, "Managing Distress Intolerance," and "Leisure Awareness." Patient A2 was not involved in any activity in his/her room.

C. Interviews

1. In an interview on 01/27/2020 at 11:20 a.m., RN2 stated that Patient A2 didn't go to groups and would not stay in the dayroom without screaming and yelling. RN2 reported, "[S/he] likes to stay in [his/her] bedroom."

2. In an interview on 01/27/2020 at 11:45 a.m., CNA3, who was the 1:1 staff member, stated that Patient A2 did not go to groups because s/he was disruptive and did not go out of the room often. When asked how the patient spent his/her day in the room, CNA3 stated that Patient A2, "works with Legos," and likes to play with the colored wooden balls and "chew on her snake," (a plastic Lego-like strip). The CNA also stated that she helped Patient A2 with his/her hygiene, encouraged him/her to eat and talked, "not really about anything."

II. Specific Patient Findings: Patient A8

A. Record Review

1. Patient A8 was admitted on 01/07/2020. The "Initial Psychiatric Evaluation," dated 01/08/2020, stated that the reason for hospitalization was the patient became, "disruptive with the staff where [s/he] was residing and was threatening to kill staff," and "[s/he] said [s/he] would bomb the place." The admitting diagnosis was "history of schizoaffective disorder and also has past history of bipolar disorders with psychosis and dementia."

2. The Psychosocial Evaluation, dated 01/18/2020, documented, "Client had been refusing to take [his/her] prescribed medications and had consequently been deteriorating physically over these past weeks. The Bayshore MD [Doctor's name] felt that [s/he] was at imminent risk of serious harm due to [his/her] refusal to take medications."

3. The MTP, dated 01/07/2020, listed the Problem, "Alteration in thought processes related to multiple comorbidity as evidenced by refusal of medications, delusions, paranoid and harming staff at assisted living by placing staff in chokehold and threating to kill staff." The STG for this problem was "[Patient] will report a decrease in frequency and intensity in altered thought process with the aid of medications and nursing interventions by 1/14/2020."

4. The MTP, updated 01/27/2020, listed the same Problem statement as that of the MTP dated 01/07/2020. The STG was identical with the following addition. "(GOAL NOT MET and continued as of 1/21/2020 per SW as [Patient] denies all altered thoughts, not appearing to have insight into [his/her] mental health status or needs." The patient's Problem and STG did not change on the update.

5. Review of "Progress Notes" from 01/07/2020 until 01/27/2020 revealed that of the 70 groups offered to the patient. S/he attended only seven groups, and those were typically "leisure groups." Progress notes documented either patient refusal or patient being in bed.

B. Observations

1. During an observation on 01/27/2020 at 12:45 p.m., a "Seeking Safety Group" was occurring. Patient A8 was in his/her room rather than in the group.

2. During an observation on 01/28/2020 at 10:30 a.m., Patient A8 was observed in the dayroom and not attending the Social Skills Group. S/he stated to the surveyor, "I don't go to that group."

3. During an observation on 01/28/2020 at 1:50 p.m., Patient A8 was not present in the scheduled group.

C. Interviews

1. In an interview on 01/27/2020 at 11:30 a.m., Patient A8 indicated vehemently to the surveyor that s/he did not attend groups. S/he further stated, "I am smarter than all those people and have heard all that stuff before."

2. In an interview on 01/27/2020 at 12:45 p.m., Social Worker 2 (SW2) indicated that Patient A8 was not going to the group. He stated, "I went around asking clients to go to group. [Patient] is not cognitively appropriate for the group." Upon further questioning, he indicated Patient A8's Social Worker would be informed of Patient A8's non-attendance.

3. In an interview on 01/27/2020 at 1:00 p.m., CNA 1 confirmed that Patient A8 rarely goes to groups and tends to isolate.

III. Specific Patient Findings: Patient C1

A. Record Review

1. Patient C1 was admitted on 01/06/2020. The "Initial Psychiatric Evaluation," dated 01/07/2020, stated that his/her admission was due to eloping from his/her group home after starting a trash can fire and becoming aggressive with a peer.

2. The MTP, dated 01/10/2020, revealed the STG, "[Patient] will engage in 45-60 minute therapeutic group session and complete 100% of a goal directed task independently in order to increase ability to complete tasks successfully by 1/13/20." This goal remained unmet and was repeated on the MTP, updated on 01/27/2020, with a new target date of 02/03/2020. Progress towards the goal stated, "Goal not met per cota [certified occupational therapy assistant] as of 1/27/20, continue through 2/3/20 as one week does not appear to be realistic for [patient] to meet this goal. [Actually, this goal had been on the MTP for 17 days.] [Patient] declines most groups, but when [s/he] does attend, it is for approx [approximately] 5 minutes. [Patient] makes an effort to engage in group discussions but is off topic. [Patient] appears disheveled with greasy, matted

3. Review of "Progress Notes" from 01/19/2020 to 01/27/2020 revealed that Patient C1 had refused 23 of 29 scheduled groups. S/he attended four groups (radio music on 01/19/2020; Packers football televised game on 01/20/2020; Goals group on 01/22/2020 and radio music on 01/22/2020). In addition, Patient C1 partially attended two groups (Arts and Crafts for 10 minutes on 01/20/2020 and movie leisure group with 50% participation on 01/22/2020). The "Progress Notes" documented that Patient C1 was often offered a "handout" when s/he refused group, but there was no documentation that s/he accepted any of those handouts, nor was there evidence that other alternatives were attempted.

B. Observations

1. During observations on the unit on 01/27/2020 from 11:15 a.m. to 12:00 p.m., Patient C1 was observed pacing on the unit, talking to him/herself.

2. During observations on the unit on 01/27/2020 from 1:00 p.m. to 2:20 p.m., Patient C1 was observed pacing in the hallway and dayroom. During this time, two groups were being held on the unit, "Managing Distress Intolerance," and "Leisure Awareness." Patient C1did not attend either group.

C. Interviews

1. In an interview on 01/27/2020 at 11:20 a.m., RN2 stated that Patient C1 rarely attended groups and would most often pace around the unit, constantly moving.

2. In an interview on 01/27/2020 at 11:45 a.m., CNA2 stated that Patient C1 was always moving and did not go to groups.

Based on medical record review and interview, the Medical Director failed to ensure:

I. The performance and documentation of physical examinations for one (1) of eight (8) active sample patients. (A5) The absence of this patient information limits the clinician's ability to diagnose the patient's condition accurately and to provide a measure of baseline functioning, thereby potentially adversely affecting patient care. The incompleteness of the examination has the potential to impair the patient receiving adequate care for primary neurological illnesses or secondary medical and psychiatric problems. (Refer to A1626/B109)

II. All active treatment measures, such as group and individual treatment, were provided for two of eight sample patients (A2 and A8), and one patient added to evaluate active treatment (C1). Specifically, Patients A2, A8, and C1were unable or unwilling to attend their scheduled treatment groups and failed to have specific therapeutic alternatives listed on their Master Treatment Plans (MTPs). Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to A1650/B125)

Interview

In an interview on 01/29/2020 at 9:30 a.m., the Associate Medical Director was informed of the deficiencies found by the surveyors and acknowledged understanding of the presented findings.

Based on record review and interview, the Director of Nursing failed to ensure that the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) contained individualized nursing interventions. The interventions were listed as routine discipline functions rather than individualized treatment options. This practice does not allow the nursing staff and other disciplines to know what the nursing staff should address in the way of individual interventions. It has the potential to result in nursing staff being unable to provide direction, consistent approaches, and focused treatment for patients identified problems.

Findings include:

A. Record Review

1. Patient A1's MTP, dated 01/26/2020, listed the Short Term Goal (STG), "[Patient] will take prescribed medications and demonstrate administration independence each shift by 1/31/20." The generic nursing interventions for this goal included, "Nursing staff will reorientate [sic] [patient] to time/place/person, as needed," and "Nursing staff will provide adequate supervision of [patient] by maintaining observation as ordered."

2. Patient A2's MTP, dated 01/24/2020, listed the STG, "[Patient] will take prescribed medications each shift by 01/31/2020." The generic nursing intervention for this goal was, "RN [Registered Nurse] will administer risperidone (d/c) [discontinued], Zyprexa Zydis, Invega, Invega Sustenna, and fluoxetine (d/c) as prescribed and monitor for effectiveness, updating MD [Medical Doctor] as needed."

3. Patient A3's MTP, dated 01/27/2020, listed the STG, "[Patient] will verbalize [his/her] needs and process through [his/her] feelings in a clear & concise way without any verbal outbursts when communicating with staff/peers by 1/30/20." The generic nursing intervention for this goal was, "RN will administer Navane [antipsychotic medication] as prescribed (after guardian verbal consent) and assess each shift while awake for any objective s/s [signs/symptoms] of side effects such as EPS [Extrapyramidal Symptoms]."

4. Patient A4's MTP, dated 01/27/2020, listed the STG, "[Patient] will use effective communication while discussing concrete things happening in life with an absence of delusions for at least 5 minutes by 2/3/20." The generic nursing intervention was, "Nursing staff will orient [patient] to time/place/person, as needed."

5. Patent A5's MTP, dated 01/27/2020, listed the STG, "[Patient] will verbalize a decrease in racing thoughts by 1/31/20." The generic nursing intervention for this goal was, "RN will administer Abilify as prescribed and assess each shift while awake for any further c/o [complaint of] racing thoughts or SI [suicidal ideation]."

6. Patient A6's MTP, dated 01/27/2020, listed the STG, "[Patient] will take all prescribed medications each shift they are scheduled by 1/18/20. (GOAL MET as of 01/24/2020, Goal will be continued to 01/31/2020 per SW ]Social worker]." The generic nursing intervention for this goal was, "Nursing staff will monitor [Patient] every 15 minutes and PRN [as needed] due to [Patient] decompensating because [s/he] has not been taking [his/her]medication as prescribed ...."

7. Patient A7's MTP, dated 01/27/2020, listed the STG, "[Patient] will be free of self harm each shift by 1/29/20." The generic nursing intervention for this goal was, "Nursing staff will monitor [Patient] every 15 minutes for the duration of [his/her] stay due to recent past hanging attempts and significant legal issues."

8. Patient A8's MTP 1/27/2020 listed the STG, "Patient will report a decrease in frequency and intensity in altered thought process with the aid of medication and nursing interventions by 1/29/20." The generic nursing intervention for this goal was, "RN will administer psychotropic medications Zyprexa, Ativan, Invega Sustenna as ordered, and report effectiveness to the MD."

B. Interview

In an interview on 01/28/2020 at 10:45 a.m., the Director of Nursing agreed that the nursing interventions presented were generic and not individualized to the patient's needs.