HospitalInspections.org

A. Based on document review and interview it was determined that for 2 of 2 (Pt #3 and Pt #25) clinical records reviewed of patients receiving electroconvulsive therapy (ECT), the Hospital failed to ensure that the patients were fully informed of the procedure.

Findings include:

1. The Hospital's policy entitled, "LOH-(Linden Oaks Hospital)-Clin 030 Electroconvulsive Therapy (ECT) dated 01/18/2018, indicated, "...E. The consulting ECT physician completes the ECT Consent Form indicating the number of treatments ordered..."

2. The Hospital's policy entitled, "Clin-198: Informed Consent," dated 01/15/2018, indicated, "Procedure...A. Patients have the right to make informed decision regarding their care...C. The provider who intends to perform a procedure or initiate treatment requiring informed consent discusses the risks, benefits and alternatives to treatment with the patient..."

3. The clinical record of Pt #3 was reviewed on 04/24/2018, at approximately 11:15 AM. Pt #3 was a 28 year old female, who was admitted on 04/16/2018, with a diagnosis of depression. Pt #3's clinical record contained a physician's order, dated 04/23/2018, that required Pt #3 receive ECT. The clinical record contained an informed consent for ECT, dated 04/23/2018, that failed to include: the name of the physician; the number of treatments, that was going to perform the ECT; the number of treatments to be administered; who explained the effect, nature of the treatment, and possible alternative methods of treatment.

4. During an interview on 4/25/2018, at approximately 10:50 AM, the Performance Improvement Coordinator (E #7) stated, "The consent is completed by the Hospital and does not belong to us (Linden Oaks). The consent should have been completed."

5. On 04/25/2018, at approximately 2:30 PM, the Hospital presented an agreement entitled, "Agreement For Ancillary Services between (Hospital #2) and Linden Oaks Hospital" (undated), that required, "...F. Electroconvulsive Therapy...2. Procedure...LINDEN OAKS patients must come to the (Hospital #2) with a complete medical record and consent while accompanied by a LINDEN OAKS employee."

6. The clinical record of Pt #25 was reviewed on 04/26/2018, at approximately 9:45 AM. Pt #25 was a 77 year old female, who was admitted on 01/09/2018, with a diagnosis of psychosis. Pt #25's clinical record contained a physician's order dated 01/15/2018, that required Pt #25 receive ECT. The clinical record contained an informed consent for ECT, dated 01/15/2018, that failed to include the name of the physician that was going to perform the ECT and the number of treatments to be administered.

7. On 04/26/2018 at approximately 10:25 AM, the Clinical Lead (E #1) stated, "Yes, the informed consent is incomplete like as we discussed earlier."


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B. Based on document review, and interview it was determined that for 1 of 3 (Pt. #20) clinical records reviewed, the Hospital failed to ensure informed consent was obtained prior to administering a psychotropic medication.

Findings include;

1. The clinical record of Pt. #20 was reviewed on 4/24/18. Pt. #20 was a 92 year old female, who was admitted on 4/15/18, with a diagnosis of dementia. The clinical record included an order dated 4/19/18, for Haldol (anti psychotic medication) 2 mg IM (intramuscularly), every 6 hours, PRN (as needed). Pt. #20 was given Haldol 2 mg injection IM on 4/19/18, at approximately 2:36 PM and 4/21/18, at approximately 5:47 PM. The clinical record did not contain an informed consent authorizing administration of the anti-psychotic medication.

2. The Hospital's policy titled, "LOH-CLIN 108 Informed Consent For Psychotropic Medication" (revised 11/14/17) required, "It is the policy of ...all psychotropic medications are administered after informed consent has been obtained ..."

3. The above findings were discussed with the Registered Nurse (E #8), during an interview on 4/24/18, at approximately 11:00 AM. E #8 stated, "We normally obtain an informed consent before we administer psychotropics. If they have a power of attorney, we get a verbal with two witnesses."

A. Based on document review and interview, it was determined that for 1 of 4 (Pt #1) clinical records reviewed on the A1-East Unit and 1 of 4 (Pt #2) clinical records reviewed on the Adolescent Unit, the Hospital failed to ensure that all patients were monitored, as required.

Findings include:

1. The Hospital's policy entitled, "LOH-(Linden Oaks Hospital)-Clin 141 Safety Checks," (dated 07/11/17) required, "Policy Statement...All patients have an initial safety check upon admission..."

2. The Hospital's policy entitled, "LOH-Clin 078 Behavioral Precautions, " (dated 08/17/2017) required, "...K. Suicide Precautions ("S) - Used when patient at risk for suicide...3. Patients on Suicide Precautions are observed every 15 minutes...O. Assault Precautions ("A") - Used when patient has a history of and/or is threatening physical harm to others."

3. The clinical record of Pt #1 was reviewed on 04/24/2018, at approximately 10:30 AM. Pt #1 was a 22 year old female who was admitted on 04/20/2018, with a diagnosis of bipolar disorder. Pt #1's clinical record contained an "Admission Summary Note," dated 04/21/2018, at 2:38 AM, that included, "...Patient placed on S (suicide) precautions and monitored for safety." Pt #1's clinical record contained a "Precautions Record, " dated 04/20/2018, that included Pt #1 was on suicide precautions. The record indicated that from 11:00 PM to 11:45 PM, Pt #1 was not monitored every fifteen (15) minutes, as required.


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4. On 4/24/2018, at approximately 10:30 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 14 year old female who was admitted on 4/20/18, due to depression. The clinical record of Pt. #2 indicated, "... Pt. (patient) has been aggressive... attempting to attack her mother..." Pt. #2's clinical record included a physician's order for assault precautions dated 4/20/18. However, the safety precautions sheet (every 15 minute checks) did not indicate that Pt. #2 was placed on assault precautions on 4/21/18.

5. The Clinical Leader (E #1) of the A1 East and West Units stated during an interview on 04/24/2018, at approximately 10:40 AM, "The patient should have been monitored every 15 minutes as required."

6. On 4/24/18, at approximately 11:00 AM, an interview was conducted with E # 2 (Registered Nurse). E #2 stated that the assault precaution order should have been marked on the safety precautions sheet, to indicate that the patient was monitored every 15 minutes.


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B. Based on observation and interview, it was determined that for 2 of 7 units (Generations/Geriatrics and A-1 West Adult), the Hospital failed to ensure plastic trash liners were not accessible to patients.

Findings include:

1. During an observational tour of the Generation/Geriatric Unit conducted on 4/24/18, at approximately 9:50 AM. A housekeeping staff (E #4) entered the unit with a cart that had 2 plastic trash bags hanging on the cart handle. E #4 parked the cart by the lounge/dining area, where 2 patients were eating their breakfast and one patient was walking down the hallway. E #4 swept the lounge floor and was approximately 15 feet away from the cart with her back to the cart. E #4 then went into the nursing station and entered to sweep, leaving the cart unattended, and no longer visible to E #4. However the cart was accessible to the patients on the unit.

2. The Generations/Geriatric Unit census was reviewed on 4/24/18, at approximately 9:50 AM. The census included 6 patients who were on suicide behavioral precautions.

3. The Manager of Social Services (E #5) was interviewed on 4/24/18, at approximately 10:00 AM. E #5 stated that paper is used for the patient's trash bin, and deferred the question regarding use of plastic bag on the housekeeping cart to the housekeeping supervisor.

4. During a tour of the A1 West Unit on 4/24/18, at approximately 10:30 AM, a plastic bag was located in the locked trash can, in the patient lounge. There was an approximate 10 inch opening in the top, allowing easy access to the bag.

5. The Housekeeping Supervisor (E #6) was interviewed on 4/25/18, at approximately 10:45 AM. E #6 stated that there is no written policy about the use of plastic liner bags to collect trash in the units. E #6 stated that plastic can be used on the housekeeping cart, but the cart cannot be left unattended, and must be in full view at all times. E #6 stated that the plastic lined trash bins in the lounges are locked and have been in use for a number of years.

6. The Performance Improvement Coordinator (E #7) was interviewed on 4/26/18, at approximately 9:05 AM. E #7 stated the Hospital has no policy that addresses the use of plastic garbage liners in the unit. However, E #7 stated that it is the practice of the Hospital not to use plastic liners.

Based on document review and interview, it was determined that for 3 of 3 Behavior Health units (Chemical Dependency Unit, Eating Disorder Unit and Adult Unit-A1East), reviewed for narcotic counts, the Hospital failed to ensure that narcotic counts were completed every 24 hours as required, and failed to ensure that the controlled substance records were signed by a manager.

Findings include:

1. On 4/24/18, at approximately 1:00 PM, the Hospital's policy titled, "Narcotic and Controlled Drugs" (revised 3/14/17) was reviewed. The policy included "...Narcotic counts are completed as designated by unit protocol - at the minimum once every 24 hours..."

2. On 4/24/18, at approximately 10:00 AM, the Controlled Substances Inventory Records on the Chemical Dependency Unit were reviewed for 3/2018 thru 4/2018. The Controlled Substance Inventory Records lacked documentation of a controlled substance inventory count as required on: 3/5/2018, 3/8/2018, 3/13/2018, 3/16/2018, 3/28/2018, 4/3/2018, 4/10/2018, 4/13/2018, 4/15/2018 and 4/18/2018. The Controlled Substance Inventory Records contained a line at the bottom of the form, that required a signature of a manager. However, for 3/2018 and 4/2018 the records were not signed by a manager.

3. On 4/24/18 at approximately 10:15 AM, the Controlled Substances Inventory Records on the Eating Disorder Unit were reviewed for 3/2018 and 4/2018. There was no documentation for the Controlled Substances Inventory Records on the following dates: 3/5/2018, 3/10/2018, 3/13/18, 3/15/18, 3/26/18, 3/30/18, 4/18/18 and 4/21/18. The Controlled Substances Inventory Records, contained a line at the bottom of the form, that required a signature of a manager. However, for 3/2018 and 4/2018, the records were not signed by a manager.

4. On 4/24/18, at approximately 11:00 AM, the Controlled Substances Inventory Record on the Adult Unit-A1East were reviewed for 3/2018 and 4/2018. There was no documentation for the Controlled Substances Inventory Records on the following dates: 3/1/2018, 4/1/2018, and 4/16/2018. The Controlled Substance Inventory Records contained a line at the bottom of the form, that required a signature of a manager. However, for 3/2018 and 4/2018 were not signed by a manager.

5. On 4/24/18, at approximately 10:10 AM, an interview was conducted with the Charge Nurse (E #3). E #3 stated that the Controlled Substance Inventory Record should be completed and documented every 24 hours. E #3 stated that the manager should sign the controlled substance inventory record.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on April 24 & 25, 2018, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Sample Validation Survey conducted on April 24 & 25, 2018, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated April 25, 2017.

I. Based on observation, interview, record review and policy review, the facility failed to ensure that Master Treatment Plans (MTPs) were sufficiently individualized and updated to ensure staff had developed appropriate problem statements, goals and treatment modalities to meet the needs of active sample patients:

A. For 11 of 11 active sample patients (A3, A17, A20, B1, B6, B10, C1, D6, D11, E1, and F4), the facility failed to develop and document comprehensive and individualized MTPs based on individual patient needs. This lack of the use of patient needs on MTPs results in the potential to compromise patients' opportunity to receive appropriate treatment measures. (Refer to B118 for details).

B. For 11 of 11 active sample patients (A3, A17, A20, B1, B6, B10, C1, D6, D11, E1, and F4), The facility failed to develop and document comprehensive and individualized MTPs based on individual patient strengths. The lack of the incorporation of patient strengths into the MTPs results in the potential to compromise patients' opportunity to receive appropriate treatment. (Refer to B119 for details).

C. For eight (8) of 11 active sample patients (A17, A20, B1, B6, B10, C1, D11, and F4), the facility failed to ensure that MTPs consistently included specific long and short-term goals written in language understandable to patients and free of psychiatric jargon. This failure could prevent the development of specific interventions to assist in reaching treatment goals in a timely fashion thereby resulting in prolonged hospital stays. (Refer to B121 for details).

D. For nine (9) of 11 active sample patients (A3, A17, A20, B6, B10, C1, D6, D11, and F4), the facility failed to ensure that MTPs consistently included individualized active treatment interventions that stated specific modalities with a frequency of contact and a specific focus or purpose of treatment. Instead, MTPs included routine discipline's functions such as "assessing," "monitoring," "encouraging," and "documenting" or instructions to staff that were written as active treatment interventions. These deficiencies result in treatment plans that fail to reflect a comprehensive, integrated, individualized approach to interdisciplinary treatment. (Refer to B122 for details).

E. For seven (7) of 11 active sample patients (A3, A17, B1, B6, B10, D6, and F4), the facility failed to specify separate psychiatrist and registered nurse responsibility for interventions identified on the MTPs. This failure leads to confusion of the responsibility of each discipline and can result in substandard care. (Refer to B123 for details).

II. Ensure that registered nurses, behavioral health associates, and clinical therapists/social work staff documented active treatment interventions identified on the Master Treatment Plan and unit schedules were held as planned. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124).

III. Based on record review and interview, the facility failed to provide complete discharge summaries for one (1) of five (5) sample patients (G4). This failure has the potential in delaying continuity of appropriate care post hospitalization. (Refer to B133 for details).

Based on record review and interview, the facility failed to ensure that psychosocial assessments included treatment plan recommendations for 10 of 11 sample patients (A3, A17, A20, B1, B6, B10, C1, D6, D11, and F4). This failure has the potential of prolonging hospitalization.

Findings include:

A. Record review

1. Patient A3's psychosocial assessment, dated 4/9/18, did not contain treatment plan recommendations.

2. Patient A17's psychosocial assessment, dated 4/20/18, did not contain treatment plan recommendations.

3. Patient A20's psychosocial assessment, dated 3/16/18, did not contain treatment plan recommendations.

4. Patient B1's psychosocial assessment, dated 4/16/18, did not contain treatment plan recommendations.

5. Patient B6's psychosocial assessment, dated 4/21/18, did not contain treatment plan recommendations.

6. Patient B10's psychosocial assessment, dated 4/23/18, did not contain treatment plan recommendations.

7. Patient C1's psychosocial assessment, dated 4/23/18, did not contain treatment plan recommendations.

8. Patient D6's psychosocial assessment, dated 4/11/18, did not contain treatment plan recommendations.

9. Patient D11's psychosocial assessment, dated 4/20/18, did not contain treatment plan recommendations.

10. Patient F4's psychosocial assessment, dated 3/30/18, did not contain treatment plan recommendations.

B. Interview

In an interview on 4/25/18 at 1:46 p.m. with the Director of Social Work, the findings were confirmed.

Based on record review and interview, the facility failed to develop and document comprehensive Master Treatment Plans (MTPs) based on individual patient needs. Specifically, the facility failed to:

I. Include strengths for 11 of 11 active sample patients (A3, A17, A20, B1, B6, B10, C1, D6, D11, E1, and F4). Failure to identify and incorporate patient strengths in the Master Treatment Plan diminishes the effectiveness of treatment interventions and can hamper the patient's achievement of treatment goals. (Refer to B119).

II. Include individualized short-term goals (called objectives by this facility) which stated what the patient would do to lessen the severity of the problems identified for eight (8) of 11 active sample patients (A17, A20, B1, B6, B10, C1, D11, and F4). Failure to identify individualized goals potentially hampers the treatment team's ability to determine whether the treatment plan is effective or needs to be revised. (Refer to B121).

III. Include individualized and specific treatment modalities/interventions to assist patients to achieve treatment goals or improve presenting symptoms for nine (9) of 11 active sample patients (A3, A17, A20, B6, B10, C1, D6, D11, and F4). These failures may potentially result in inconsistent or ineffective treatment. (Refer to B122)

IV. Ensure that interventions assigned to the physicians and registered nurses were delineated to show which discipline would be responsible for each intervention listed on the Master Treatment Plans (MTPs) for seven (7) of 11 active sample patients (A3, A17, A20, B1, B10, D6, and F4). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities. (Refer to B123)

V. Ensure that the attending physician reviewed and approved the Master Treatment plans (MTPs) of 10 of 11 active sample patients (A3, A17, A20, B1, B10, C1, D6, D11, E1, and F4). This deficiency results in the failure to show that active treatment outlined on the MTPs involved all members of the team and is coordinated and directed by the attending physician, potentially resulting in patient's treatment needs not being addressed in the MTPs.

Findings include:

A. Record Review and Interviews

A review of the MTPs in the facility's electronic record revealed that there were no signatures to authenticate who attended the treatment team meetings to formulate to the MTPs. There was no systematic way to determine if the MTPs were finalized in 72 hours and based on all clinical assessments per facility policy or reviewed by the attending physician. During an interview on 4/25/18 at 8:40 a.m. with the Adult Services Manager and Adolescent Unit Manager, the treatment planning process was discussed. They reported that the plan was initiated on admission by the RN and this was the date on the MTPs and noted the clinical therapists served as coordinators of the MTP. They admitted that there were no electronic signatures to authenticate that the treatment plan was completed within 72 hours of admission per hospital policy. Also, there were no authenticate signatures to show who attended the treatment team meetings to the formulate or finalize the treatment plan. The Adult Services Manager noted that there was a section on the electronic record for attending psychiatrists to verify that they had reviewed the MTPs. However, on 4/26/18 at 1:25 p.m., she admitted that only one (1) of the active sample patients had this verification.

B. Policy Review

The facility's policy titled, "LOH-CLIN 044 Interdisciplinary Care Plan" stipulated that "A working Care Plan is established within 72 hours after a patient is admitted to an acute unit... The plan is based on completed assessments from the multidisciplinary team ... Each plan is developed and implemented under the direction of the attending psychiatrist." The facility failed to show authenticated evidence to show that the plan was developed under the direction of the attending psychiatrist.

Based on record review, and interview, the facility failed to ensure that Master Treatment Plans (MTPs) included and was based on an inventory of strengths and disabilities for 11 of 11 active sample patients (A3, A17, A20, B1, B6, B10, C1, D6, D11, E1, and F4). These failures can lead to prolonged hospitalization and result in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems.

Findings include:

A. Record Review

1. Patient A3's MTP, dated 4/10/18, did not address patient strengths.

2. Patient A17's MTP, dated 4/20/18, did not address patient strengths.

3. Patient A20's MTP, dated 3/16/18 did not address patient strengths.

4. Patient B1's MTP, dated 4/18/18, did not address patient strengths.

5. Patient B10's MTP, dated 4/24/18, did not address patient strengths.

6. Patient C1's MTP, dated 4/20/18, did not address patient strengths.

7. Patient D6's MTP, dated 4/19/18, did not address patient strengths.

8. Patient D11's MTP, dated 4/25/18, did not address patient strengths.

9. Patient E1's MTP, dated 4/23/18, did not address patient strengths.

10. Patient F4's MTP, dated 3/30/18, did not address patient strengths.

B. Interview

In an interview on 4/26/18 at 1:25 p.m., the Adult Services Manager acknowledged that an inventory of strengths was not included in the treatment plans of the active sample patients.

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) included specific long and short-term goals (referred to as objectives in this facility) written in language understandable to patients and free of psychiatric jargon for eight (8) of 11 active sample patients (A17, A20, B1, B6, B10, C1, D11, and F4). This failure could prevent the development of specific interventions to assist in reaching treatment goals in a timely fashion thereby resulting in prolonged hospital stays.

Findings include:

A. Record review

1. Patient A17's MTP, dated 4/20/18, had an objective [short-term goal], "[Patient's name] will attend clinical process group at least one (1) Dialectical Behavioral Therapy ..." This objective was the staff's expectations for the patient to comply with the treatment program not a patient outcome regarding what the patient will be saying or doing to improve the unique patient symptoms associated with suicidal ideations.

2. Patient A20's MTP, dated 3/16/18, had an objective [short-term goal], "Pt [Patient] will comply with treatment plan, exhibit decrease in symptoms of mania." This objective was a treatment compliance statement and not a patient outcome regarding what the patient will be saying or doing to improve the unique patient symptoms of mania.

3. Patient B1's MTP, dated 4/18/18, had an objective [short-term goal], " ...Power of Attorney will be notified of medication (s) as prescribed and provided education."

4. Patient B6's MTP, dated 4/19/18, had objectives [short-term goals], " ...will report a decrease in paranoid thinking in three days." " ...will be able to freely discuss his somatic ideation with clinical therapist and unit staff in five days."

5. Patient B10's MTP, dated 4/24/18, had an objective [short-term goal], " ...will verbalize improved daily functioning as evidenced by her actively participating in skills groups to teach distress tolerance and emotional regulation by day 4."

6. Patient C1's MTP, dated 4/20/18, had an objective [short-term goal], " ...will be able to communicate with a rate of speech that is slower and less pressured by urgency with family/friends for support and obtain their feedback to aid in recovery."

7. Patient D11's MTP, dated 4/25/18, had an objective [short-term goal], "[Patient's name] will take medications as prescribed and report any side effect to nurse and/or Dr which will be evaluated on day one." This objective was a treatment compliance statement and not a patient outcome regarding what the patient will be saying or doing to improve the unique patient symptoms associated with suicidal behavior.

8. Patient F4's MTP, dated 3/30/18, had an objective [short-term goal], " ...will identify a minimum of one goal related to reducing her anxiety as measured by her collaborating with her treatment team on this goal and objectives in order to achieve that."

B. Interviews

1. In an interview on 4/25/18 at 1:46 p.m. with the Director of Social Work, the findings were confirmed.

2. In an interview on 4/25/18 at 1:00 p.m. with the Medical Director, the findings were confirmed.

Based on record review, and interview, the facility failed to ensure that Master Treatment Plans (MTPs) consistently included individualized active treatment interventions that stated specific modalities with a frequency of contact and a specific focus or purpose of treatment for nine (9) of 11 active sample patients (A3, A17, A20, B6, B10, C1, D6, D11, and F4). Instead, MTPs included routine discipline's functions such as "assessing," "monitoring," "encouraging," and "documenting" or staff instructions that were written as active treatment interventions. These intervention statements were not related to each patient's individual psychiatric problems and failed to show what would be done by clinical disciplines to assist and involve patients in their recovery. Failure to include specific and planned active treatment interventions reflecting contact with each patient to provide clinical information and active psychiatric treatment potentially results in inconsistent and/or ineffective active treatment.

Findings include:

A. Record Review

A review of medical records revealed that interventions on MTPs assigned to the psychiatrist (MD), clinical therapist (CT), and registered nurse (RN) contained the following generic and routine discipline functions written as active treatment interventions instead of individualized specific active treatment interventions to assist patients to replace problem behaviors and to improve, reduce, and/or eliminate, presenting psychiatric symptoms. In addition, many intervention statements were identical or similarly worded despite different presenting symptoms and needs of each patient.

1. Patient A3's MTP, dated 4/10/18, contained the following generic statements and discipline functions for the problem, "Risk for Suicide ..."

MD Interventions: "Psychiatrist will meet with [Patient's name] 1 x daily to monitor and work with [him/her] on medications to stabilize [his/her] anxiety and mood symptoms." These intervention statements were non-specific, routine MD functions, did not relate to the patient's unique psychiatric problems or needs, and failed to identify the particular medication to be used.

RN Interventions - "Registered nurse ... will monitor for safety at least 1x daily. [Patient's name] will receive mediations per [MD's name] orders at least 1 x daily. These intervention statements were normal and routine nursing functions and would be performed as a part of regular job duties.

2. Patient A17's MTP, dated 4/10/18, contained the following generic statements and discipline functions for the problem, "Risk for Suicide ..."

MD & RN Interventions - "Nurse will meet with [Patient's name] 1 x daily to monitor/assess how [Patient's name] is responding to [his/her] medications and any side effects." These intervention statements were normal and routine nursing functions and would be performed as a part of regular job duties.

3. Patient A20's MTP, dated 3/16/18, contained the following generic statements and discipline functions for the problem, "Mania ..."

MD Interventions: "[Patient's name] to be evaluated by a psychiatrist daily and assessed regarding safety medication and ability to care for self." These intervention statements were non-specific, routine MD functions, did not relate to the patient's unique psychiatric problems or needs, and failed to identify the particular medication to be used.

RN Interventions - " ... Encourage to verbalize thoughts for processing in groups." Encourage to utilize individual therapy and family session towards discharge planning." These intervention statements regarding encouraging the patient were routine tasks performed by any discipline. There were no intervention statements regarding assisting the patient to manage symptoms of mania in individual or group sessions.

4. Patient B6's MTP, dated 4/19/18, contained the following generic statements and discipline functions for the problem, "Psychosis/Inability to Care for Self" and a goal description "to get out of the hospital and go home."

MD Intervention: "Medical Doctor to meet with [patient] daily to assess for benefits of medication and potential side effects."

Clinical Therapist intervention: "Clinical Therapist (CT) to meet with [patient] for individual session daily to identify a daily goal and what is needed to help [patient] meet this goal.

RN Interventions - "Registered Nurse to administer medication to [patient] as prescribed and assess for side effects." These intervention statements were routine nursing functions and would be performed as a part of regular nursing job duties. There were no active treatment interventions included that reflected planned contact to assist this patient to improve, reduce, and/or understand the identified psychiatric problems.

5. Patient B10's MTP, dated 4/24/18, contained the following generic statements and discipline functions for the problem, "Risk for Suicide."

MD Interventions: "Psychiatrist will meet with [patient] 1x [time] daily to evaluate her medications for effectiveness and adjust dosage as appropriate and provide feedback to the treatment for level of care to the treatment team." There was no focus for the supportive therapy to be offered, or specific medications noted. The intervention statement regarding checking medications for safety, efficacy, and side effects was a routine MD function.

RN Interventions - "Nurse meet daily with [patient] to provided [sic] medication as prescribed, assess for effectives/reactions to medications changes, and provided medication education to patient as needed." These intervention statements were normal and routine nursing functions and would be performed as a part of regular nursing job duties. There were no nursing interventions developed for this patient's MTP reflecting planned contacts with the patient to assist him or her with the identified psychiatric problems.

Therapist - "Expressive Therapist (ET) will facilitate groups 3-4 times per week to teach [patient] grounding skills when feeling emotionally overwhelmed and having delusional thoughts and feelings." This intervention statement did not identify a specific frequency of contact, which coping skills based on assessed needs would be the focus of the intervention.

6. Patient C1's MTP, dated 4/20/18, contained the following generic statements and discipline functions for the problem, "Psychosis/Inability to Care for Self."

MD Interventions: " ...will meet with [patient] one time daily to complete psychiatric evaluation, review medication effectiveness and prescribe medications as required. This intervention was a routine MD function, did not identify medications, or have any specific focus to assist the patient with his or her identified psychiatric problems such as providing information about medications (side effects, benefits, etc.) and/or assisting this patient to manage psychiatric symptoms.

RN Interventions - "Registered nurse will meet [patient] daily to provide medication education and administer medication." These intervention statements were normal and routine nursing functions and would be performed as a part of regular nursing job duties. There were no active treatment interventions focusing on assisting the patient to improve and/or reduce the identified psychiatric problems.

7. Patient D6's MTP, dated 4/19/18, contained the following generic statements and discipline functions for the problem, "Risk for Suicide ..."

MD Interventions: "MD to meet with [Patient's name] daily to assess for medications and monitoring psychiatric symptoms." These intervention statements were routine MD functions, did not related to the patient's unique psychiatric problems or needs, and failed to identify the particular medication to be used.

RN Interventions - There were no RN interventions the psychiatric problem identified.

8. Patient D11's MTP, dated 4/25/18, contained the following generic statements and discipline functions for problem, "Risk for Suicide ..."

MD Interventions: "MD will assess for safety and determine the need for psychotropic medications daily." This intervention statement were routine MD job duties and did not relate to the patient's unique psychiatric problems or needs.

RN Interventions - "Registered nurse ... will monitor for safety at least 1x daily. [Patient's name] will receive mediations per [MD's name] orders at least 1 x daily. These intervention statements were normal and routine nursing functions and would be performed as a part of regular job duties.

9. Patient F4's MTP, dated 3/30/18, contained the following generic statements and discipline functions for the problem, "Anxiety, Panic, OCD. [Obsessive Compulsive Disorder]."

MD Interventions: "Attending psychiatrist will meet with [patient] individually daily in order to assess her anxiety and the effectiveness of her medications. This intervention was a routine MD function, did not identify medications, or have any specific focus to assist the patient with his or her identified psychiatric problems such as providing information about medications (compliance, side effects, benefits, etc.) and/or assisting this patient to manage psychiatric symptoms.

RN Interventions - "RN will administer medications as prescribed and monitor for side effects. RN will provide education on the purpose and importance of medication. These intervention statements were normal and routine nursing functions and would be performed as a part of regular nursing job duties. There were no active treatment interventions focusing on assisting the patient to improve and/or reduce the identified psychiatric problems. In addition, these interventions included no delivery method or frequency of contact.

B. Interviews

1. In an interview on 4/25/18 at 1:00 p.m. with the Medical Director, the findings were confirmed.

2. During an interview with the Director of Social Work on 4/25/18 at 1:00 p.m. the findings were not refuted.

Based on record review and the staff Interview, the facility failed to ensure that interventions assigned to the physicians and registered nurses were delineated to show which discipline would be responsible for the interventions listed on the Master Treatment Plans (MTPs) for seven (7) of 11 active sample patients (A3, A17, B1, B6, B10, D6, and F4). This practice results in the facility's inability to monitor staff accountability for specific active treatment interventions.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates signed by the patient in parentheses): A3 (4/10/18); A17 (4/20/18), A20 (3/16/18); B1 (4/18/18); B10 (4/24/18); C1 (4/20/18); D6 (4/18/18); D11 (4/25/18); and F4 (4/30/18). This review revealed the responsibility for the following interventions were assigned to both the physician and registered nurse and no individual staff name was listed on the plan as responsible for implementing particular interventions.

1. Patient A3 - For the problem of, "Risk for Suicide ...," the interventions were, "Nurse will Administer medication as ordered by doctor. Provide medication education to patient."

2. Patient A17 - For the problem of, "Risk for Suicide ...," the interventions were, "Registered nurse and/or behavioral health associate (BHA) will monitor for safety at least 1x daily. [Patient's name] will receive medications per [MD's name] orders at least 1x daily."

3. Patient B1 - For the problem of, "History of Hypertension, MI, CAD and glaucoma," the interventions included, "Administer medications and treatments as ordered. Monitor for and notify/LIP of changes as needed. VS BID."

4. Patient B6 - For the problem of, " ... pt. [patient] had a single seizure 4-5 yrs. Ago," the interventions were, "Administer medications and treatments as ordered. Monitor for and notify/LIP of changes as needed. Institute seizure precautions and monitor per unit protocol."

5. Patient B10 - For the problem of, "UTI, Respiratory infection and had Breast Cancer," the interventions were, "Administer medications and treatments as ordered. Monitor for and notify/LIP of changes as needed. Monitor for UTI symptoms; dysuria, polyuria.

6. Patient D6 - For the problem of, "History of Hypercholesterolemia ... obesity ... Ovarian cyst ...," the interventions were, "Administer medications and treatments as ordered. Monitor for and notify/LIP of changes as needed. Educate PT [patient] about healthy nutrition options."

7. Patient F4 - For the problem of, "Cardiovascular, as evidenced by eating disorder behavior ...," the interventions were, "Monitor vital signs and trend daily for three days, then daily and as needed for concerns of cardiac output. Assess skin color and temperature daily."

B. Interviews

1. In an interview on 4/26/18 at 2:40 p.m., MTPs were discussed. The Director of Nursing (DON) did not dispute the findings.

2. In an interview on 4/25/18 at 1:00 pm, the Medical Director did not refute the findings.

Based on record review, observation, and interview, the facility failed to ensure that registered nurses, behavioral health associates, and clinical therapists/social work staff documented active treatment interventions on the Master Treatment Plan and unit schedules. There was no or limited documentation to show detailed and comprehensive information about active treatment provided for 10 of 11 active sample patients (A3, A17, A20, B1, B10, C1, D6, D11, and F4). Specifically, documentation did not consistently include the patients' attendance or non-attendance in planned and scheduled active treatment sessions, and specific topics discussed during sessions. Also, the notes did not consistently report the patients' response to interventions, including the level of participation, understanding of the information provided, behavior during interventions, and specific patients' comments if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates signed by the patient in parentheses): A1 (XXX), A3 (4/10/18); A17 (4/20/18), A20 (3/16/18); B1 (4/18/18); B10 (4/24/18); C1 (4/20/18); D6 (4/18/18); D11 (4/25/18); and F4 (4/30/18). This review revealed the following findings regarding the planned and assigned treatment interventions for registered nurses (RN), behavioral health associates (BHAs, and clinical therapists (SW), and rehabilitation therapists (AT).

1. Registered Nurse Intervention:

a. The MTPs of six (6) active sample patients (A3, A20, B1, B10, C1, and F4) had interventions included patient education interventions regarding medication such as: " ... Provide medication education to patient." " ...Educated [sic] on medications, indications and interactions." " ...provide education on the purpose and importance of medication."

b. Notes from the electronic medical record from 4/10/18 through 4/24/18 were reviewed and revealed that there were limited or no treatment notes reflecting that the RN provided education regarding these assigned interventions. There was no documented evidence that included the actual name(s) of medications discussed and the patient's response that provided evidence that the patient understood the information provided, level of participation, behaviors exhibited during sessions and any specific comments if any.

c. During an observation on 4/25/18 at 9:45 a.m., a "Healthy Living Group" was held in the group room with active sample patient D11 and eight (8) other non-sample patients attending. A review of the medical record from 4/19/18 through 4/25/18 showed no treatment notes regarding this group was documented for patient D11 or any of the active sample patients. During an interview at 10:00 a.m. after the group with RN1, documentation of group sessions was discussed. RN1 reported, "There is no requirement to document the group sessions." She noted that only "BIRP [Behavior, Intervention, Response, Plan] Notes" were required for her assigned patients.

d. A review of the unit daily schedules included the following active treatment groups assigned to nursing staff that had deficient treatment notes. No treatment notes reflected what nursing staff discussed during each session, any handouts provided, or the patient's response to the group sessions that included each patient's level of participation, level of understanding, or any behaviors exhibited during the group sessions.

- A1 West: RNs had the following group assignments: Monday at 5:30 p.m. - "Wellness with the Nurse." Wednesday at 5:30 p.m., "Medication Education with the Nurse." BHA assignments included the following groups: Monday at 1:15 p.m., "Life Skills" and Tuesday at 1:15 p.m., "Interpersonal Effective." And Friday at 1:15 p.m. Distress Tolerance."

-A1 East: - A1 West: RNs had the following group assignments: Wednesday at 5:15 p.m., "Medication Education." BHA assignments included the following groups: Monday at 11:00 a.m. "Acceptance/Willingness Skills" and at 1:00 p.m., "Emotional Awareness." and Tuesday at 11:00 p.m., "Interpersonal Effective."

- Adolescent Unit: Red team - RNs had the following group assignments for the patients on the Red team: Monday at 9:45 a.m. - "Healthy Living (Medications)." Saturday at 6:00 p.m., "Healthy Living (Nutrition)." BHA assignments included the following groups: Monday at 6:00 p.m., "Mindfulness" and Tuesday at 1:15 p.m., "Interpersonal Effective." And Friday at 1:15 p.m. Distress Tolerance." Purple team - RNs had the following group assignments for the patients on the Red team: Wednesday at 9:45 a.m. - "Healthy Living (Stress)." Sunday at 4:00 p.m., "Healthy Living (Exercise)." BHA assignments included the following groups: Monday at 11:30 a.m., "Mindfulness" and Thursday at 9:45 a.m., "Suicide Prevention ...."

- Eating Disorder: RNs had the following group assignment: Thursday at 4:00 p.m. - "Med [Medication] Education."

e. During an interview on 4/25/18 at 2:40 p.m., the Director of Nursing did not dispute the findings that nursing documentation of treatment notes regarding on the MTP lacked specific information about participation or non-participation in assigned active treatment interventions.

f. During an interview on 4/25/18 at 3:40 p.m., RN4 attempted to locate evidence of nursing documentation regarding medication education and healthy living groups listed on the unit schedules. She concurred treatment notes for group sessions (Medication Education and Healthy Living Groups) were not documented.

2. Social Worker Interventions

a. The MTPs for active sample patients A17, A20, and B10 had a "clinical process group" or "group therapy" assigned to be held by the clinical therapists/LCSW. A review of notes from the electronic medical record from 4/10/18 through 4/24/18 revealed that the clinical therapists failed to document participation in these group sessions consistently. There was no evidence of what was discussed during sessions, if handouts were distributed, the patient's response that provided evidence that the patient understood the information provided, level of participation, and any specific comments if any.

b. A review of the unit daily schedules included the following active treatment groups assigned to clinical therapists/social work staff. A review of the electronic medical record revealed that there no treatment notes showing what clinical therapists/social work staff discussed during group sessions, any handouts provided, or the patient's response to the sessions that included each patient's level of participation, level of understanding, or any behaviors exhibited during the group sessions.

- A1 West: SWs had the following group assignments: Monday - Friday at 10:00 a.m. - "Clinical Therapy."

-A1 East: - A1 West: SWs had the following group assignments: Monday - Friday at 9:45 a.m. - "Clinical Therapy."

- Adolescent Unit: Red & Purple teams - SWs had the following group assignment: Monday - Friday at 10:15 a.m. - "Clinical Therapy Group."

- Eating Disorder: SWs had the following group assignments: Monday - Friday at 1:00 p.m. - "Process Group."

- Chemical Dependency: SWs had the following group assignments: Monday - Friday at 1:00 p.m. - "Group Therapy (DBT [Dialectical Behavioral Therapy on Tuesday and Friday and CBT [Cognitive Behavioral Therapy] on Wednesday."

e. During an interview on 4/25/18 at approximately 3:00 p.m., clinical therapist 3 admitted that the notes could have more information about group sessions assigned and provided. She admitted that groups sessions not attended were not consistently documented.

Based on record review and interview, the facility failed to provide discharge summaries for one (1) of five (5) discharged patient records (G1) which included a detailed summary of the course of hospitalization, and active treatment modalities provided. This failure can result in a delay of appropriate care being provided as part of the continuum of care.

Findings include:

1. Record Review

A. Patient G4's discharge summary dated,3/2/18, did not contain a detailed summary of the hospital course.

2. Interview

In an interview with the Medical Director on 4/25/18, the findings were not refuted.

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

I. Ensure that treatment plans were comprehensive, specific and individualized goals for eight (8) of 11 active sample patients (A17, A20, B1, B6, B10, C1, D11, and F4), individualized and specific active treatment interventions for nine (9) of 11 active sample patients (A3, A17, A20, B6, B10, C1, D6, D11, and F4), and separately identified registered nurse and psychiatrist responsibility for treatment interventions for seven (7) of 11 active sample patients (A3, A17, B1, B6, B10, D6, and F4). This deficient practice could lead to prolonged hospitalization and ineffective treatment. (Refer to B118, B119, B121, B122, and B123).

II. Ensure that patient discharge summaries are completed and contain a detailed summary of the hospital course and treatment provided to allow for smooth and coordinated aftercare treatment for one (1) of five (5) discharge records (G4). This deficient practice results in disruption in continuity of care and increases the potential for inappropriate treatment. (Refer to B133)

Based on observation, record review, document review, and interview, the facility failed to provide adequate oversight to ensure the quality of nursing practices. Specifically, the Director of Nursing failed to monitor to:

I. Ensure that MTPs were adequately developed and documented individualized active treatment interventions with a specific modality, frequency, and focus of treatment based on presenting psychiatric symptoms of nine (9) of 11 active sample patients (A3, A17, A20, B6, B10, C1, D6, D11, and F4). Specifically, nursing interventions identified on MTPs were routine nursing functions associated with normal job duties. In addition, the facility failed to ensure that active treatment interventions listed on the unit schedule and assigned to nursing staff were included on MTP. These deficiencies result in treatment plans that failed to reflect comprehensive and individualized nursing approaches to active treatment. (Refer to B122).

II. Ensure that registered nurses and behavioral health associates (BHAs) documented active treatment interventions on the Master Treatment Plan and unit schedule to show detailed and comprehensive information about treatment for 10 of 11 active sample patients (A3, A17, A20, B1, B10, C1, D6, D11, and F4). Specifically, nursing documentation did not consistently include the patients' attendance or non-attendance in planned and scheduled active treatment sessions and specify topics discussed during sessions. Also, the notes did not report the patients' response to interventions, including the level of participation, understanding of the information provided, behavior during interventions, and specific patients' comments if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions provided by, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124).

Based on record review and interview, the Facility failed to ensure that qualified Therapeutic Activities staff [called Rehabilitation Therapy staff by the facility] completed assessments following each patient's admission and provide appropriate input into the formulation of the Master Treatment Plans (MTPs). Specifically, the Master Treatment Plans (MTPs) included rehabilitation interventions for 10 of 11 active sample patients (A3, A17, A20, B1, B6, B10, C1, D6, D11, and F4). However, there was no assessment completed by rehabilitation staff to ensure that interventions were based on the individualized needs and interest of each patient. In addition, the facility did not have any written description of a therapeutic activities program based on the population they served. Populations served by the facility included geriatric, adolescents, acute adult psychiatric, and chemical dependency patients. These failures result in patients not being assessed adequately regarding rehabilitation needs, interests, and capabilities. Thus, hampers the therapeutic activity staff's ability to provide specific, individualized, and focused active treatment for each patient.

Findings include:

A. Record Review

None of the following active sample patients had an assessment completed on admission or before the formulation of the treatment plan (dates of admission in parenthesis). There was no rehabilitation assessment to ensure adequate information regarding each patient's needs, interest needed to formalize an individualized therapeutic activity therapy plan: A1 (XXX), A3 (4/7/18), A17 (4/19/18), A20 (3/15/18), B1 (4/15/18), B6 (4/19/18), B10 (4/22/18), C1 (4/19/18), D6 (4/10/18), D11 (4/19/18), and F4 (3/29/18).

B. Policy Review

The facility's policy titled, "LOH-CLIN 044 Interdisciplinary Care Plan" stipulated that "A working Care Plan is established within 72 hours after a patient is admitted to an acute unit... The plan is based on completed assessments from the multidisciplinary team ..." The facility failed to base rehabilitation activities on an individual therapeutic activities assessment conducted by rehabilitation staff.

B. Interview

In an interview on 4/25/18 at 1:30 p.m., the lack of a rehabilitation assessment to determine individualized rehabilitation interventions for the MTPs was discussed. The Director of Rehabilitation Services did not dispute the findings. She noted that the facility currently employed art therapists, music therapists, occupational therapists, recreational therapists, and dance movement therapists but admitted that these therapists did not complete rehabilitation assessment to determine individualized interventions for each patient based on their needs and interest. She also acknowledged that the facility did not have a written program description that outlined appropriate rehabilitation activities based the patient populations they serve.