HospitalInspections.org

Based on document review and interviews, the facility failed to develop treatment plans that identified short-term goals [called objectives by the facility] stated in observable, measureable, and behavioral terms for eight (8) of eight (8) active sample patients (G1, G2, G5, G10, R6, R8, R9, and R11). This failure hinders the ability of treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify treatment plans in response to patient needs, as well as staff being unable to provide consistent and focus treatment.

Findings include:

A. Review of Records

The MTPs for the following patients were reviewed (dates of plans in parentheses): G1 (12/6/14), G2 (12/7/14), G5 (12/4/14), G10 (12/2/14), R6 (12/3/14), R8 (12/3/14), R9 (12/3/14), R11 (12/2/14). This review revealed that MTPs included but not limited to the following objectives that were not stated in behavioral and measurable terms with an alternative or replacement behavior that would allow the patient an increased level of functioning. In addition, some objectives stated what the patient will not do instead of stating what the patient would be saying and/or doing to eliminate, reduce, and/or improve his/her presenting problems. Objectives related to patients attending groups, being compliant, and being educated were staff expectations rather than patient specific goals based on their presenting symptoms.

1. Patient G1: Problems- "SI [suicidal ideation] cut wrist and had plans to shoot self with gun." The following short term goals were formulated to address these problems:

"Patient will refrain from self-injury behavior...." "Pt [patient] will be compliant with prescribed medication..." "Patient will attend two (2) to three (3) daily therapeutic groups and demonstrate an improvement in mood aeb [as evidenced by] increased activity level..." "Pt will report on absence of SI [suicidal ideation]....."

2. Patient G2: Problems listed- "Pt [patient] fear mafia is trying to kill her and her daughter and has made faces in her carpet at home." The following short term goals were formulated to address these problems:

"Pt [patient] will show compliance to take prescription medication prior to d/c [discharge]..." "Pt [patient] will have adequate plan to manage psychosis." "Pt [patient] will have resources to address substance abuse. Pt [patient] will have appropriate support for discharge." and "Pt [patient] will attend three (3) to four (4) therapeutic groups and attempt to learn at least two (2) to three (3) coping strategies to manage psychosis symptoms, anxiety, stress, and family conflict."

3. Patient G5: Problems- "SI [suicidal ideation] and HI [homicidal ideation] with no specific stated plan." The following short term goals were formulated to address these problems:

"PT [patient] will not attempt to harm self or others during hospitalization; will state absence of SI [suicidal ideation] and HI [homicidal ideation] prior to D/C [discharge] from IPU [inpatient program unit]" and "The PT [patient] will learn at least two (2) ways to manage depression, anger, visual hallucinations and stress." "[S/he] will attend group and demonstrate an improvement in mood."

4. Patient G10: Problem- "Pt [patient] with delusions impacting health, safety and welfare." The following short term goals were formulated to address these problems:

"The patient will participate in three (3) to four (4) daily therapeutic groups and demonstrate an improvement in mood aeb [as evidenced by] increased activity level and appropriate social interaction." "The patient will be educated on two (2) ways to improve reality-based thinking and prevent relapse on alcohol," and "Pt will report that delusions have returned to baseline level of functioning."

5. Patient R6: Problems- "SI [suicidal ideation] with attempt by overdose in association with med non-compliance, conflict with sister, financial stressors, and auditory hallucinations." The following short term goals were formulated to address these problems:

"Will state absence of SI [suicidal ideation] prior to discharge; will not attempt to harm self while hospitalized..." "Will attend three (3) to four (4) daily therapeutic groups and attempt to learn at least two (2) to three (3) coping skills to manage depression, med-compliance..."

6. Patient R8: Problems- "Psychotic thoughts and medication non-compliance." The following short term goals were formulated to address these problems:

"Patient will remain safe on the unit......" "Patient will attend three (3) to four (4) daily groups to learn at least two (2) to three (3) coping strategies to manage psychotic symptoms, stress, sleep and med compliance," "Patient will have adequate plan to manage mood instability."

7. Patient R9: Problems- "Psychosis with some confusion, delusional thinking with AVH [auditory/visual hallucinations], and medication non-compliance." The following short term goals were formulated to address these problems:

"Patient will remain safe on the unit. Patient will report an absence of A/V/H [auditory/visual hallucinations]..." "Patient will attend three (3) to four (4) daily groups to learn at least two (2) to three (3) coping strategies to manage psychotic symptoms (including paranoia and voices), med compliance...." "Patient will have adequate plan to manage psychosis....."

8. Patient R11: Problems- "Medication and treatment compliance, suicidal ideation, impaired sleep, impaired insight, and psychosis." The following short term goals were formulated to address these problems:

"Will report absence of AVH [auditory/visual hallucinations] or delusional thought by D/C [discharge]....." "Patient will attend three (3) to four (4) daily groups and attempt to learn at least two (2) to three (3) coping strategies to manage psychotic symptoms including delusional thoughts as well as insomnia, stress, and medication compliance." "Patient will demonstrate reality based thinking by disch [discharge]."

B. Policy Review

1. Clinical staff failed to follow their own facility policy titled, "Treatment Planning Process and Writing Progress Notes" dated 10/19/12. This policy stipulated that, "The treatment plan provides...goals, measurement, objectives....Goals and objectives must be observable, measurable, and time-framed......Objectives are short-term and must be stated as behavioral outcomes that relate to identified problems. Objectives must be written in observable, measurable language..."

C. Staff Interview

During interview on 12/9/14 at 4:45 p.m. with the Director of Nursing, MTPs were reviewed. She acknowledged that short term goals were not measurable, objective and treatment focused. She stated that there were problems with treatment plans.

Based on review of the records and interviews the facility failed to develop individualized treatment plans that clearly delineated interventions to address specific patient problems and assist patients to accomplishment treatment objectives. Instead, interventions on the Master Treatment Plans (MTPs) included:

1. Routine and generic discipline functions that were written as treatment interventions for eight (8) of eight (8) active sample patients (G1, G2, G5, G10, R6, R8, R9, and R11) and

2. Interventions that failed to identify delivery method and/or frequency of contact for seven (7) of eight (8) active sample patients (G1, G5, G10, R6, R8, R9, and R11). These deficiencies potentially result in staff being unable to provide consistent and focus treatment.

Findings include:

I. Routine and generic discipline functions

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): G1 (12/6/14), G2 (12/7/14), G5 (12/4/14), G10 (12/2/14), R6 (12/3/14), R8 (12/3/14), R9 (12/3/14), R11 (12/2/14). This review revealed that MTPs included but not limited to the following interventions that failed to be individualized and contained the following routine and generic discipline functions (such as assessing, evaluating, and encouraging) written as treatment interventions to be delivered by the physician (MD), registered nurse (RN), activity therapist (AT), and social worker (SW). Several intervention statements were identical or similarly worded.

1. Patient G1:

RN Intervention- "1:1 q [every] shift & PRN [with] pt [patient] to assess mood, thought ... [S/he] will safety detox on the unit & move toward realistic goals to deal [with] family conflict & A&D [Alcohol & Drug] issue..."

MD Intervention- "MD to evaluate & prescribe accordingly..."

AT Intervention- "AT staff will offer three (3) to four (4) daily therapeutic and monitor the patient for improvements in mood..."

SW Intervention- "Social work staff will explore substance abuse Tx [treatment] programs resources with patient." Outpatient to be schedule at Cherokee Health System..."

2. Patient G2:

MD Intervention- "Physician will evaluate pt [patient] daily and as needed to order meds to alleviate psychosis..."

AT Intervention- "AT staff will offer four (4) daily therapeutic groups..." "AT staff will monitor pt [patient] for improvement in mood and reality-based thinking..."

3. Patient G5:

RN Intervention- "Meet [with] pt [patient] 1:1 q [every] shift & PRN [with] pt [patient] to assess for SI [suicidal ideation], HI [homicidal ideation] mood;..."

MD Intervention- "Evaluate need for meds [medications] & Rx [prescribe] adequate meds [medications] to manage symptoms."

AT Intervention- "AT staff will offer three (3) to four (4) daily therapeutic and monitor the patient for improved mood..."

SW Intervention- "SW [social worker] will contact CM [case management to ensure plan to ensure pt [patient] doesn't have access to gun after d/c [discharge]."

4. Patient G10:

RN Intervention- "RN will meet [with] pt [patient] q [every] shift & PRN [with] pt [patient] to assess mood/affect, mental status...will assess med [medication] efficacy."

MD and Pharmacy Intervention- "MD to evaluate & prescribe accordingly..." "RPH will dispense meds [medications] as ordered..."

AT Intervention- "AT staff will offer three (3) to four (4) daily therapeutic and monitor the patient for improvements in mood..."

SW Intervention- "Social work staff will schedule outpatient appointments at..." "Referral to PSR [Psychosocial Rehabilitation] program to be discussed with pt [patient]."

5. Patient R6:

RN Intervention- "RN will meet [with] pt [patient] q [every] shift & PRN [with] pt [patient] to assess SI/mood..."

MD Intervention- "Evaluate need for meds [medications] and Rx [prescribe] appropriate to manage symptoms."

AT Intervention- "AT staff will offer three (3) to four (4) daily therapeutic...AT staff will monitor pt [patient] for improvements in mood..."

SW Intervention- "Outpatient Mental Health services to be scheduled outpatient appointments at RV [Ridgeview] Outpatient..."

6. Patient R8:

RN Intervention-

"(1) 1:1 with pt [patient] q [every] shift to discuss safety on the unit and assist with adaptive behaviors to handle psychosis."

"(2) Hold pt [patient] per order to given medications."

MD Intervention- "MD will meet with pt [patient] daily to assess and prescribe medications."

AT Intervention- "AT staff will offer three (3) to four (4) daily therapeutic..." "AT staff will monitor pt [patient] for improved reality based thinking aeb [as evidence by] ¿ focus, participation in groups..."

SW Intervention- "Social work staff will schedule outpatient appointments at...Referral to PSR [Psychosocial Rehabilitation] program to be discussed with pt [patient]."

7. Patient R9:

RN Intervention- "1:1 [with] pt [patient] q [every] shift to discuss safety & PRN [with] pt [patient] on the unit..." "[sic] presence of A/V/H [auditory/visual/hallucination] [illegible] to assist [with] reality based thinking..."

MD Intervention- "MD will meet [with] pt [patient] daily to [sic] and prescribe medications as indicated."

AT Intervention- "AT staff will offer three (3) to four (4) daily therapeutic groups...AT staff will monitor pt [patient] for stabilized mood and reality based thinking..."

8. Patient R11:

RN Intervention- "(1) Reassess for [change] in mental state, safety & coping skill development."

MD Intervention- There was no interventions included at all on the MTP regarding what the MD would do to assist this patient.

AT Intervention- "AT staff will offer four (4) daily therapeutic...to teach pt [patient] at least two (2) to three (3) coping skills to manage psychosis..." AT staff will monitor pt [patient] for reality based thinking [sic] ¿ focus..."

SW Intervention- "Outpatient Mental Health services to be scheduled at CMHC [community mental health center] where he will reside."

B. Staff Interviews

1. During interview on 12/9/14 at 1:00 p.m. with the Director of Social Work, the MTPs for Patients G1, G2, G5, and G10 were reviewed. He agreed with the findings that some of the intervention statements were generic and/or routine social work functions with many statements identical or similarly worded.

2. During interview on 12/9/14 at 2:05 p.m. with RT2, the MTP for R6 was reviewed. She agreed with the findings regarding the interventions on the MTP. She stated that she understood that intervention statements were not individualized.

3. During interview on 12/9/14 at 4:45 p.m. with the Director of Nursing, MTPs were reviewed. She acknowledged that nursing intervention statements were routine nursing functions and noted that she understood the intent of intervention statements written by nursing staff but agreed that the statement were not specific enough.

II. Interventions that failed to include delivery method and/or frequency of contact

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): G1 (12/6/14), G2 (12/7/14), G5 (12/4/14), G10 (12/2/14), R6 (12/3/14), R8 (12/3/14), R9 (12/3/14), R11 (12/2/14). This review revealed that MTPs included but not limited to the following interventions that did not include how the intervention would be delivered (individual or group sessions) and/or the frequency of contact with the patient.

1. Patient G1:

MD Intervention- "Education on Rx [prescribed] will be provided in language [s/he] can comprehend."

AT Intervention- AT staff will teach the patient two (2) ways to manage depression, grief, insomnia, recovery and relapse prevention."

2. Patient G5:

AT Intervention- AT staff will teach pt [patient] coping skills for depression, anger, VH [visual hallucinations], and stress."

SW Intervention- "Social work staff will meet with the pt [patient] to explain community resources to address depression, financial strain."

3. Patient G10:

AT Intervention- "The AT staff will also teach the patient at least two (2) ways to manage depression, grief, insomnia, recovery, and relapse prevention plan."

4. Patient R6:

SW Intervention- "Social work staff will explore community resources to provide support for grief issues."

AT Intervention- "AT staff will teach pt [patient] coping skills for depression, anger, VH [visual hallucinations], and stress."

5. Patient R8:

SW Intervention- "SW staff will work with the pt [patient] to explore community resources to address mood instability, psychosis."

AT Intervention- "AT staff will teach pt [patient] coping skills for depression, anger, VH [visual hallucinations], and stress."

6. Patient R9:

SW Intervention- "SW staff will work with the pt [patient] to explore community resources to address pt's [patient's] psychosis..."

SW Intervention- "SW staff to work with the pt [patient] to explore community resources to address pt's [patient's] psychosis, assist with compliance."

7. Patient R11:

RN Intervention- "(2) Educate on sleep hygiene." "(3) Teach coping skills to decrease or inhibit psychosis. "

AT Intervention- "AT staff will teach pt [patient] coping skills for depression, anger, VH [visual hallucinations], and stress."

B. Policy Review

Clinical staff failed to follow their own facility policy titled, "Treatment Planning Process and Writing Progress Notes" dated 10/19/12. This policy stipulated that, "...interventions must describe what staff are going to do, and identify a focus and frequency for the intervention."

Based on observation, record review and interview, the Medical Director failed to adequately ensure the quality and appropriateness of services provided. Specifically, the Medical Director failed to:

I. Develop treatment plans that identified short-term goals [called objectives by the facility] stated in observable, measureable, and behavioral terms for eight (8) of eight (8) active sample patients (G1, G2, G5, G10, R6, R8, R9, and R11). This failure hinders the ability of treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify treatment plans in response to patient needs, as well as staff being unable to provide consistent and focus treatment (Refer to B121).

II. Develop individualized treatment plans that clearly delineated physician interventions to address specific patient problems and assist patients to accomplishment treatment objectives. Instead, interventions on the treatment plans included:

(1) Routine and generic physician functions that were written as treatment interventions for eight (8) of eight (8) sample patients (G1, G2, G5, G10, R6, R8, R9, and R11).

(2) An intervention that failed to include delivery method and frequency of contact for one (1) of eight (8) active sample patients (G1). These deficiencies potentially result in staff being unable to provide consistent and focus treatment.

Findings include:

I. Routine and generic physician Functions

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): G1 (12/6/14), G2 (12/7/14), G5 (12/4/14), G10 (12/2/14), R6 (12/3/14), R8 (12/3/14), R9 (12/3/14), R11 (12/2/14). This review revealed that MTPs included but not limited to the following interventions that failed to be individualized and contained the following routine and generic physician functions and statements (such as assessing, evaluating, and prescribing) written as treatment interventions. Intervention statements were similarly worded.

1. Patient G1:

MD Intervention- "MD to evaluate & prescribe accordingly..."

2. Patient G2:

MD Intervention- "Physician will evaluate pt [patient] daily and as needed to order meds to alleviate psychosis..."

3. Patient G5:

MD Intervention- "Evaluate need for meds [medications] & Rx [prescribe] adequate meds [medications] to manage symptoms."

4. Patient G10:

MD and Pharmacist Intervention- "MD to evaluate & prescribe accordingly..." "RPH will dispense meds [medications] as ordered..."

5. Patient R6:

MD Intervention- "Evaluate need for meds [medications] and Rx [prescribe] appropriate to manage symptoms."

6. Patient R8:

MD Intervention- "MD will meet with pt [patient] daily to assess and prescribe medications."

7. Patient R9:

MD Intervention- "MD will meet [with] pt [patient] daily to [sic] and prescribe medications as indicated."

8. Patient R11:

MD Intervention- There was no interventions included at all on the MTPs regarding what the MD would do to assist this patient.

B. Staff Interview

During interview on 12/9/14 at 11:00 a.m. with the Medical Director, MTPs were reviewed. She agreed with the findings and noted that intervention needed to be more specific.

II. Intervention that failed to include delivery method and/or frequency of contact

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): G1 (12/6/14), G2 (12/7/14), G5 (12/4/14), G10 (12/2/14), R6 (12/3/14), R8 (12/3/14), R9 (12/3/14), R11 (12/2/14). This review revealed that the following physician intervention that did not include how the intervention would be delivered (individual or group sessions) and the frequency of contact with the patient.

Patient G1:

MD Intervention- "Education on Rx [prescribed] will be provided in language [s/he] can comprehend."

B. Policy Review

The psychiatrist failed to follow the facility policy titled, "Treatment Planning Process and Writing Progress Notes" dated 10/19/12. This policy stipulated that, "...interventions must describe what staff are going to do, and identify a focus and frequency for the intervention."

Based on record review and interview, the Director of Nursing (DON) failed to provide oversight to ensure quality nursing services. Specifically, the DON failed to develop individualized treatment plans that clearly delineated nursing interventions to address specific patient problems and assist patients to accomplishment treatment objectives. Instead, interventions on the treatment plans included:

1. Routine and generic nursing functions that were written as treatment interventions for eight (8) of eight (8) sample patients (G1, G2, G5, G10, R6, R8, R9, and R11)

2. An intervention that failed to include delivery method and/or frequency of contact for one (1) of eight (8) active sample patients (R11). These deficiencies potentially result in staff being unable to provide consistent and focus treatment.

Findings include:

I. Routine and Generic Nursing Functions

A. Review of Records

The MTPs for the following patients were reviewed (dates of plans in parentheses): G1 (12/6/14), G2 (12/7/14), G5 (12/4/14), G10 (12/2/14), R6 (12/3/14), R8 (12/3/14), R9 (12/3/14), R11 (12/2/14). This review revealed that MTPs included but not limited to the following interventions that failed to be individualized and contained the following routine and generic nursing functions (such as assessing behaviors) written as treatment interventions.

1. Patient G1:

RN Intervention- "1:1 q [every] shift & PRN [with] pt [patient] to assess mood, thought...[S/he] will safety detox on the unit & move toward realistic goals to deal [with] family conflict & A&D [Alcohol & Drug] issue..."

3. Patient G5:

RN Intervention- "Meet [with] pt [patient] 1:1 q [every] shift & PRN [with] pt [patient] to assess for SI [suicidal ideation], HI [homicidal ideation] mood;..."

4. Patient G10:

RN Intervention- "RN will meet [with] pt [patient] q [every] shift & PRN [with] pt [patient] to assess mood/affect, mental status...will assess med [medication] efficacy."

5. Patient R6:

RN Intervention- "RN will meet [with] pt [patient] q [every] shift & PRN [with] pt [patient] to assess SI/mood..."

6. Patient R8:

RN Intervention-

"(1) 1:1 with pt [patient] q [every] shift to discuss safety on the unit and assist with adaptive behaviors to handle psychosis."

"(2) Hold pt [patient] per order to given medications."

7. Patient R9:

RN Intervention- "1:1 [with] pt [patient] q [every] shift to discuss safety & PRN [with] pt [patient] on the unit..." "[sic] presence of A/V/H [auditory/visual/hallucination] [illegible] to assist [with] reality based thinking..."

8. Patient R11:

RN Intervention- "(1) Reassess for [change] in mental state, safety & coping skill development. "

B. Staff Interview

During interview on 12/9/14 at 4:45 p.m. with the Director of Nursing, MTPs were reviewed. She acknowledged that nursing intervention statements were routine nursing functions and noted that she understood the staff 's intent for the intervention statements but agreed that the statements were not specific enough.

II. Intervention that failed to include delivery method and/or frequency of contact

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): G1 (12/6/14), G2 (12/7/14), G5 (12/4/14), G10 (12/2/14), R6 (12/3/14), R8 (12/3/14), R9 (12/3/14), R11 (12/2/14). This review revealed the following nursing intervention that did not include how the intervention would be delivered (individual or group sessions) and/or the frequency of contact with the patient.

Patient R11:

RN Intervention- "(2) Educate on sleep hygiene." "(3) Teach coping skills to ¿ or inhibit psychosis."

B. Policy Review

1. Registered nurses failed to follow their own facility policy titled, "Treatment Planning Process and Writing Progress Notes" dated 10/19/12. This policy stipulated that, "...interventions must describe what staff are going to do, and identify a focus and frequency for the intervention."