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Based on a review of facility documents, and staff interview (EMP), it was determined that Roxbury Treatment Center failed to ensure that patients were notified of their Rights for 13 of 13 medical records reviewed (MR1-MR13).

Findings include:

A review on May 25, 2012, of the facility's "Treatment Program, Patient Handbook and Orientation Manual" revealed that the patients "Bill of Rights" contained in the handbook was the Patient Bill of Rights for psychiatric patients and did not address Medicare/Medicaid rights, as outlined in the Conditions of Participation.

An interview was conducted with EMP1 on May 25, 2012, at 10: 20 AM. EMP1 confirmed that their Patients Bill of Rights information did not address the patients rights as outlined in the Conditions of Participation. EMP1 revealed that the facility does not have a policy that addresses Medicare/Medicaid rights.

Based on a review of medical records (MR) and interview with staff (EMP), it was determined that Roxbury Treatment Center failed to ensure the patients right to be free of abuse (Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish.) for three of 13 medical records reviewed (MR6, MR9, and MR13).

Findings include:

A review of facility policy, "Patient Rights and Responsibilities," reviewed February 2012 revealed, "... As part of the admission process, Intake staff will provide to patients, and families as appropriate, a copy of the Patient Bill of Rights ... Included in these rights are: ... The right to personal dignity. The right to treatment and services that are respectful of the personal values and beliefs of the individual. The right to practice the religion of their choice ... The right to participate in the development and review of their treatment plan ... The Right not to be subjected to any harsh or unusual treatment. ... ."

A review of facility policy, "Restriction of Patient Rights/Privileges," reviewed February 2012 revealed, "... Policy: ... It is the policy of Roxbury Treatment Center to ensure that the exercise of patient rights may only be limited or restricted by the process of a treatment team decision and only when there is clear justification for such restriction. Procedure: ... 6. Any restrictions placed on patients must be reviewed by the Treatment Team for the therapeutic effectiveness and impact on the behavior initially warranting the restriction. This must be timely (within 48 hours) to determine whether or not to continue with this course of intervention. 7. Should the intervention be effective, the restriction will be lifted immediately and the patient informed of the reinstitution of his /her privileges. ... ."

A review of facility policy, "Elopement Precautions and Response," reviewed February 2012 revealed, the policy did not include removing a patient's personal belongings or clothing.

1) A review of MR6 revealed a "Therapeutic Contract - Revision ... Goal - Decrease acts of aggression while in treatment ... Plan: 1. If I threaten peers or staff, or act out aggressively in any way, I will be restricted to the unit for 24 hours. 2. After this 24 hour period, if I am able to control my behavior for 24 hours more, I may have an extra 10 minute phone call to my mother daily in the afternoon (or at MHT's earliest convenience). 3. If I am able to manage my behavior for an additional 24 hours, at 3:00 PM, I may have the choice of either going to the gym for a 15 minute period to play basketball by myself OR choose a snack from the nurses' station (Going to the gym will occur at this time if staffing situations allow. If not, it may be postponed to later in the evening, or I may be encouraged to choose the alternative snack instead.). 4. If I act out or threaten a peer, I will be required to begin earning these privileges again from #1. 5. If I act out in response to not receiving one of these privileges at the time I desire, I will have all of my personal belongings, including clothing placed in contraband and be required to wear scrubs. For every 24 hours I am compliant with expectations, I may earn back 2 items of my choice from contraband. I agree that these expectations are reasonable and achievable and will make an effort to be compliant while in treatment." The area for the patient signature was blank. Staff signed and dated the document on May 17, 2012. Further review revealed hand written notations on the plan of "In effect as of 10:20 AM 5/17/12" and "Pt refused to sign or review terms."

An interview was conducted with EMP2 on May 24, 2012, at 2:00 PM. EMP2 confirmed that the "Therapeutic Contract" was placed into effect for the patient and that the patient refused to sign the contract. EMP2 confirmed that the elopement policy did not include removing patients personal belongings or clothing.

2) A review of MR9 revealed "Therapeutic Contract ... Goal: Engage fully in the treatment process while in treatment including group, individual and self work. Secondary Goals: Decrease elopement attempts, decrease disruptive behavior on the unit. I recognize that: 1. It is against the rules to leave the unit without permission. 2. It is disruptive to other patients to create extra noise. ... 3. I must cooperate with nursing by taking medications and not attempting to hide contraband on my person. Engaging in these behaviors will have consequences: 1. While on elopement precautions, I will not be allowed to keep my clothing or other belongings, and will be restricted to the unit. 2. If I act out in a way that the staff deems to be disruptive to my peers OR if I am found to have contraband hidden on my person, I will lose the immediately following cigarette break. 3. If I continue to act out, I will lose more cigarette breaks. If I am able to control my behaviors, I may earn certain privileges: ... If I am able to cooperate for 5 days, my clothing will be returned to me (no shoes) ... ." A review of the contract revealed that it was signed by the patient, and revealed hand written notations on the plan stating: "To go into effect 12/14/11" and "(Pt wrote incorrect date)."

An interview was conducted with EMP2 on May 24, 2012 at 2:10 PM. EMP2 confirmed that the "Therapeutic Contract" was placed into effect for the patient.

3) A review of MR13 revealed a "Therapeutic Contract ... Goal: Engage fully in the treatment process while in treatment including group, individual and self work. Secondary Goal: Eliminate aggressive and threatening behavior on the Unit. Tertiary Goal: Cease damaging/tampering with Roxbury Hospital Property ... My behaviors that have led to this contract being initiated have consequences: 1. Due to continuing to damage property I have lost the following privileges: I must surrender my cloth religion tiles to staff to be placed in my safe, and all other personal belongings from my room with the exception of clothing ... If I am able to manage my behavior I may earn certain privileges back ... Upon completing an additional twenty four hours of positive behavior I may choose either to select one cloth religious tile or personal item to be returned to me ... Every twenty four I may select an additional personal OR phone call until all items are returned to me or this plan is no longer needed as determined by staff members. If I am able to control my behavior for four days, I may attend visitation in the gym if applicable ... If I damage /tamper with property or threaten staff/ peers during this time I will lose 2 consecutive cigarette breaks, and again lose all privileges as listed above and begin my 24 hours over." Further review of the contract revealed "pt refused to sign".

An interview was conducted with EMP2 on May 24, 2012 at 2:10 PM. EMP2 confirmed the the "Therapeutic Contract" was placed into effect for the patient and that the patient refused to sign the contract.

Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined that Roxbury Treatment Center failed to ensure that the use of restraint was in accordance with a written modification to the patients Plan of Care for six of 13 medical records reviewed (MR8, MR9, MR10, MR11, MR12 and MR13).

A review of facility policy "Seclusion and Restraints", reviewed February 2012, revealed, "...15. Treatment Plan Review/Revision: When the patient has presented behavior that is dangerous to themselves or others so that restraints/seclusion were indicated, a review and modification to the Treatment Plan is indicated ... the RN shall review and update the Treatment Plan within 8 hours. The entire Treatment Team will review the Plan at the next scheduled review. The updated Treatment Plan shall reflect: A. The identification of an assessed problem associated with the use of restraints/seclusion. B. Goals related to prevention of the further use of restraints/seclusion. C. Interventions which define alternative approaches to address the identified problem. Responsibility for each intervention is assigned. D. Review of the Plan with the patient. ... ."

A review of MR8, MR9, MR10, MR11, MR12 and MR13 did not reveal documented evidence to reflect the use of restraint on the Plan.

An interview was conducted with EMP2 on May 25, 2012. EMP2 confirmed that the Care Plans were not updated after restraints were used.

Based on review of facility policy, medical records (MR), and interviews with staff (EMP), it was determined that Roxbury Treatment Center failed to have an Registered Nurse authorize the initiation of restraints for one of six medical records that were reviewed for patients in restraints. (MR9).

A review of facility policy, "Seclusion and Restraints," reviewed February 2012, revealed, "...Physician Orders, Consultation, and Evaluation: A. Restraint or seclusion shall be used in emergency situations only and requires an order from a physician ...1. In the absence of a physician/authorized LIP the registered nurse may authorize the initiation of restraints or seclusion in an emergency. ... ."

A review of MR9 revealed a"Restraint/Seclusion Order/Record," dated December 15, 2011, initiated at 1:50 PM. A space was designated for a signature of the RN initiating if physician /LIP not present: it was noted that an LPN signed the order.

An interview was conducted with EMP2 on May 25, 2012, at 10:00 AM. EMP2 confirmed that the restraints were initiated by an Licensed Practical Nurse not an Registered Nurse as required by the policy.

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A review of facility policy "Seclusion and Restraints," reviewed February 2012, revealed "... Physician Orders, Consultation, and Evaluation ... 2. The physician/LIP must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated. 3. Telephone/verbal orders for restrain/seclusion may be received and recorded by an RN ... ."

A review of MR9 revealed a"Restraint/Seclusion Order/Record" dated December 15, 2011, initiated at 1:50 PM." The order received from was left blank and the order authentication was dated December16, 2011."

An interview was conducted with EMP2 on May 25, 2012, at 10:00 AM. EMP2 confirmed that the patient did not have an order for restraints.

Based on a review of facility documents and interview with staff (EMP), it was determined that Roxbury Treatment Center failed to ensure that each inpatient unit had a Registered Nurse (RN) assigned to, and immediately available, for the beside care of any patient in the facility's Military Unit.

Findings include:

A review of facility policy, "Core Staffing Patterns: Inpatient Unit," reviewed February 2012, revealed, " ... Policy: 1. A core number of nursing staff headed by a Registered Nurse shall be on duty at all times." The policy did not address the CMS requirement that there must be staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.

A review on May 24, 2012, of the Nursing matrix from December 2011 through May 2012 was conducted. The review revealed that there were two separate and distinct patient care units: the Psych Unit and the Military Unit. The matrix did not consistently indicate which Unit the staff was assigned to work.

An interview was conducted with EMP5 on May 24, 2012. EMP5 confirmed that the staffing matrix did not indicate which Unit the staff members were assigned to. EMP5 revealed that there was a daily schedule completed to show actual staffing on each Unit; that these forms were not kept on file; and that only the forms for May 20-24, 2012, were available for review.

A review on May 24, 2012, of the daily staffing schedules for May 20-24, 2012, revealed that they were divided into two shifts, day shift and night shift. There was no RN assigned to the Military Unit on either the day or night shift of May 20, 21, 22 and 23. Further review revealed that during the night shift on May 20, 2012, there was neither an RN nor a Licensed Practical Nurse (LPN) assigned and that the Unit was staffed by only one Mental Health Technician (MHT).

An interview was conducted with EMP5 on May 24, 2012. EMP5 confirmed that there was no RN on the Military Unit on the day or night shift of May 20, 21, 22 and 23. EMP5 also confirmed that on May 20, 2012, there was no nurse (RN or LPN) and the Unit was staffed only by one MHT.