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Based on interview, documentation review, and policy and procedure review the facility failed to ensure a system was developed for identifying, reporting, and investigating infectious/communicable disease. Failing to develop an infection control program affects all patients' safety for the prevention and control of the possible spread of infection by patients and personnel.

Findings:

During an interview with the Assistant Director of Nursing (ADON), on 1/9/2019 at 8:40 AM she stated, she took this position as the Infection Control Nurse for a little over a year ago. ADON stated she has multiple responsibilities in this facility and infection control is just one of them. She does not maintain a log of incidents related to infections and communicable diseases for patients and or employees. ADON confirmed on 1/9/2019 at 8:52 AM there has been no active surveillance program for the prevention, control and investigation of a communicable disease. The ADON was not able to provide evidence of an ongoing infection control process/program.

During an interview with the Director of Nursing (DON) / Registered Nurse (RN) on 1/9/2019 at 9:33 AM stated she has been the DON for two years. She stated the designated Infection Control Practitioner (ICP) has been the ADON for over a year. The DON confirmed at 9:34 AM when she came aboard, there was no infection control nurse (ICN) in the facility. The DON stated that she has a surveillance process when a patient is on an antibiotic, or have a cold and/or urinary tract infection, we monitor these patients. When asked to provide evidence of the infection control surveillance log for the past 12 months, the DON stated the log is locked in the medical practitioner's office. The DON returned ten minutes later and provided a one page document of a list of six (6) patients who received antibiotics in March and April, year unknown. The surveillance log indicators included the patients' name, antibiotic ordered, date ordered, duration of therapy, diagnostic tests/Rationale and follow up results. No other documents were provided to this Surveyor of an infection surveillance log. The DON stated, "It is what it is", we did not do any surveillance other than this one page. The DON stated the ADON is not aware of this surveillance log because it was done by the Nurse Practitioner.

During an interview on 1/8/2019 at 1:32 PM with the Director of Building Services he stated, he has worked here since it was being built 30 years ago. He stated he is the Director of Building Services that includes Maintenance, Housekeeping, Dietary, and also Chair of the Safety Committee. When asked if there is a Quality Assurance program conducted to ensure environmental sanitation is provided, he replied; yes the Supervisor does that.

During an interview on 1/8/2019 at 1:46 PM with the Environmental Service Supervisor (ESS), he stated he has held this position for the past four years. When asked about an ongoing QAPI (Quality Assurance Performance Improvement) program on sanitation; he replied; yes, I do it every other week. This Surveyor requested evidence of QAPI audit forms for the past 12 month. No documentation was provided.

During an Interview with the Hospital Administrator, on 1/9/2019 at 11:21 AM he stated he has been the Hospital Administrator since April of this year. The Administrator stated there is a monthly Quality meeting and monthly Hospital Management Meeting attended by myself, the DON, the Risk Manager and all Department Managers. He stated medical staff does not attend this meeting. He confirmed at 11:40 AM he does not receive any infection control surveillance reports from the ADON. The Administrator confirmed clinical infection reports are the most important item and we just do not have the enforcement process for the program. The Administrator confirmed at 11:25 AM the facility does not have a facility wide quality assurance program pertaining to infection control. The facility does not have evidence of tracking and trending of infections.

Review of the Hospital Management Meeting Agendas for the period of 12/12/2018 to 01/01/2019 showed an infection control program was not listed on the agendas. This was confirmed by the DON on 01/09/2019 at 1:48 PM.

Review of the Infection Control Operational procedure approved on 4/7/2017 read: Purpose: Infections acquired in a facility or brought into a facility from the community are potential hazards for all persons having contact within the facility. The procedure establishes a mechanism of reporting, monitoring, evaluating, investigating and recommendations of measures designed to prevent, identify and control infections. Under procedure # I read: The Infection Control Coordinator shall be a part of the Environmental Panel. All issues concerning infectious disease will be addressed in the panel. Item #IV read: The Environmental Panel shall investigate reported infections, maintaining information on trends, identifying potential hazards and making recommendations for corrective action.




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Based on observation and interview the facility failed to ensure all drugs were in a secured, locked area for 1 of 3 medication storage areas.

Findings:

A tour of the pharmacy of the Medsafe Medication Disposal System, located in the Prescription Assistance Coordinator's office was conducted on 1/08/2019 beginning at 10:30 AM. Observed were four Risperdal 25 mg solution vials located in the employee refrigerator that contained food, and was not locked.

During an interview on 01/08/2019 at 10:30 AM with the Pharmacist (RPH), she stated, "I did not know these were here. They should not be there."

During an interview on 01/08/2019 at 11:45 AM with the Prescription Assistant Coordinator, the Coordinator stated, " I received four vials of 25 mg solution for a patient on 11/21/2018; the patient did not come back for treatment and I placed these medications in the refrigerator when I received them, because I knew they needed to be refrigerated. I did not let the pharmacist know they were here."

A follow-up tour of the Prescription Assistant's Office on 01/08/2019 at 4:00 PM revealed the four Risperdal 25 mg injectable vials remained in the employee refrigerator, which was unlocked. At that time the pharmacist asked if she could store them in the pharmacy. She took the medications to the pharmacy.

Based on observation, interview, and policy and procedure review the facility failed to ensure medications, including Scheduled IV medications, were locked and secure.

Findings:

During an observation of the Adult Geriatric Unit on 01/09/2019 at 12:30 PM with the ADON (Assistant Director of Nursing) in the medication room there was an unsecured Medication Bin on the counter that was unlocked and contained the following Scheduled IV medications: 1). 27 Ativan 0.5 mg tablets, 2). 25 Ativan 1 mg tablets, and 3). 16 Tramadol 50 mg tablets.

During an observation of the Patient Care Unit-Men's Unit on 01/09/2019 at 12:35 PM with the ADON, of the medication room there were unlocked Schedule IV medications in a medication storage container that had a one key lock, that was unlocked. Stored in the container was: 1). 17 Ativan 0.5 mg tablets, 2). 65 Ativan 1 mg tablets, 3). 20 Tramadol 50 mg tablet, and 4) 21 Klonopin 0.5 mg tablets.

During an observation of the Patient Care Unit Female on 01/09/2019 at 12:40 PM with the Assistant Director of Nursing revealed unlocked Schedule IV medications in a Medication Storage container that had individual locks on all the drawers which were all unlocked. Stored in the container was: 1). 48 Ativan 0.5 mg tablets, 2). 49 Ativan 1 mg tablets, and 3). 23 Tramadol 50 mg tablets.

A review of the Policy and Procedure titled, "Controlled Substances- Distribution and Administration Policy Reference number 290-01, Procedure: 755-14 last revised 03/2017" stated, "Controlled substances kept on the Nursing Unit shall be locked in the Nursing Narcotic Drawers in the medication room."

An interview with the ADON, on 01/09/2019 at 12:30 PM, revealed "They have never been locked. I don't know what the Policy states."

An interview with the Pharmacist (RPH), on 01/11/2019 at 1:00 PM revealed, "The locks have never worked, they are in a locked room. I haven't seen the policy."

Interview with Registered Nurse (RN - Staff T), "The Scheduled IV medications are locked in the medication room, I don't know the specific policy, but I know where to find the policy."

Based on observation and interview the facility failed to ensure expired, unusable medications were not available for patient use in 3 of 3 hospital medication storage areas.

Findings:

A.) An observation of the Adult Geriatric Unit Medication Room, on 01/08/2019 at 10:45 AM with the Pharmacist (RPH), and Assistant Director of Nursing (ADON) revealed: An unlabeled Pro-Air HFA Inhaler, Novolin-R Insulin with no open date on the box, or the bottle to provide a time of expiration was located the medication refrigerator, ten Aspirin 325 mg tablets with an expiration date of 09/2018, in the medication cabinet, eighteen packages of Triple Antibiotic Ointment in medication cabinet with an expiration date of 04/2016, an Emergency Kit which contained one bottle of 0.9% Normal Saline, with an expiration date of 08/2016, and three packages of Triple Antibiotic Ointment, with an expiration date of 08/2016.

An interview with the ADON, on 01/08/2019 at 10:45 AM revealed, "I don't know who is responsible for checking the Emergency Kits. The Nursing Supervisors should be checking the Insulin."

An interview with the RPH, on 01/08/2019, at 10:55 AM revealed, "They are supposed to date the Insulin when they open it, it's good for 30 days after it's opened. I don't know who is responsible for checking the emergency kits. I don't know how these expired medications are still in here, I check these cabinets."

B.) An observation of the Patient Care Unit Male of the medication room on 01/08/2019 at 11:00 AM with RPH, and ADON revealed: an unlabeled Pro-Air HFA Inhaler, twenty one Vraylar 3 mg capsules in a medication closet, with an expiration date of 09/30/2018, an Emergency Kit that contained three Triple Antibiotic Ointments, with an expiration date of 07/2015, 08/2016, and 08/2016, and one bottle of 0.9% Normal Saline irrigation that expired on 08/2016.

C.) An observation of the Patient Care Unit Female of the medication room on 01/08/2019 at 11:15 AM with the RPH, and ADON revealed: Novolin R Insulin opened and unlabeled, Pro-Air HFA inhaler unlabeled, Polymycin B Sulfate and Trimethoprim ophthalmic solution with no open date, that expired on 12/2018, and three Albuterol 2.5 mg in 3 milliliters that expired on 08/2018

An interview with the ADON was conducted on 01/08/2019 at 11:15 AM. She stated, "The nurses know they are supposed to label medications after they open them. I do not do audits of insulin."

An interview was conducted with the RPH, on 01/08/2019 at 11:15 AM. She stated, "Each of these medications should be labeled." The RPH further stated, "I know the policy for labeling insulin, it expires 30 days after it is opened. I do not do weekly audits of the insulin bottles."

Based on observation, interview and policy review, the facility failed to ensure blood specimens were maintain and stored for safekeeping, failed to prepare the specimen for appropriate testing, and failed to ensure specimen vacutainers were not expired.

Findings.

Tour of the laboratory storage room with the Assistant Director of Nursing (ADON) on 1/8/2019 at 9:00 AM revealed the following findings.

1. There was a Centrifuge machine on top of the counter with the last preventive maintenance date documented as 9/30/2016.

2. The refrigerator where specimens would be stored before pick up; with a thermometer reading at 45 degrees.

An interview on 1/8/2019 at 9:10 AM with the ADON she stated and confirmed the facility does not maintain, monitor, nor log the refrigerator temperature.

3. Observation on 1/8/2019 at 11:52 AM on top of the medication room counter in the male patient care unit revealed four vacutainers of drawn blood specimens labeled for Patient #12. One of the vacutainers contained urine per the Assistant Director of Nursing (ADON) and the urine sample according to the label was obtained at 9:50 AM on 1/8/2019.

An interview with Staff AA, LPN (Licensed Practical Nurse) on 1/8/2019 at 12:20 PM she stated, she is a Licensed Practical Nurse (LPN) assigned to Patient #12. Staff AA stated that the night nurse drew the blood specimens this morning about 6:00 AM and reported to her about it. When asked about the process when blood is drawn from a patient, the LPN replied, we take them to the geriatric unit to be spun in the centrifuge. Then after the centrifuge, we take them to the children's unit where we put all our specimens in a refrigerator. This process should be done within two hours from when the blood was drawn. Staff AA confirmed at 12:21 PM that the specimen had not been taken to the centrifuge for spinning.

4. Observation of the centrifuge in the Geriatric Patient Care Unit (PCU) at 12:26 PM revealed a centrifuge with a sticker dated 9/28/2016 for preventive maintenance.

5. Observation on 1/9/2019 at 11:32 AM revealed two (2) vacutainers containing blood product still in the centrifuge that were drawn at 6:00 AM on 1/9/2019.

An interview with the Director of Nursing (DON) on 1/9/2019 at 9:51 AM she stated, when the night nurse draws a blood specimen, she is supposed to call the night supervisor. The night supervisor then takes the specimen to the geriatric patient care unit medication room and places the specimen in the centrifuge. The supervisor is supposed to wait until the spin cycle is complete and take the specimen and store it in the refrigerator located in the children's special care unit laboratory room.

6. Observation on 1/10/2019 at 11:05 AM with Staff DD, RN (Registered Nurse) in the geriatric unit medication room revealed a blood specimen with a "tiger" colored top was labeled for Patient #17.

An interview with Staff DD at 11:07 AM she stated, the blood was drawn at 5:15 AM and I am supposed to take it to the children's unit where the lab refrigerator is located.

7. Observed a centrifuge machine on the counter top with a preventive maintenance date of 9/28/2016. When asked who performs preventive maintenance on the centrifuge; Staff DD replied; "I do not know". When asked which specimens require spinning in the centrifuge she replied, all the tiger top specimens.

8. Observation of the laboratory storage room with the Assistant Director of Nursing (ADON) on 1/8/2019 at 9:00 AM revealed numerous stacks of vacutainers on the counter top, in a box on the floor and in the cabinet drawer under the sink. Further observation revealed that these vacutainers, used for blood specimens were expired. a) Black and tan tiger colored tops vacutainers with an expired date of 11/4/2017 - total 198 vials. b) Rust colored tops - expired on 10/31/2018, 9/30/2017, 7/31/2018 and 12/31/2018 - total 154 vials. c) Yellow colored tops - expired on 3/2018, 6/2018, and 7/31/2018 - total 231 vials. d) Tiger colored tops - expired 12/31/2018 - total 42 vials. e) White colored tops - expired on 5/2017 - total 134 vials. f) Red colored tops - expired on 9/30/2017 - total 54 vials. g) Green colored tops - expired on 10/2017 - total 427 vials. h) Gray colored tops - expired on 9/2017 - total 16 vials. i) Gold colored tops - expired 8/3/2018 - total - 27 vials. j) Blue colored tops - expired on 4/30/2017 - total 53 vials. k) Navy Blue colored tops - expired on 5/2017 and 6/2017 - total 269 vials. l) Tan colored tops - expired 8/2017 and 9/2017 - total 239 vials. m) Red Pedia colored tops - expired 11/2017 - total 100 vials. n) Pedia lavender colored tops - expired 10/2018 - total - 111 vials. o) BD blood culture vials - expired on 4/2017 - total 21 vials. p) Aerobic blood culture vials - expired 2/28/2017 - total 15 vials. q) Anaerobic blood culture, purple colored tops - expired 3/31/2017 - total 21 vials. Observed was a total of 2,102 vacutainers that had been expired, excluding those found in each individual medication room.

Telephone interview with Staff BB, with Staff CC, on 1/10/2019 at 10:15 AM stated they both work for Laboratories as Sales/Physician Account Executives. Staff BB confirmed they provide laboratory services to this facility. Staff BB confirmed at 10:16 AM the hospital has three (3) centrifuge machines on site. Staff BB stated the three centrifuges require calibration and laboratory personnel is responsible for the preventive maintenance (PM) as required. When asked what the manufacturer's recommendation on the frequency of calibration and PM, Staff BB stated she was not 100% sure and will send me further documentation. Staff BB stated that some blood specimens require refrigeration and others do not. The facility should have a refrigerator to store the specimens, it must have a thermometer and the facility should check and maintain a temperature log daily. When asked about the integrity of the specimens if they are not placed in the centrifuge to spin, and if the blood specimen is obtained using an expired vacutainer; Staff BB replied, if the specimen is not spun in the centrifuge we do not perform the test, there will be no results. If the vacutainer is expired, we do not run the test.

As of 1/14/2019 at 4:35 PM, the documentation requested for the manufacturer's recommendation on the proper calibration and PM of the centrifuge had not been received as requested.

Review of the policy and procedure titled, "Specimen Storage Operational Procedure" read: Purpose: To provide for the storage of specimens obtained for the purposes of laboratory studies in a manner which retains the integrity of the specimen and ensures accurate results. Procedure: 1. Urine specimens shall be refrigerated as soon as possible after they are received in a closed screwed top container.

Review of the policy and procedure titled, "Laboratory, Pathology Services Operational Procedure" read: Purpose: To provide for the provision of pathology, laboratory services consistent with the needs of the consumer population of LifeStream within available resources and to ensure that such services meet established standards of quality and statutory mandates. Item #V under procedure read: Collection of specimens for pathology or laboratory tests shall be consistent with the policies and procedures of the contracting laboratory.

Review of the policy and procedure titled, "Refrigerator Operational Procedure" Procedure under V. indicates: Documentation of daily temperature checks should be logged and available for review on request.

Based on interview and policy review the facility failed to develop a system for identifying, reporting, investigating and preventing the possible spread of infection by patients and personnel.

Findings:

During an interview with the Assistant Director of Nursing (ADON), on 1/9/2019 at 8:40 AM she stated she took this position as the Infection Control Nurse for a little over a year ago. ADON stated she has multiple responsibilities in this facility and infection control is just one of them. ADON stated that she does not maintain a log of incidents related to infections and communicable diseases for patients and or employees. ADON confirmed on 1/9/2019 at 8:52 AM that there has been no active surveillance program for the prevention, control and investigation of a communicable disease. ADON was not able to provide any evidence of an ongoing infection control process/program.

Interview with the ADON on 1/9/2019 at 11:22 AM when asked what is her process for surveillance of infection in the facility, ADON responded; first of all we do not accept patients that are not medically cleared. If patient comes like coughing blood, we send them back to the hospital. There are medical criteria's that we have to meet before we can admit a patient.

Interview with the Director of Nursing (DON) / Registered Nurse (RN) on 1/9/2019 at 9:33 AM stated she is the DON for two years. She stated that the designated Infection Control Practitioner (ICP) is the ADON for over a year. DON confirmed at 9:34 AM stated that when she came aboard, there was no infection control nurse (ICN) in the facility. DON stated that she has a surveillance process when a patient is on antibiotic, have a cold and or urinary tract infection, we monitor these patients. When asked to provide evidence of the infection control surveillance log for the past 12 months, the DON stated the log is locked in the medical practitioner's office. The DON returned ten minutes later and provided a one page document of a list of six (6) patients who received antibiotics in March and April, year unknown. The surveillance log indicators included the patients' name, antibiotic ordered, date ordered, duration of therapy, diagnostic tests/Rationale and follow up results. No other documents were provided to this Surveyor of an infection surveillance log. The DON stated, "It is what it is", we did not do any surveillance other than this one page. The DON stated the ADON is not aware of this surveillance log because it was done by the Nurse Practitioner.

Review of the Infection Control Operational procedure approved on 4/7/2017 read: Purpose: Infections acquired in a facility or brought into a facility from the community are potential hazards for all persons having contact within the facility. The procedure establishes a mechanism of reporting, monitoring, evaluating, investigating and recommendations of measures designed to prevent, identify and control infections. Under procedure # I read: The Infection Control Coordinator shall be a part of the Environmental Panel. All issues concerning infectious disease will be addressed in the panel. Item #IV read: The Environmental Panel shall investigate reported infections, maintaining information on trends, identifying potential hazards and making recommendations for corrective action.

Based on record review, interviews, and policy and procedure review the facility failed to ensure medical records were maintained to ensure patient safety, the effectiveness of treatment, and the degree and intensity of the treatment needed for individuals who were furnished services. For these reasons, the Condition of Special Medical Record Requirements for Psychiatric Hospitals was found to be out of compliance. These failures potentially hamper the physical and psychosocial well-being of patients.

I. Document a full psychosocial assessment for 2 of 8 active sampled patients, Patients #6 and #8. Psychosocial assessments were incomplete and lacked a summary of pertinent anticipated necessary steps for discharge to occur, or specific community resources/support systems for utilization in discharge planning. (Refer to B108)

II. Ensure the Master Treatment Plans (MTPs) were revised when patients were placed in restraint (manual hold). Specifically, for 1 of 8 active sampled patients, #10, the MTP was not revised to reflect problem statements related to the use of restraint to control aggressive behavior, treatment goals and active treatment interventions outlining healthy alternatives and approaches for the patient to use to replace aggressive behavior(s). This failure impedes the provision of active treatment to meet the specific treatment needs of patients. The facility failed to ensure Master Treatment Plans (MTP) were comprehensive and individualized, and/or updated for 3 of 8 sampled active patients, Patients #6, #7 and #8. Not updating the MTP for individualized problems with goals and objectives for each admission potentially hampers the treatment team's ability to determine whether the treatment plan goals and objectives were met and/or are current. (Refer to B118)

III. Ensure the Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for 6 of 8 active sample patients, Patients #6, #7, #8, #10, #12, and #13. Specifically, the MTPs did not include:

(1) The actions to be taken by the patients that would lessen the severity of problems identified on admission, the patient outcomes or areas of patient improvement were not specific, or described routine hospital functions performed by clinical staff. Failure to identify individualized goals potentially hampers the treatment team's ability to determine whether the treatment plan is effective and if it needs to be revised. (Refer to B121).

(2) Specific individual active treatment interventions (Refer to B122). Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

Based on record review, and interview the facility failed to ensure a comprehensive psychosocial assessment was completed for 2 of 8 active sample patients, Patients #6, and #8. The Bio-Psychosocial Intake Assessment is to be completed at the time of the patients' initial intake assessment. Some psychosocial assessments were incomplete for the anticipated social work role in treatment and discharge planning. This failure to comprehensively assess the patient's psychosocial needs potentially resulted in suboptimal inpatient progress and/or inadequate discharge care plans.

Findings:

Patient #6 was admitted on 12/09/2018 with a diagnosis of Major depressive disorder.

Review of the Bio-Psychosocial Intake Assessment documented under the section titled "Social Functioning Status" the following: "Reports he has been married for 8 years and separated for 4, reports two children who have been adopted due to his SA (substance abuse) and his estranged wife's SA issues. He reports that he is currently dependent upon others for living and reports that he is at times triggered to use due to the relationship with his father and his history with trauma, he reports that his father was abusive toward his mother and himself growing up and reports that his father's alcohol issue was a factor in the abuse. There was no documentation pertinent to anticipated necessary steps for discharge to occur, or specific community resources/support systems for utilization in discharge planning.

Patient #8 was admitted on 12/15/2018 with diagnosis of Bipolar I disorder, Brief psychotic disorder, and Major depressive disorder.

Review of the Bio-Psychosocial Intake Assessment documented under the section titled, "Social Functioning Status" the following: "She reports that she is currently homeless. She reports that she was kicked out of her parent's house and her fiancé's house as well. She reports verbal abuse. She reports one year of college. No children. No support system. Not a veteran. There was no documentation pertinent to anticipated necessary steps for discharge to occur, or specific community resources/support systems for utilization in discharge planning.

During an interview on 01/09/2019 at 11:29 AM with the Acute Care Services Manager she verified the Bio-Psychosocial Intake Assessment for Patients #6 and #8 were not complete and did not provide for discharge planning related to the necessary steps that would need to be taken for discharge to occur, there were no specific community resources/support systems for utilization in discharge planning.

Based on interview, record review and policy and procedure review the facility failed to ensure a complete neurological examination was conducted for 1 of 8 sampled patients, Patient #7.

Findings:

Patient #7 was admitted into the facility on 11/27/2018 with a diagnosis of Schizophrenia and Headache.

Review of the History and Physical dated 11/28/2018 showed the examination was not completed for orientation, alertness, and the nervous system for the Trochlear, Trigeminal, Abducens, Facial, Vagus, Spinal and Tongue were blank.

During an interview on 01/10/2019 at 11:12 AM with the DON (Director of Nursing) she verified the History and Physical form was not complete for Patient #7 regarding the patient's level of alertness, and orientation. The DON further verified the nervous system findings were not documented for the Trochlear, Trigeminal, Abducens, Facial, Vagus, Spinal and Tongue.

Review of the policy and procedure titled, "Physical Assessment" it showed A. Purpose: To establish a mechanism wherein the health needs of individuals admitted to the facility may be identified and, to the extent that it is determined appropriate, included in the plan of treatment. B. Procedure: I. A physician or licensed physician's extender under supervision shall obtain a medical history and conduct a physical examination on each individual within twenty-four (24) hours of their admission to the facility.

Based on interview, record review and policy and procedure review the facility failed to ensure the Master Treatment Plan (MTP) was revised when a patient was placed in restraint. The MTP was not revised to reflect a problem statement related to the use of restraint to control aggressive behavior, identification of treatment goals and interventions outlining healthy alternatives and approaches for the patient to use to replace aggressive behavior(s) for 1 of 8 active sampled patients, Patient #10. This failure impedes the provision of active treatment to meet the specific treatment needs of the patient, and the facility failed to ensure Master Treatment Plans (MTP) were comprehensive and individualized, and/or updated for 3 of 8 sampled active patients, Patients #6, #7 and #8. Not updating the MTP for individualized problems with goals and objectives for each admission potentially hampers the treatment teams' ability to determine whether the treatment plan goals and objectives were met.

Findings:

During an interview on 01/8/2019 at 8:19 AM with Patient #10 he stated, "When I came in I was trying to get out of here. They wouldn't let me out, so I tried to break out. It was like eight of them took me to the floor and they gave me a shot. I don't know who it was, I just know that I was put on the floor and I got a shot."

Record review of the physician's orders showed dated 01/05/2019 at 9:35 AM 400 mg Thorazine IM due to increased agitation and being aggressive towards staff and trying to destroy property.

Review of the Data Assessment Plan (DAP) showed dated 01/05/2019 Description: Consumer had increased agitation and was aggressive towards staff, several attempts were made to de-escalate the situation. Consumer attempted to break the glass door with his shoulder and a Dr. Strong, in an interview with the Risk Manager she stated this is the code that is called when a patient exhibits aggressive behavior for staff to come to the area and assist, was called, the physician was notified and received an order for 400 mg Thorazine IM (intramuscularly). Injection administered to right buttock, tolerated without difficulty, Team hold was required during administration of injection and two minutes afterwards.

During an interview on 01/10/2019 at 12:35 PM with the Acute Care Services Manager (ACSM) when asked if a patient has an ETO (emergency treatment order) is the MTP updated. The ACSM stated, "Yes, it is to be updated on the MTP each time the injection is given. The ACSM reviewed the MTP for Patient #10 and stated, "Whatever led to the ETO (emergency treatment order) would be listed on the MTP." The ACSM verified the MTP was not updated to document the ETO on the MTP that occurred on 01/05/2019.

Record review of the policy and procedure titled, "Master Treatment Planning" showed B. Procedure: XI. Treatment plans are reviewed and updated at each key decision point in the course of treatment, including transfer to another unit, a major change in the individual's condition, completion of or lack of progress toward goals and at discharge, after receipt of any form of restraint, seclusion or ETO and no less than once per week.

Patient #6 was admitted to the facility on 12/09/2018 with a diagnosis of Major depressive disorder, History of spinal cord injury, History of traumatic brain injury, Seizure disorder, and Suprapubic urinary catheter in situ.

Review of the Master Treatment Plan (MTP) showed Revision Date 12/09/2018. Under the section titled, "Summary of Key Assessment Findings: Admitted under monitoring for signs and symptoms of Benzodiazepine withdrawal with suicide precautions, seizure precautions, and high fall risk.

Record review of the UDS (urine drug screen) showed positive for cocaine and Benzodiazepine.

The MTP showed a problem for opioid use disorder, presents to detox for fentanyl and other substances showing active and dated 06/30/2018, with STGs (Short Term Goals), Objectives and interventions showing active with dates of 06/30/2018 to 07/01/2018. The dates provided were prior to the current admission. The MTP did not provide for a treatment plan of the patient's medical problems related to seizure precautions, high fall risk or the patient presenting with a suprapubic urinary catheter.

Patient #7 was admitted to the facility on 12/26/2018 with diagnosis of Schizophrenia and Headache.

Review of the MTP revision date 11/27/2018 showed Problem: Schizophrenia. The STG, Objectives, and Interventions showing active, Target Date 11/27/2018. Problem: Alteration in thought process AEB (as evidenced by) rapid speech and flight of ideas, the STGs, Objectives, and Interventions showed active, Target dates of 11/26/2018 to 12/03/2018. The MTP did not provide for the patient's medical condition related to headache.

Patient #8 was admitted to the facility on 12/15/2018 with diagnosis of Bipolar I disorder, Brief psychotic disorder, and Major depressive disorder.

Review of the MTP revision date 12/15/2018 Problem: Brief Psychotic disorder, active with STGs, Objectives, and Interventions active, Dated 02/10/2017. Problem: will begin to control symptoms and behaviors AEB a decrease in presenting issues that lead to her admission. STGs, Objectives and Interventions showed active, Target date: 02/20/2017. Problem: Bipolar I disorder, active with STGs, Objectives, and Interventions active, Target date: 11/05/2018. Problem: presents with hallucinations and manic behavior secondary to Bipolar D/O (disorder) AEB statements on BA (Baker Act), Active. With STGs, Objectives, and Interventions showing active with Target dates of 11/05/2018 to 11/08/2018. The Target dates were prior to the patient's current admission. The treatment plan did not provide for treatment related to discharge planning.

During an interview on 01/09/2019 at 11:12 AM with the Chief Auditor (CA) when asked why MTPs show Target Dates prior to the patients' current admission dates she stated, those were from prior admissions. This happens because it is due to the problem not being closed out properly when the patient has been discharged. When asked if the problems with targets dates prior to the current admission dates would be considered in affect for this admission the CA stated, "No, they shouldn't be. The MTPs should be established for the current admission. I am embarrassed it should not be showing that."

During an interview on 01/10/2019 at 12:00 PM with the Acute Care Services Manager the MTPs (Master Treatment Plans) were reviewed for Patients #6, #7, and #8. The ACSM stated, the goals that are dated for before this admission shouldn't show they are active. They should have been put as inactive. The ACSM verified the MTP was not comprehensive and did not provide for the assessed problems with goals, and interventions. The ACSM further verified the MTPs had not been updated.

During an interview on 01/10/2019 at 10:38 AM with the Chief Hospital Officer (CHO) when asked the purpose of the Master Treatment Plan (MTP) the CHO stated, "To state the goals for the patients while here, and to delineate the treatment for that patient based on that delineation of the goals that are set to see if the patient, to help the patient is better, to help the patient meet goals. When asked how involved disciplines would know the goals are met, the CHO stated how we would know they met their goals or not is by the DAP (Data Assessment Plan) notes it would show if the patient has met their goal. We continue with the same goal if the patient doesn't change their mind. You have to understand the average length of stay is two to four days. In order for us, we are not following up with the patient long term care. If the patient is going to be a long term stay we would be able to look at if they met the goal for medications for example, we establish the goal so they can meet the goals. When asked how the disciplines involved in the care of the patient would know the patient met their goals the CHO stated by getting shift report, they don't talk about all goals, but they talk about goals. The nurse, if the patient is here more than 12 days, we must reassess on the 12th day. On the 30th day the care plan should be updated. The care plan is done within 72 hours. If the patient is here more than 12 days the treatment plan is reevaluated and signed by the physician. If it has been 30 days the treatment plan should be updated. We look at the goals, and may not change the goals. We look at the goals that are established and note that on the plan, if the patient has not met those goals and if it should be continued.

Review of the policy and procedure titled, "Master Treatment Planning" showed III. Within eight (8) hours after admission, nursing staff will complete a nursing assessment and formulate a nursing diagnosis. The nurse shall develop and document the plan on the approved master treatment planning forms. V. Within twenty-four (24) hours after admission, the Recovery Specialist will review the psychosocial assessment in the electronic health record. Problems and issues identified in the assessment shall be included in the treatment plan. The emphasis shall be on stabilizing the immediate crisis and making referrals for long term treatment objectives. VIII. Within twenty-four (24) hours after admission, the treatment team will evaluate all verbal and written assessment information. All members will complete their respective components and the Recovery Specialist shall review the plan in its entirety for completeness and assure: a. Completion of the master treatment plan assessment summary by a team member from each discipline. B. Completion of the problems list. C. Completion of the master treatment plan, to include: 1) Individual strengths and liabilities. 2) Substantiated diagnosis. 3) Behaviorally descriptive psychiatric problem statements based on how each consumer manifested presenting symptoms. 4) Problem statement, discharge criteria and target date for goal attainment. 5) Interventions, person(s) responsible and target dates. 6) Observable and measurable short-term goals written in behavioral terms. 7) Long-term objectives, Individualized goals with measurable objectives, interventions, person(s) responsible and target dates. 8) Specific individualized active treatment interventions. IX. Medical staff, nursing staff, Recovery Specialists, and activity therapists are each responsible for documenting on the treatment plan the interventions to be provided by their own discipline. XI. Treatment plans are reviewed and updated at each key decision point in the course of treatment, including transfer to another unit, a major change in the individual's condition, completion of or lack of progress toward goals and at discharge, after receipt of any form of restraint, seclusion or ETO (Emergency Treatment Order) and no less than once per week. XIII. All treatment team members are responsible for the development and implementation of the treatment plan, under the overall direction of the psychiatrist. All team members participate in the documentation of the plan. The Recovery Specialist coordinates with team members to see that documentation is complete.

Based on record review, interview, and policy and procedure review the facility failed to ensure Master Treatment Plans (MTPs) for 6 of 8 active sampled patients, Patients #6, #7, #8, #10, #12, and #13 identified individualized patient-related short-term goals (STGs) stated in observable, measurable, and behavioral terms. Short-term goals (STG) statements did not include what the patient would do to lessen the severity of problems identified on admission. In addition, the STGs did not define patient outcomes or areas of patient improvement, were not specific, or described routine hospital functions performed by clinical staff. Failure to identify individualized goals potentially hampers the treatment team's ability to determine whether the treatment plan is effective and if it needs to be revised.

Findings:

Patient #6 was admitted to the facility on 12/09/2018 with a diagnosis of Major depressive disorder, single episode, severe.

Review of the Treatment Plan showed Revision Date 12/09/2018. Problem: Presents with opioid use disorder as evidenced by (AEB) presents to detox for fentanyl and other substances. He reports onset of opiate use after his spinal injury 13 years ago after being under the influence of cocaine he jumped from 30 feet. Short Term Goal: will express understanding that current situation is negatively impacting emotional and physical wellbeing. The STG was not stated in behavioral and specific terms with positive alternative or replacement behaviors that would show the patient's increased level of understanding.

Patient #7 was admitted to the facility on 11/27/2018 with a diagnosis of Schizophrenia.

Review of the MTP showed Problem: Schizophrenia. STG: will begin to control symptoms AEB (as evidenced by) a decrease in presenting issues that led to admission. This STG does not include direct positive action behavior(s) that the patient would achieve to show a decrease in the presenting issues leading to admission. Problem: Was displaying aggressive behavior at her group home. STG: Will minimize the possibility of restraint use during outbursts of aggression or violence. The STG was not stated in behavioral terms reflecting what the patient would be doing or saying to minimize the possibility of restraint. Intervention: Will exhibit restraint when confronted with difficult situations. This intervention was not a specific behavioral and measurable patient outcome statement.

Patient #8 was admitted to the facility on 12/15/2018 with diagnosis of Major depressive disorder, Bipolar I disorder, and Schizoaffective disorder.

Review of the MTP dated 12/15/2018 showed Problem: Brief Psychotic disorder. Objective: Will develop an understanding of how symptoms negatively affect daily living of self and others daily 10 min. This objective does not reflect an action statement(s) regarding the patient's understanding about symptoms and the negative affect it would have on daily living to self and others. Problem: Major depressive D/O (disorder). STG: Will experience a decrease in acute, reactive, psychotic symptoms and return to normal functioning. This STG was not stated in behavioral terms reflecting what the patient would be doing or saying related to the diagnosis of depressive disorder. Objective: Will report a decrease in hallucinations/delusions and will learn healthy coping to improve daily functioning. This objective was not stated in behavioral terms reflecting what the patient would be doing or saying related to the diagnosis of depressive disorder.

Patient #10 was admitted to the facility on 01/04/2019 with a diagnosis of Bipolar I disorder.

Review of the MTP dated 01/04/2019 showed Problem: Bipolar I D/O (disorder). STG: Will experience a decrease in acute, reactive, psychotic symptoms and return to normal functioning. This STG was not stated in behavioral and specific terms with positive alternative or replacement behavior that would show a decrease in the patient's psychotic symptoms. Problem: Bipolar I disorder, current or most recent episode manic, with psychotic features. STG: Will display a decrease in paranoid delusions (psychosis) and will demonstrate orientation on all spheres. This STG was not stated in behavioral and specific terms with positive alternative or replacement behavior that would show a decrease in paranoid delusions.

Patient #12 was admitted to the facility on 01/06/2019 with a diagnosis of Bipolar I disorder, Schizoaffective disorder, bipolar type.

Review of the MTP dated 01/06/2019 showed Problem: Bipolar I disorder, current or most recent episode manic, severe. STG Will exhibit and report stable mood and reduced suicidal ideation. This STG was not stated in behavioral and specific terms with positive alternative or replacement behavior that would show the patient was exhibiting a stable mood. Problem: Bipolar I D/O, suicidal ideations. STG: Will experience a reduction in thoughts of self-harm and will refrain from self-harming behaviors during current admission. This STG was not specific behavioral and measurable patient outcome statement for the reduction in thoughts of self-harm. Objective: Will experience a reduction of self-injurious behaviors, passive suicidal ideations, mood stabilization and medication compliance. This objective was not specific to behavioral and measurable patient outcome statement for passive suicidal ideations, and mood stabilization. This objective was stated as a negative with the patient being less medication compliant.

Patient #13 was admitted to the facility on 12/31/2018 with a diagnosis of Major depressive disorder, recurrent episode, severe.

Review of the MTP dated 12/31/2018 showed Problem: Major depressive D/O, suicidal ideations. STG: Will experience a reduction in thoughts of self-harm and will refrain from self-harming behaviors during current admission. This STG was not specific to behavioral and measurable patient outcome statement for a reduction in thoughts of self-harm. Objective: Will experience a reduction of self-injurious behaviors, passive suicidal ideations, mood stabilization and medication compliance. This objective was not specific to behavioral and measurable patient outcome statement for passive suicidal ideations, and mood stabilization. This objective was stated as a negative with the patient being less medication compliant. Problem: On a scale of 1 to 10, with 10 being the highest, Patient reported her depression rating at a 10. This problem did not provide for STGs. Objective: Will actively engage in at least 30 minutes of daily psycho-educational groups and learn at least 2 coping strategies to reduce symptoms of depression. This objective was not stated in behavioral terms reflecting what the patient would be doing or saying to show that the patient learned at least 2 coping strategies in the reduction in symptoms of depression.

During an interview on 01/10/2019 at 10:38 AM with the Chief Hospital Officer (CHO) when asked the purpose of the Master Treatment Plan (MTP) the CHO stated, "To state the goals for the patients while here, and to delineate the treatment for that patient based on that delineation of the goals that are set to see if the patient, to help the patient is better, to help the patient meet goals. When asked how involved disciplines would know the goals are met, the CHO stated how we would know they met their goals or not is by the DAP (Data Assessment Plan) notes it would show if the patient has met their goal. We continue with the same goal if the patient doesn't change their mind. You have to understand the average length of stay is two to four days. In order for us, we are not following up with the patient long term care. If the patient is going to be a long term stay we would be able to look at if they met the goal for medications for example, we establish the goal so they can meet the goals. When asked how the disciplines involved in the care of the patient would know the patient met their goals the CHO stated by getting shift report, they don't talk about all goals, but they talk about goals. The nurse, if the patient is here more than 12 days, we must reassess on the 12th day. On the 30th day the care plan should be updated. The care plan is done within 72 hours. If the patient is here more than 12 days the treatment plan is reevaluated and signed by the physician. If it has been 30 days the treatment plan should be updated. We look at the goals, and may not change the goals. We look at the goals that are established and note that on the plan, if the patient has not met those goals and if it should be continued.

During an interview on 01/10/2019 at 12:00 PM with the Acute Care Services Manager (ACSM) the MTP (Master Treatment Plan) were reviewed for Patients #6, #7, #8, #10, #12, and #13. The ACSM verified some of the goals were not specific or measurable patient oriented goals.

Review of the policy and procedure titled, "Master Treatment Planning" showed III. Within eight (8) hours after admission, nursing staff will complete a nursing assessment and formulate a nursing diagnosis. The nurse shall develop and document the plan on the approved master treatment planning forms. V. Within twenty-four (24) hours after admission, the Recovery Specialist will review the psychosocial assessment in the electronic health record. Problems and issues identified in the assessment shall be included in the treatment plan. The emphasis shall be on stabilizing the immediate crisis and making referrals for long term treatment objectives. VIII. Within twenty-four (24) hours after admission, the treatment team will evaluate all verbal and written assessment information. All members will complete their respective components and the Recovery Specialist shall review the plan in its entirety for completeness and assure: a. Completion of the master treatment plan assessment summary by a team member from each discipline. B. Completion of the problems list. C. Completion of the master treatment plan, to include: 1) Individual strengths and liabilities. 2) Substantiated diagnosis. 3) Behaviorally descriptive psychiatric problem statements based on how each consumer manifested presenting symptoms. 4) Problem statement, discharge criteria and target date for goal attainment. 5) Interventions, person(s) responsible and target dates. 6) Observable and measurable short-term goals written in behavioral terms. 7) Long-term objectives, Individualized goals with measurable objectives, interventions, person(s) responsible and target dates. 8) Specific individualized active treatment interventions. IX. Medical staff, nursing staff, Recovery Specialists, and activity therapists are each responsible for documenting on the treatment plan the interventions to be provided by their own discipline. XI. Treatment plans are reviewed and updated at each key decision point in the course of treatment, including transfer to another unit, a major change in the individual's condition, completion of or lack of progress toward goals and at discharge, after receipt of any form of restraint, seclusion or ETO (Emergency Treatment Order) and no less than once per week. XIII. All treatment team members are responsible for the development and implementation of the treatment plan, under the overall direction of the psychiatrist. All team members participate in the documentation of the plan. The Recovery Specialist coordinates with team members to see that documentation is complete.

Based on record review, interview and policy and procedure review the facility failed to provide 8 of 8 active sampled patients, Patients #6, #7, #8, #9, #10, #11, #12, and #13 with Master Treatment Plans (MTPs) that included individualized active treatment interventions that stated specific treatment modalities with a focus of treatment based on each patient's presenting problems and goals. Specifically, MTPs included routine discipline functions selected from options on the facility's electronic medical record. These options stated as treatment interventions were generic, vague, and global statements without an identified method of delivery. They included no interventions related to psychiatric problems identified to be implemented by the attending psychiatrist for 6 of 8 active sampled patients, Patients #6, #7, #9, #11, #12 and #13, no RN (Registered Nurse) interventions for 7 of 8 active sampled patients, Patients #6, #7, #8, #9, #11, #12 and #13, and no social work intervention identified for 1 of 8 sampled patients, Patients #6.

Findings:

Patient #6's Bio-Psychosocial Intake Assessment dated 12/09/2018 the Patient stated "he feels hopeless without his father. Stated that he wants to 'put his lights out'. Stated that he was discharged from the hospital a few days ago and went to a field. He stated that "everything's not working." He stated that he has been having issues with memory and he stated that his father was concerned about him. He stated that his father "knows if I'm alone I'll hurt myself."

Review of the MTP showed Problem: Major depressive disorder, there were no modalities listed, no RN interventions, or interventions related to psychiatric problems identified to be implemented by the attending psychiatrist.

Patient #7's Bio-Psychosocial Intake Assessment showed dated 11/27/2018 the patient was causing a disturbance at a group home. Upon arrival, I made contact with staff and was advised that the listed subject who has just returned home from Lifestream, was causing a disturbance. The subject was uncooperative with staff, aggressive towards other residents and threatening to harm others by killing them with kitchen knives. The subject also refused to eat since returning to the home.

Review of the MTP showed Problem: Schizophrenia. Intervention: Will be encouraged by staff to attend and participate in daily groups and activities and respond appropriately. The intervention was vague and was a staff function and not related to the patient's diagnosis. Intervention: Group Modality: Will attend psycho-educational groups to increase knowledge of appropriate coping skills to manage life stressors and depression, 2 x daily for 30 minutes each session. This intervention was generic and/or a routine discipline function written as a treatment intervention instead of an individualized intervention based on the patient's psychiatric symptoms or problems identified upon admission. Problem: Will have a better understanding of her mental illness by her behavior on the unit. Intervention: Nurse will educate Patient about the importance of taking her medication and developing positive coping skills to help her deal with her stressors. The nursing intervention was a routine staff function and not a specific patient outcome statement related to the patient's improvement. There were no RN interventions, and no interventions related to psychiatric problems identified to be implemented by the attending psychiatrist.

Patient #8's Bio-Psychosocial Intake Assessment dated 12/15/2018 showed her mental condition now has deteriorated and she cannot make sound decisions for personal care and financial responsibility. Her mental state is delusional and out of touch. She lies about her activities, does things secretively. Attitudes and actions/shows no love and respect to family and brother. She is currently on street with Cowboy who may have a criminal past. He wears a knife. She keeps referring to a man with a gun that is trying to kill her. This may be delusional."

Review of the MTP showed Problem: Brief Psychotic Disorder: Intervention: Individual Modality: RS will provide referrals for outpatient treatment and discuss these referrals with the Patient daily for 10 minutes until discharge. This intervention was generic and/or a routine discipline function written as a treatment intervention instead of an individualized intervention based on the patient's psychiatric symptoms or problems identified upon admission. Intervention: Group Modality: Will attend psycho-educational groups to increase knowledge of appropriate coping skills to manage life stressors, 2 x daily for 30 minutes each session. This intervention was generic and/or a routine discipline function written as a treatment intervention instead of an individualized intervention based on the patient's psychiatric symptoms or problems identified upon admission. Problem: Will begin to control symptoms and behaviors AEB (as evidenced by) a decrease in presenting issues that led to admission. Intervention: Modality: Staff Intervention: Will be compliant with taking her medication as prescribed by the physician. This intervention is generic, general staff would not be responsible for medication compliance. This intervention was generic and/or a routine discipline function written as a treatment intervention instead of an individualized intervention based on the patient's psychiatric symptoms or problems identified upon admission. Problem: Bipolar I disorder. There were no interventions. Problem: Presents with hallucinations and manic behavior secondary to Bipolar D/O (disorder) AEB (as evidenced by) statements on BA (Baker Act). Intervention: Staff will assess for negative symptoms and behaviors, will encourage medication compliance and will provide therapeutic groups. Intervention: Psycho-educational groups to focus on medication management skills. Intervention: Will take medications as prescribed to decrease her current symptoms. Problem: Symptoms and Behaviors which impair functioning. Intervention: Will take medications as prescribed to decrease her current symptoms. Intervention: Will actively participate in discussion with staff about the nature of and need for medication daily 15 minutes. Intervention: RS Group Modality: Will attend psycho-educational groups to increase knowledge of appropriate coping skills to manage life stressors and depression, 2 x daily for 30 minutes each session. Intervention: Staff will educate Patient about the nature of and need for medication regiment daily 10 mins. Intervention: RS and staff will assist Patient in learning new coping skills for stressful situations, daily for 15-20 mins. These interventions were generic and/or routine discipline functions written as a treatment intervention instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. Some of the interventions named staff as the responsible discipline which would not meet the standards of practice for medication education and medication compliance. There were no RN (Registered Nurse) interventions.

Patient #9's Bio-Psychosocial Intake Assessment dated 12/23/2018 showed "Patient is actively hallucinating and responding to internal stimuli. She has been refusing to take Risperidone for a few weeks now. She has a long history of mental health problem including stays w/ (sic) state hospitals. She has refused to sign releases to get information as "we would think she's crazy."

Review of the MTP showed Problem: Manic/paranoid behaviors related to Bipolar D/O (disorder) and medication noncompliance AEB statements on BA (Baker Act) Intervention: Staff will encourage medication compliance and provide therapeutic groups during Patient's admission. Intervention: Will actively participate in discussion with staff about the nature of and need for medication daily 15 mins. Intervention: Will attend psycho-educational groups to increase knowledge of appropriate coping skills to manage life stressors and depression, 2 x daily for 30 minutes each session. Intervention: Nursing will educate Patient about the importance of med compliance as prescribed. These interventions were generic and/or routine discipline functions written as a treatment intervention instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. Intervention: Nursing will educate about the importance of med compliance as prescribed. This intervention is a routine staff function and not a specific patient outcome statement related to the patient's improvement. There were no RN interventions, or interventions related to psychiatric problems identified to be implemented by the attending psychiatrist.

Patient #10's Bio-Psychosocial Intake Assessment dated 01/04/2019 showed "Beginning about 3 weeks ago, Patient started being very paranoid about a group called the luminoty! He said they were out against us and tried to get one of his brothers to bring a gun to our church to protect us. He did not! So we tried that week to reason with him thinking he was having a mental breakdown. He had been to a friend's house and smoked something called wax? Day after Christmas he had called 911 and told them God said he was to be a sacrifice. "I have the reports, they Baker Acted him to Gainesville kept him 72 hours, let him out. So we have continued trying to talk him down most of these past days. He has been very paranoid off and on and accusing anyone that doesn't agree with him of trying to sabotage his bank account, vehicle and him in general. We have tried to reason with him and get him to go talk with a counselor. He has talked with our pastor from our church, but not followed his advice. He's not sleeping much, has changed his diet and has given all his possessions that were meaningful to him. He says he's a man from Gods on a mission, but he is not being responsible for his wellbeing or can hold any reasonable conversation from us to help him. Last conversation today, he said he will not ever see me again". The petitioner's husband also provided additional information stating the following: "he refuses to listen to any reasoning concerning his behavior acting out against his family thinking they are all against him and they are working with an organization to harm and steal from him. He cannot have a normal conversation without it leading to anger and disrespectful accusations. We think because he is growing worse in his reality that he will become more aggressive and uncontrollable. He lives with mom, dad and brother, and now does not trust any of us. We have tried for days to reason with him and get him to understand he may have some family mental problems. But he thinks we are all mental and against him."

Review of the MTP showed Problem: Bipolar I D/O. Modality: Individual, frequency: daily, duration: 15 min. RS will encourage Patient to discuss symptoms as they occur to increase understanding of their negative impact on wellbeing. This intervention was generic and/or routine as to a discipline function written as a treatment intervention instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission.

Patient #11's Bio-Psychosocial Intake Assessment dated 01/04/2019 the subject was arguing with several family members. He was extremely hostile and in a fit of rage began causing significant damage to property inside of the residence. Due to his extreme level of anger there is a high likelihood he could cause harm to others without treatment. Reported that he was in a verbal argument with his brother's girlfriend who is 17 whom has been living in their home for a month. Reported he was having a conversation with his sister and the brother's girlfriend came in the room demanding they need to shut it. Stated he is 22 years old and a minor should have more respect towards adults. Due to his anger and frustration he kicked and punched holes in the wall then left the home. Once he came back into the home he noticed that his sister was in verbal arguments with the brother's girlfriend and other members of the home. Reported he just became angry at the current situation.

Review of the MTP showed Problem: Aggression and violent behaviors. Intervention: RS: Modality: Individual, frequency: daily, duration: 15 min. RS will encourage Patient to keep a journal of automatic thoughts associated with depressive behavior and share them daily. This intervention was generic and/or routine as to a discipline function written as a treatment intervention instead of individualized interventions for the problem of aggressive and violent behaviors. There were no RN interventions, or interventions related to psychiatric problems identified to be implemented by the attending psychiatrist.

Patient #12's Bio-Psychosocial Intake Assessment dated 01/06/2019 showed "Responded to residence, made contact with Patient. He advised he had just walked to Citrus County from Palm Harbor. Patient stated he had been off his meds for days and wants to kill himself. Patient stated if he didn't get help he doesn't know what he will do to himself."

Review of the MTP showed Bipolar I disorder, current or most recent episode manic, severe with no interventions. Problem: Bipolar I D/O, suicidal ideations. Intervention: RS: Modality: individual, frequency: daily, duration: 15 min. RS will encourage Patient to keep a journal of automatic thoughts associated with depressive behavior and share them daily. This intervention was generic and/or routine as to a discipline function written as a treatment intervention instead of individualized interventions for the problem of suicidal ideations. There were no RN interventions, or interventions related to psychiatric problems identified to be implemented by the attending psychiatrist.

Patient #13's Bio-Psychosocial Intake Assessment dated 12/31/2018 showed "I responded to home in reference to the Patient. Upon making contact with the Patient, she advised she has been really stressed and has been looking for an outlet so she can cut her hair bald. The Patient also advised that she wanted to harm herself by tying a hose to a vehicle's exhaust pipe and breathe the fumes in. Reported hoping to get answers for what is triggering her depression. She was unable to identify any triggers for her depressed mood. She reported feeling a lot of anxiety earlier today, which led to the suicidal thoughts. "Eventually it grows more and more until I do something wrong, because I'm over analyzing." Reported this leads to a breakdown, where she wants to harm herself. "It always centers around paranoia, thinking that I'm not doing good enough or making people happy." On a scale of 1 to 10, with 10 being the highest, reported depression and anxiety rating both at a 10.

Review of the MTP showed Problem: Major depressive D/O, suicidal ideations. Intervention: No modality interventions, no RN interventions were documented for this problem. Problem: On a scale of 1 to 10, with 10 being the highest, reported depression rating at a 10. Intervention: Will discuss symptoms with staff. Intervention: RS: Individual Modality: Will actively participate in simple short-term activities to improve orientation, focus and concentration for 15 minutes daily. Intervention: RS: Individual Modality: RS will provide referrals for outpatient treatment and discuss these referrals with Patient daily for 10 minutes until discharge. Intervention: RS: Group Modality: Will attend psycho-educational groups to increase knowledge of appropriate coping skills to manage life stressors and depression, 2 x daily for 30 minutes each session. These interventions were generic and/or routine discipline functions written as treatment interventions instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. No RN interventions were documented for this problem.

During an interview on 01/10/2019 at 10:38 AM with the Chief Hospital Officer (CHO) when asked the purpose of the Master Treatment Plan (MTP) the CHO stated, "To state the goals for the patients while here, and to delineate the treatment for that patient based on that delineation of the goals that are set to see if the patient, to help the patient is better, to help the patient meet goals. When asked how involved disciplines would know the goals are met, the CHO stated how we would know they met their goals or not is by the DAP (Data Assessment Plan) notes it would show if the patient has met their goal. We continue with the same goal if the patient doesn't change their mind. You have to understand the average length of stay is two to four days. In order for us, we are not following up with the patient long term care. If the patient is going to be a long term stay we would be able to look at if they met the goal for medications for example, we establish the goal so they can meet the goals. When asked how the disciplines involved in the care of the patient would know the patient met their goals the CHO stated by getting shift report, they don't talk about all goals, but they talk about goals. The nurse, if the patient is here more than 12 days, we must reassess on the 12th day. On the 30th day the care plan should be updated. The care plan is done within 72 hours. If the patient is here more than 12 days the treatment plan is reevaluated and signed by the physician. If it has been 30 days the treatment plan should be updated. We look at the goals, and may not change the goals. We look at the goals that are established and note that on the plan, if the patient has not met those goals and if it should be continued.

During an interview on 01/10/2019 at 12:00 PM with the Acute Care Services Manager (ACSM) the MTPs (Master Treatment Plans) were reviewed for Patients #6, #7, #8, #9 #10, #11, #12 and #13. The ACSM verified the interventions were more general in nature, and not individualized. Some of the interventions would be normal functions of the staff during a patient's admission process. The MTPs often did not have an intervention by a registered nurse or the psychiatrist.

Review of the policy and procedure titled, "Master Treatment Planning" showed III. Within eight (8) hours after admission, nursing staff will complete a nursing assessment and formulate a nursing diagnosis. The nurse shall develop and document the plan on the approved master treatment planning forms. V. Within twenty-four (24) hours after admission, the Recovery Specialist will review the psychosocial assessment in the electronic health record. Problems and issues identified in the assessment shall be included in the treatment plan. The emphasis shall be on stabilizing the immediate crisis and making referrals for long term treatment objectives. VIII. Within twenty-four (24) hours after admission, the treatment team will evaluate all verbal and written assessment information. All members will complete their respective components and the Recovery Specialist shall review the plan in its entirety for completeness and assure: a. Completion of the master treatment plan assessment summary by a team member from each discipline. B. Completion of the problems list. C. Completion of the master treatment plan, to include: 1) Individual strengths and liabilities. 2) Substantiated diagnosis. 3) Behaviorally descriptive psychiatric problem statements based on how each consumer manifested presenting symptoms. 4) Problem statement, discharge criteria and target date for goal attainment. 5) Interventions, person(s) responsible and target dates. 6) Observable and measurable short-term goals written in behavioral terms. 7) Long-term objectives, Individualized goals with measurable objectives, interventions, person(s) responsible and target dates. 8) Specific individualized active treatment interventions. IX. Medical staff, nursing staff, Recovery Specialists, and activity therapists are each responsible for documenting on the treatment plan the interventions to be provided by their own discipline. XI. Treatment plans are reviewed and updated at each key decision point in the course of treatment, including transfer to another unit, a major change in the individual's condition, completion of or lack of progress toward goals and at discharge, after receipt of any form of restraint, seclusion or ETO (Emergency Treatment Order) and no less than once per week. XIII. All treatment team members are responsible for the development and implementation of the treatment plan, under the overall direction of the psychiatrist. All team members participate in the documentation of the plan. The Recovery Specialist coordinates with team members to see that documentation is complete.

Based on record review, interview and policy and procedure review the Medical Director failed to monitor and evaluate the quality and effectiveness of the treatment program to assure patients received the intensity and quality of care appropriate to their needs. Specifically, the Medical Director failed to:

I. Ensure the Master Treatment Plans (MTPs) were revised when patients were placed in restraint (manual hold). Specifically, for 1 of 8 active sample patients, Patient #10, the MTP was not revised to reflect problem statements related to the use of restraint to control aggressive behavior, treatment goals, and active treatment interventions outlining healthy alternatives and approaches for the patient to use to replace aggressive behavior(s). This failure impedes the provision of active treatment to meet the specific treatment needs of patients. The facility failed to ensure Master Treatment Plans (MTP) were comprehensive and individualized, and/or updated for 3 of 8 sampled active patients, Patients #6, #7 and #8. Not updating the MTP for individualized problems with goals and objectives for each admission potentially hampers the treatment teams' ability to determine whether the treatment plan goals and objectives were met. (Refer to B118)

II. Ensure Master Treatment Plans were comprehensive, individualized and behaviorally descriptive with all necessary components for 8 of 8 active sampled patients, Patients #6, #7, #8, #9, #10, #11, #12, and #13.

(1) Observable and measurable short-term goals written in behavioral terms. (Refer to B121)

(2) Specific individualized active treatment interventions. (Refer to B122). Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

Based on observation, interview, and policy and procedure review the facility failed to ensure direct monitoring and evaluation of nursing care was furnished to meet acceptable standards of nursing practice related to the disruption of a therapeutic group titled "Coping Skills/Does Stress Cause Illness" to administer medication to a patient, Patient #12.

Findings:

During an observation on 01/09/2019 at 9:12 AM it showed there was a group with eleven patients in attendance including patient #12. The group was being conducted by a Registered Nurse (RN), the group was on Coping Skills/Does Stress Cause Illness. A disruption was caused by a nurse, she entered the group at 9:24 AM and approached Patient #12 and indicated it was time for him to take his medications. Patient #12 stood up, the nurse gave him the medication in a medication cup and a drink of water. The other patients turned to watch what was happening. Patient #12 sat back down and the group continued. The nurse exited the group.

During an interview on 01/09/2019 at 9:26 AM with Staff Q, Licensed Practical Nurse (LPN) when asked if medications were to be administered during group the LPN stated, "I am not sure. We have been giving medications during group." When asked how long the nurse had worked for the facility she stated, "I have worked for this facility for approximately a year."

During an interview on 01/10/2019 at 12:38 PM with the Director of Nursing (DON) she verified groups should not be interrupted for a patient to take medication. The medication should have been given before or after the group.

Review of the policy and procedure titled, "Group Sessions" under section B. "Procedure" IV. Due to the importance of group therapy for effective care, it is vital that group sessions are not interrupted. Interruptions disturb the therapy process and are distracting for the individuals as well as the therapists. Interruptions can indicate to the individuals that therapy is not an important part of their care while they are in the hospital.