HospitalInspections.org

Based on document review and staff interview, it was determined for one of one medical records departments, the hospital failed to ensure medical records were completed within 30 days after discharge.

Findings include:

1. On 8/28/14 at approximately 9:30 AM, a tour was conducted in the Medical Records department. During the tour the surveyor was presented a report signed by the Director of the Health Information Management Department (E #2) which noted there were 18 medical records that were incomplete 31 days after patient discharge as of 8/28/14.

2. On 8/28/14 the Hospital's medical staff rules and regulations (revised 4/15/14) was reviewed and required, "Appendix A., section B. Patient Records...19b. Completion of Patient Records...the patient's record shall be completed at time of discharge...where not possible, the record shall be completed within 30 days after discharge or transfer..."

3. On 8/28/14 at approximately 10:00 AM, E #2 stated the records were deficient because she had been on vacation, and had not had the opportunity to ensure the physicians updated the records.

Based on observation, document review, and interview, it was determined that for 1 of 6 refrigerators in use, the hospital failed to ensure temperature was maintained within the hospital policy's limits for the safe storage of refrigerated food items.

Findings include:

1. An observational tour of the kitchen was conducted on 8/26/14 between 9:45 and 11:15 AM. Refrigerator #11 located next to the hot food prep area contained an automatic internal monitor that showed a temperature of 49 degrees . A separate thermometer found inside the refrigerator showed a temperature of 45 degrees. Example of items in the refrigerator included 4-5, pint size, cartons of milk; 2 large mustard jars, 1 large jar of mayonnaise, and other miscellaneous food items.

During the tour the refrigerator and freezer temperature logs were reviewed. The temperature log for refrigerator #11 indicated temperatures between 40 and 51 degrees daily from 8/1/14-8/25/14.

2. The Hospital Policy titled, "Infection control Techniques" (revised 7/05) was reviewed on 8/28/14 at 9:50 AM. The policy required, "Thermometers are monitored frequently throughout the day. Proper temperatures for the various refrigerators are: Meat and Poultry: 36-40 F; Dairy: 36-40 F; Produce: 36-40 F...."

3. During interviews with the Support Service Administrator (E #1) on 8/26/14 at approximately 11:00 AM and 8/28/14 at approximately 10:00 AM (by phone), E #1 stated the expectation for the refrigerator temperature is between 36 to 40 for appropriate food storage. E #1 stated temperatures are being recorded at the height of the hot food preparation when the refrigerator is frequently being opened, resulting in these temperature readings.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on August 25 - 26, 2014, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

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

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on August 25 - 26, 2014, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated 08/26/2014.

Based on Record review, Staff interview, Policy review, Observation and Patient interview, the facility failed to:

1) Provide Comprehensive Social Work Assessments that include social evaluation of high risk psychosocial issues that require early interventions and recommendations that include Social work role in treatment and discharge planning. This results in absence of Professional Social Services and inappropriate treatment and discharge planning. (Refer to B108)

2) Develop and document Individualized Multidisciplinary Treatment Plans based on individual needs of patients. This could lead to lack guidance to staff, lack of addressing patient's progress and potentially longer lengths of hospital stays. (Refer to B118)

3) Provide appropriate therapeutic interventions including alternative interventions, ensure the Psychiatrists are active participants and ensure alternative staffs are available when an assigned staff is absent. Failure to ensure appropriate therapeutic interventions are delivered in a timely manner can potentially extend patients hospitalization unnecessarily. (Refer to B125)

Based on records review and staff interview, the facility failed to provide social work assessments that include a social evaluation of high risk psychosocial issues requiring early treatment planning and intervention; and recommendations that are individualized which include social work roles in treatment and discharge planning. This resulted in an absence of professional social work treatment services for five (5) (A1, A2, A3, A5 and A8) of eight (8) patients in the sample.

The findings include:

A. Record review

1) Patient A1 was hospitalized on 08/10/14 with complaints of "FBI is after me" and history of non compliance after discharge. The Comprehensive Social Work Assessment completed on 08/12/14 lacked sufficient information to accomplish appropriate treatment plan. It lacked information relative to family and community resources and anticipated social work role in appropriate discharge planning. The Social work recommended Interventions were "Medication management, individual therapy, linkage case management and case coordination".

2) Patient A2 was hospitalized on 08/14/14. The Comprehensive Social Work Assessment completed on 08/15/14 lacked sufficient information to accomplish safe and appropriate discharge planning. It lacked information relative to family ("Pt. confirmed relationship stressors with mother and "sometimes" with boyfriend", with whom she lives) and anticipated social work role in appropriate discharge planning. The Social Work recommended interventions were "case coordination, group therapy, after care with DCHD".

3) Patient A3 was hospitalized on 08/15/14 with suicidal thoughts and plans. The Social Work assessment was completed on 08/18/14 lacked sufficient information relative to family and community resources and anticipated social work role in accomplishing appropriate discharge planning. The recommended social work interventions were "Medication management, individual therapy and group therapy".

4) Patient A5 was hospitalized on 07/31/14 with history of aggressive behaviors and physical/emotional abuse at home by the family members with whom he lives with. The Social Work assessment completed on 07/31/14 lacked sufficient information relative to family and community resources and anticipated social work role in accomplishing appropriate discharge planning. The Recommended social work interventions were "Individual and group therapy, medication monitoring and education, aftercare linkage, and case coordination".

5) Patient A8 was hospitalized on 08/03/14 with history of suicidal thoughts and plans, recent break up with girlfriend, loss of job, legal problems and history of physical/sexual abuse. The social work assessment completed on 08/05/14 lacked sufficient information relative to family and community resources and anticipated social work role in accomplishing appropriate discharge planning. The recommended social work interventions were "Meet with patient 1x/wk to teach more effective coping skills in dealing with everyday life stressors".

B) Staff Interview:

In a meeting and review of the above findings with the Director of Social Services on 08/26/14 at 1:00 PM, he/she concurred with the above deficiencies and stated "does not meet the standards".

Based on record review and interview the facility failed to develop and document comprehensive multidisciplinary treatment plans based on the individualized needs of patients for two (2) of four (4) active sample patients on the Hinton Unit (A1 and A2). Specifically the facility failed to develop an initial comprehensive Master Treatment Plan (MTP) and failed to review/modify the MTP following a restraint for Patient A1. In addition, the facility failed to ensure that the treatment interventions documented on the MTP addressed the identified needs for Patient A2. Failure to individualize treatment plans can prevent patients from progressing in treatment and fail to give staff guidance for addressing specific patient problems which can result in unmet needs and potentially longer lengths of hospitalization.

Findings include:

A. Patient A1

1. Record Review

Patient A1 was admitted on 8/10/14 due to psychotic behavior and threatening his/her father. The Comprehensive Psychiatric Evaluation dated 8/12/14 documented the diagnosis of "Schizophrenia, acute". The evaluation described the patient as "disheveled, unkempt, has not bathed or eaten much in a few days." The admission nursing note dated 8/10/14 at 9:45 PM states "Pt. placed on frequent observation for unpredictable behavior and aggression." Review of the Progress Notes from 8/10/14 - 8/25/14 revealed that Patient A1 was aggressive with staff, sexually inappropriate with male patients, delusional in thinking that Mental Health Technicians were FBI and he/she was a terrorist. Patient A1 required Restriction of Rights for a forced shower on 8/11/14 at 10:25 AM. The Progress Notes also documented a need for emergency medications with a seven minute physical hold on 8/11/14 at 10:18 AM (hold for medications and shower) and a five minute physical hold on 8/12/14 at 10:48 AM.
The MTP dated 8/12/14 listed one problem, "Psychosis as evidenced by paranoid, persecutory delusions and poor ADLs (Activities of Daily Living)". The short-term goals were "Pt will verbalize alleviation of paranoid delusions re being raped and being pregnant" and "Pt will verbalize need to comply with meds for psychosis and attend 75% of assigned groups". The only intervention for these goals was "1:1 weekly (with the psychiatrist) to assess effectiveness of meds to alleviate psychosis and to monitor for efficacy." There were no Treatment Groups assigned on the MTP nor was there mention of the need for restrictions of rights related to emergency medications and personal hygiene. There was no update of the MTP following the 8/12/14 physical hold which occurred after the formulation of the MTP. The MTP was not updated to include interventions needed to address Patient A1's sexual behavior with male patients, inability to participate in any organized treatment activity or to maintain adequate personal hygiene. In addition, there were no treatment goals or interventions written by Nursing, Social Work or Activity Therapy.

2. Interview

During interview on 8/26/14 at 9:40 AM, RN1 acknowledged that the psychiatrist intervention was the only treatment intervention documented on Patient A1's MTP and that there was no input from Nursing, Activity Therapy or Social Work.
During interview on 8/26/14 at 1:00 PM, the Director of Nursing when told of the lack of nursing goals and interventions on Patient A1's MTP stated that she would "start working on that".
During interview on 8/26/14 at 2:00 PM, the Director of Activity Therapy verified that there were no Activity Therapy goals or interventions on Patient A1's MTP.
During interview on 8/27/14 at 9:30 AM, the Director of Quality Improvement stated that a Treatment Plan Review form was to be filled out after each episode of seclusion or restraint. She verified that a Treatment Plan Review form had not been completed for Patient A1's 8/12/14 physical hold.

B. Patient A2

1. Record Review

Patient A2 was admitted on 8/14/14. The Comprehensive Psychiatric Evaluation dated 8/15/14 documented the diagnosis as "Depressive Disorder NOS". The MTP dated 8/15/14 documented under the Patient/Family Comments section, "Pt] has anger issues. Needs pill for anger." Patient A2 was not on any medications when admitted and was not placed on medications until 8/25/14. For the documented short-term goal, "Verbalize benefit of aftercare to prevent relapse of depressive symptoms to return home", nursing intervention listed on the MTP was "Medic educ (medication education) 1 time per wk (week) with RN to teach about the meds indic (indications), doses, timing and freq (frequency) of meds." The Group Progress Note for the Medication Education Group dated 8/22/14 stated, "Pt. attentive, questioned why [he/she] needed to be in this group since [he/she] has no meds."

2. Interview

During interview on 8/25/14 at 11:15 AM, Patient A2 stated "They have me in a medication group and I'm not taking medications."

During interview on 8/26/14 at 1:00 PM, the Director of Nursing acknowledged that Patient A2 was assigned to the Medication Education group but was not receiving medications.

Based on record review, observation and interviews, the facility failed to:

l. Provide therapeutic treatment interventions, including alternative interventions, for four (4) of four (4) active sample patients on the Hinton Unit (A1, A2, A3 and A4). Patient A1 was unable to attend his/her assigned groups while Patients A2 and A3 were unwilling to attend many of their assigned groups. Patient A4 did not attend all the treatment groups listed on his/her Master Treatment Plan (MTP) due to an inaccurate individualized unit schedule.

ll. Ensure that the psychiatrist was actively involved in the assessment and treatment of one (1) of four (4) patients on the Hinton Unit (A2).

lll. Follow their stated practice of providing an alternate group leader to assist patients in completing the group goals when the usual assigned group leader was unavailable.

Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement.

Findings include:

l. Treatment Interventions

A. Patient Findings

1. Patient A1 was admitted on 8/10/14. The Comprehensive Psychiatric Evaluation dated 8/12/14 documented the diagnosis of "Schizophrenia, acute". The MTP dated 8/12/14 listed only one intervention which was a "1:1 weekly (with the psychiatrist) to assess effectiveness of meds to alleviate psychosis and to monitor for efficacy." Patient A1's individualized "Hinton Unit Schedule" showed that Patient A1 was to attend Community Meeting Group (twice daily with attendance monitored by a sign-in sheet) and Treatment Groups (requiring progress notes). The Treatment Groups assigned to Patient A1 on the "Hinton Unit Schedule" were Focus Group, Discharge Planning and Relapse Prevention. The total number of groups assigned for the period 8/12/14 - 8/25/14 were 28 Community Groups and eight (8) Treatment Groups. Review of the Group Progress Notes, Group Attendance Sheets and Group Sign-In Sheets revealed that Patient A1 attended 7.1% of the Community Meeting Groups and 0% of the assigned Treatment Groups.

Observation on the Hinton Unit on 8/25/14 at 10:45 AM revealed that Patient A1 was in bed under the covers with the lights off. During interview at this same time, RN1 stated that A1 often stayed in his/her room and did not attend groups due to his/her psychotic behavior. When asked about the groups that were offered in the dayroom during the day and were on the overall unit schedule, RN1 stated that they were "freebies" and all patients were encouraged to go to those but they were not considered treatment groups. RN1 reported that Patient A1 had not attended the morning Community Group nor had he/she attended the Exercise Group in the dayroom that morning.

During interview on 8/25/14 at 10:50 AM, Patient A1 stated that he/she was "a terrorist" and that one of the male technician was "with the FBI and they are after me".

Review of Patient A1's Progress Notes revealed that he/she was not considered stable enough to be assigned Treatment Groups (even though his/her individual schedule included groups). A Social Work note dated 8/15/14 at 10:00 AM stated, "Currently client is unstable so [he/she] will not be scheduled any recommended treatment groups at this time." The next progress notes addressing groups was written by Activity Therapy on 8/25/14 at 9:32 AM and stated, "Patient has now been assigned treatment group [sic] as [his/her] mood has started to be more stable allowing [him/her] to engage in groups."

Review of the MTP on 8/25/14 revealed that the plan had not been reviewed and no alternative interventions had been added to address Patient A1's inability to attend Treatment Groups or other groups offered on the unit.

2. Patient A2 was admitted on 8/14/14. The Comprehensive Psychiatric Evaluation dated 8/15/14 documented the diagnosis as "Depressive Disorder NOS". The MTP dated 8/15/14 assigned the following treatment groups: Medication Education, Solution for Wellness, Relapse Prevention, Dialectical Behavioral Therapy (DBT), Coping Skills, Relaxation Skills, Emotional Regulation, Discharge Planning, Symptom Management, Goals Group and Current Events. In addition, Patient A2's individualized "Hinton Unit Schedule" assigned twice daily Community Meeting Groups. The total number of assigned groups for the period 8/15/14 - 8/25/14 were 22 Community Meeting Groups and 16 Treatment Groups. Review of the Group Progress Notes, Group Attendance Sheets and Group Sign-In Sheets, revealed that Patient A2 attended 59% of the Community Meeting Groups and 31% of the assigned Treatment Groups.

During interview on 8/25/14 at 11:15 AM, Patient A2 stated, "I'm not really going to groups." In interview on 8/25/14 at 11:25 AM, RN1 stated that Patient A2 went to groups, "when [he/she] wants to."

Observations of the DBT Group on the Hinton Unit on 8/25/14 from 1:15 PM - 1:30 PM revealed that Patient A2 stayed in the group for 10 minutes and left without participating. When asked why he/she left the group after 10 minutes Patient A2 stated "I don't understand what he (group leader) was talking about." (Interview on 8/25/14 at 2:40 PM) Observations on the Hinton Unit on 8/26/14 at 8:50 AM and 9:40 AM revealed that Patient A2 was under the covers in bed with the lights out. In interview on 8/26/14 at 9:40 AM, RN1 stated that Patient A2 was staying up late talking with other patients and then not wanting to get up early. RN1 reported that Patient A2 had not attended the morning Community Group nor had he/she attended the Exercise Group in the dayroom that morning.

Review of the MTP on 8/26/14 revealed that Patient A2's unwillingness to attend most of the assigned Treatment Groups had not been addressed in the plan nor had alternative treatment modalities/interventions been assigned.

3. Patient A3 was admitted on 8/15/14. The Comprehensive Psychiatric Evaluation dated 8/15/14 documented the diagnosis "Bipolar NOS r/o (rule out) Substance Induced Mood Disorder." The MTP dated 8/18/14 assigned the following Treatment Groups: Relapse Prevention, Symptoms Management, MISA (Mental Illness Substance Abuse), Medication Education, Relaxation Skills, DBT, Emotional Regulation, Coping Skills, Discharge Planning, Goals Group and Solutions for Wellness. In addition, Patient A3's individualized "Hinton Unit Schedule" assigned twice daily Community Meeting Groups. The total number of assigned groups for the period 8/18/14 - 8/25/14 were 16 Community Meeting Groups and 18 Treatment Groups. Review of the Group Progress Notes, Group Attendance Sheets and Group Sign-In Sheets, revealed that Patient A3 attended 18.7% of the Community Meeting Groups and 55.5% of the assigned Treatment Groups.

In interview on 8/25/14 at 11:30 AM, Patient A3 when asked about his/her activities on the unit stated, I stay in my room, read a book. Once in a while I go to groups."

Review of the MTP on 8/26/14 revealed that Patient A3's unwillingness to attend many of the assigned Treatment Groups had not been addressed in the plan nor had alternative treatment modalities been assigned.

4. Patient A4 was admitted on 8/15/14. The Comprehensive Psychiatric Evaluation documented a diagnosis of "Bipolar Disorder". The MTP dated 8/19/14 documented the problem "Mood/Thought Disturbance" and assigned the Treatment Groups, DBT and Emotional Regulation, as interventions. For the identified problem, "Continuity of Care/Discharge Planning", the Treatment Group, Relapse Prevention, was listed as an intervention.

Review of Patient A4's individualized "Horton Unit Schedule" revealed that the DBT, Emotional Regulation and Relapse Prevention groups were not circled indicating that they were not part of Patient A4's active treatment.

Observation of the DBT group held on the Horton Unit from 2:15 PM - 3:00 PM on 8/25/14 revealed that Patient A4 did not attend.

During interview on 8/25/14 at 2:50 PM, Patient A4 stated that he/she did not go to DBT because, "It is not on my schedule so it's not one of my groups." Patient A4 also acknowledged that he/she had not attended Relapse Prevention or Emotional Regulation for the same reason.

During interview on 8/25/14 at 2:55 PM, RN1 stated that he/she was unaware that Patient A4 had Treatment Groups listed on the MTP that were not assigned on the individualized schedule.

ll. Psychiatrist involvement in Treatment

A. Patient Findings

Patient A2 was admitted on 8/14/14. The Comprehensive Psychiatric Evaluation dated 8/15/14 documented the diagnosis as "Depressive Disorder NOS" with the Chief Complaint "Suicidal Ideation". Patient A2 was not on medications prior to admission and was not put on medications until 8/26/14.

B. Record Review

1. Review of the MTP dated 8/15/14 revealed that Patient A2 stated his/her problem was anger and that he/she needed some "pills" for anger.

2. Review of Patient A2's Progress Notes showed that Physician 1 had written a "Psych MD Note" on 8/15/14, the day after admission. There was not another "Psych MD Note" written until 8/25/14 when Physician 1 noted that Patient A2 was "feeling depressed and agreed to take meds."

C. Interview

1. During interview on 8/25/14 at 11:15 AM, Patient A2 stated that he/she wanted to get on medications and felt like he/she was Bipolar. When RN1 suggested that he/she talk to the doctor about medications, Patient A2 stated that he/she had not seen a doctor in over a week.

2. During interview on 8/26/14 at 9:15 AM, RN2 stated that the psychiatrist assigned to Patient A2, Physician 1, had been on vacation the previous week and that Physician 2 had been covering his/her patients. RN2 reviewed the Progress Notes and agreed that no physician progress notes had been written from 8/15/14-8/25/14.

3. During interview on 8/26/14 at 10:00 AM, Physician 1 voiced surprise that Physician 2 had not seen Patient A2 and that a physician progress note had not been written. Physician 1 also stated that when he/she returned from vacation he/she was surprised that Patient A2 was still hospitalized.

4. During interview on 8/26/14 at 11:30 AM, the Medical Director stated that although it was not written in policy, it was the expectation and practice that psychiatrists write progress notes at least weekly.

lll. Alternate group leader

A. Interview

1. During interview on 8/25/14 at 3:40 PM, Mental Health Technician 1 (MHT) stated that when the leader of a Treatment Group was unavailable, the MHT gave out the handouts provided by the leader and the MHT "goes over them with the patients".

2. During interview on 8/26/14 at 8:50 AM, Patient A3 stated that the Coping Skills Group offered at 2:15 PM on 8/25/14 was not led by the Activity Therapist but by the MHT back-up. Patient A3 stated that the MHT gave out a sheet on "Let Go of Stress" with a stress journal worksheet. The MHT did not stay or help the group work on the sheets. Patient A3 stated that he/she did not complete the sheet and left it in a chair in the dayroom.

3. During interview on 8/26/14 at 9:40 AM, Patient A4 stated that the Relaxation Group held on 8/25/14 at 12:15 PM was not led by the Activity Therapist but by the MHT back-up. Patient A4 stated that the MHT gave out the hand-out sheets but didn't sit with them. The members of the group were told to finish the hand-outs. Patient A4 did not finish his/her sheet.

4. During interview on 8/26/14 at 1:00 PM, the Director of Nursing stated that she was surprised that the MHT did not help the group members fill out the sheets and stated that she would look into it.

5. During interview on 8/26/14 at 2:00 PM, the Director of Activity Therapy stated that the process to be followed when an Activity Therapist was unable to lead the assigned group was to give hand-outs to the milieu staff (MHT). The expectation was that the MHT would pass out the sheets and assist the group members in filling out the sheets which they would take to their next Activity Therapy group.

B. Observation

Observation on 8/25/14 at 2:30 PM on the Hinton Unit revealed that the group, Coping Skills, was not being held in the dayroom as scheduled from 2:15 PM - 3:00 PM. During interview at 3:45 PM on 8/25/14, MHT1, who had given the hand-outs for the group, stated that the group had been a "very short" group.

Based on record review and staff interview, the Psychiatrist failed to document weekly progress note for one (1) (A2) of eight (8) active sample patients. The absence of timely documentation prevented an up to date picture of patient ' s psychiatric condition being available to treatment team members, depriving the patient of continuity of care.

The findings include:

Record review:

1) Patient A2 was hospitalized on 08/14/14 and a psychiatric assessment note was written on 08/15/14. The next Psychiatrists note was on 08/25/14 and was started on a medication for the first time during this hospitalization.

Staff interview:

In a meeting with the Clinical Director on 08/26 at 11:30 AM, and review of the hospital progress note policy, the Clinical Director stated the hospital policy as, a minimum of weekly progress note is expected of the Psychiatrists and concurred with the absence of progress note between 08/15/14 to 08/25/14 for patient A2.

The Clinical Director Failed to adequately monitor and ensure:

A) Social Work staff for providing Comprehensive Social Services assessments, Interventions and appropriate discharge planning for five (5) (A1,A2,A3,A5 and A8) of eight (8) active sample patients.(refer to B118)

B) Staff develop and document individualized comprehensive, multidisciplinary treatment plans for two (2) (A1 and A2) of eight (8) active sample patients. (refer to B118)

C) Staff develops appropriate, timely active therapeutic interventions including alternative interventions, Psychiatrists are active participants and that appropriate alternative staff are available when an assigned staff is absent. (refer to B125)


In a meeting with the Clinical Director on 08/26/14 at 11:30 AM, the Clinical Director concurred with the above findings.

Based on record review and interview the Director on Nursing failed to

l. Ensure that nursing was involved in the development of MTPs for one (1) of four (4) active sample patients on the Hinton Unit (A1) and ensure that nursing goals and interventions addressed the identified needs for one (1) of four (4) active sample patients on the Hinton Unit (A2). Failure of nursing staff to participate in the development of the MTP can prevent patients from progressing in treatment and fail to give nursing staff guidance for addressing specific patient problems which can result in unmet needs and potentially longer lengths of hospitalization. (Refer to B118)

ll. Follow their stated practice of providing an alternate group leader to assist patients in completing the group goals when the usual assigned group leader was unavailable. Failure to assist patients during assigned Treatment Groups can lead to patients not completing assignments thus not fully benefitting from the stated purpose of the group. (Refer to B125 lll)

Findings include:

l. Nursing MTP Input

A. Patient A1

1. Record Review

Patient A1 was admitted on 8/10/14 due to psychotic behavior and threatening his/her father. The Comprehensive Psychiatric Evaluation dated 8/12/14 documented the diagnosis of "Schizophrenia, acute". The evaluation described the patient as "disheveled, unkempt, has not bathed or eaten much in a few days." The admission nursing note dated 8/10/14 at 9:45 PM states "Pt. placed on frequent observation for unpredictable behavior and aggression." Review of the Progress Notes from 8/10/14 - 8/25/14 revealed that Patient A1 was aggressive with staff, sexually inappropriate with male patients, delusional in thinking that Mental Health Technicians were FBI and he/she was a terrorist. Patient A1 required Restriction of Rights for a forced shower on 8/11/14 at 10:25 AM. The Progress Notes also documented a need for emergency medications with a seven minute physical hold on 8/11/14 at 10:18 AM and a five minute physical hold on 8/12/14 at 10:48 AM.

The MTP dated 8/12/14 listed one problem, "Psychosis as evidenced by paranoid, persecutory delusions and poor ADLs (Activities of Daily Living). The short-term goals were "Pt will verbalize alleviation of paranoid delusions re being raped and being pregnant" and "Pt will verbalize need to comply with meds for psychosis and attend 75% of assigned groups". The only intervention for these goals was "1:1 weekly (with the psychiatrist) to assess effectiveness of meds to alleviate psychosis and to monitor for efficacy." The MTP was not updated to include interventions needed to address Patient A1's sexual behavior with male patients, inability to participate in any organized treatment activity or to maintain adequate physical hygiene. There were no treatment goals or interventions written for Nursing.

2. Interview

During interview on 8/26/14 at 9:40 AM, RN1 acknowledged that the psychiatrist intervention was the only treatment intervention documented on Patient A1's MTP and that there was no input from Nursing.

During interview on 8/26/14 at 1:00 PM, the Director of Nursing when told of the lack of nursing goals and interventions on Patient A1's MTP stated that she would "start working on that".

B. Patient A2

1. Record Review

Patient A2 was admitted on 8/14/14. The Comprehensive Psychiatric Evaluation dated 8/15/14 documented the diagnosis as "Depressive Disorder NOS". The MTP dated 8/15/14 documented under the Patient/Family Comments section, "[Pt] has anger issues. Needs pill for anger." Patient A2 was not on any medications when admitted and was not placed on medications until 8/25/14. For the documented short-term goal, "Verbalize benefit of aftercare to prevent relapse of depressive symptoms to return home", the nursing intervention listed on the MTP was "Medic educ (medication education) 1 time per wk with RN to teach about the meds indic (indications), doses, timing and freq (frequency) of meds." The Group Progress Note for the Medication Education Group dated 8/22/14 stated, "Pt. attentive, questioned why [he/she] needed to be in this group since [he/she] has no meds."

2. Interview
During interview on 8/25/14 at 11:15 AM, Patient A2 stated "They have me in a medication group and I'm not taking medications."
During interview on 8/26/14 at 1:00 PM, the Director of Nursing acknowledged that Patient A2 was assigned to the Medication Education group but was not receiving medications.

ll. Alternate group leader


1) B. Interview
1. During interview on 8/25/14 at 3:40 PM, Mental Health Technician 1 (MHT) stated that when the leader of a Treatment Group was unavailable, the MHT gave out the handouts provided by the leader and the MHT "goes over them with the patients".

2. During interview on 8/26/14 at 8:50 AM, Patient A3 stated that the Coping Skills Group offered at 2:15 PM on 8/25/14 was not led by the Activity Therapist but by the MHT back-up. Patient A3 stated that the MHT gave out a sheet on "Let Go of Stress" with a stress journal worksheet. The MHT did not stay or help the group work on the sheets.

3. During interview on 8/26/14 at 9:40 AM, Patient A4 stated that the Relaxation Group held on 8/25/14 at 12:15 PM was not led by the Activity Therapist but by the MHT back-up. Patient A4 stated that the MHT gave out the hand-out sheets but didn't sit with them. The members of the group were told to finish the hand-outs. Patient A4 did not finish his/her sheet.

4. During interview on 8/26/14 at 1:00 PM, the Director of Nursing stated that she was surprised that the MHT did not help the group members fill out the sheets and stated that she would look into it.

5. During interview on 8/26/14 at 2:00 PM, the Director of Activity Therapy stated that the process to be followed when an Activity Therapist was unable to lead the assigned group was to give hand-outs to the milieu staff (MHT). The expectation was that the MHT would pass out the sheets and assist the group members in filling out the sheets which they would take to their next Activity Therapy group.

B. Observation

Observation on 8/25/14 at 2:30 PM on the Hinton Unit revealed that the group, Coping Skills, was not being held in the dayroom as scheduled from 2:15 PM -3:00 PM. During interview at 3:45 PM on 8/25/14, MHT1, who had given the hand-outs for the group, stated that the group had been a "very short" group.