HospitalInspections.org

Based on record review, facility staff interview and interview with a dietary contracted service staff, the facility failed to ensure that the contracted dietary service completed pre-employment screening, to include CORI (Criminal Offender Record Inquires) checks for 4 out of 5 employees, (employees A, B, D and E) contracted to provide dietary services to the facility.

Findings included:

During the Entrance Conference on 4/15/14 at 9:00 A.M. it was identified by the facility director that the facility had a contract with an outside food service vendor. All dietary employees were hired by the dietary contract vendor and all dietary personnel files were maintained at the vendor's corporate office.

Review of the April 2014 dietary employee schedule indicated that there are 5 employees who currently worked at the facility. Interview with the vendor representative on 4/16/14 at 11:00 A.M. identified that the company has a screening process prior to hiring dietary personnel which include completed application, references checks, verification of qualifications and CORI (Criminal Offender Record Inquiry) check request. After the CORI check is completed, the HR representative would call the food manager at the facility and identified that the new employee could begin work.

All dietary employee files were reviewed with the contracted vendor representative.
1. Employee A was hired on 11/13/07. The file did not contain an application or reference check.

2. Employee B was hired 2/7/12. The file did not contain an application or reference check.

3. Employee D was hired on 3/29/14. The file did not contain an application or reference check.

4. Employee E did not have a documented date of hire. The file contained a copy of a passport and drivers licence however, there was no application, reference check or CORI verification.

Interview via telephone with the HR representative for the dietary contracted vendor on 11/17/14 at 10:30 A.M. said that although she had a CORI verification for Employee D she could not locate an application or reference checks. The HR representative also said that there was no application, reference check or CORI verification for Employee E. She further identified that Employee E was a friend of the contract food service vendor's district manager who utilized Employee E for vacation relief the week of April 6, 2014.

Interview with the Facility Administrator on 4/17/14 at 11:00 A.M. said that he was unaware that the pre-employment screening process for dietary employees was incomplete.

Based on observation and staff interview, the Hospital failed to ensure that the environment was free of safety hazards for the 16 patients residing on the psychiatric inpatient unit. The inpatient unit provided care to patients with various psychiatric diagnoses including patients with a history of suicide attempts and risk of self-harm.

Findings included:

A tour of the Hospital's 16-bed, inpatient psychiatric unit, was conducted with the facility Director on 4/15/14 at 9:15 A.M.

During the tour, the surveyor observed metal door closure devices on three of the exterior doors of the inpatient psychiatric unit. One door was situated opposite and to the left of the nurses station. The other two doors were positioned on the north and south ends of the long corridor where patient rooms were located.

The metal door closures were located on the upper left portion of the metal doors, extended out approximately ten inches, and posed a serious safety risk in the event that a suicidal patient considered self-harm by strangulation. The door closures were constructed of sturdy metal that would not break off when the weight of a patient was applied to the device.

The DON (Director of Nursing) was interviewed on 4/17/14 at 10:55 A.M. regarding the potential strangulation risk posed by the three exterior door closure units. The DON said that he/she never noticed the hazard before and also commented that he/she didn't think it would break away if a load were to be applied to it. The DON said that he/she would inform the Hospital Director and the maintenance department to address the potential safety hazard posed by the exposed metal door closure devices on the three exterior doors of the inpatient psychiatric unit.

The Hospital Director, DON, and Inpatient Unit Director, acknowledged on 4/17/14 at 3:15 P.M. the safety hazard that the metal door closure devices created for psychiatric patients residing on the inpatient unit who were at risk for self-harm.

I. Ensure that the master treatment plans for two (2) of eight (8) active sample patients (Patient #6 and Patient #16) were revised when the patients failed to participate in the prescribed treatment. MTP's were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

II. Ensure that patients attended programming or received alternative treatment based on individualized treatment needs for two (2) of eight (8) active patients (Patient #6 and Patient #16). These patients spent much of their time in their bedroom, sitting in the hallway, or sitting alone in a unit room, often missing assigned programming. This prevented patients from achieving their optimal level of functioning during hospitalization. (Refer to B125 Part I)

III. Provide individualized active treatment for eight (8) of eight (8) sample patients (3, 5, 6, 7, 9, 12, 14, and 16) sample patients on evenings and weekends. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion potentially delaying improvement. (Refer to B125 Part II)

IV. Assess and treat the medical problems of 1 discharged patient (D6) reviewed for medical care, in order to identify potentially treatable medical etiologies of mental status changes, and identify potential concurrent medical illnesses. Failure to address medical issues and obtain a correct diagnosis and treatment results in a potential risk to patients' lives/health and prevents patients from achieving an optimal level of functioning. (Refer to B125 Part III)

Based on record review and interview, the facility failed to ensure that the master treatment plans for two (2) of two (2) active sample patients (Patient #6 and Patient #16) were revised when the patients failed to participate in the prescribed treatment. MTP's were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

Findings include:

A. Record Review

1. Patient #6

Patient #6 was admitted on 3/5/14 with the diagnoses of, "Schizoaffective d/o (disorder) vs (versus) schizophrenia paranoid type", and "antisocial personality disorder with antisocial and narcissistic traits."

a. The MTP for Patient 6, revised 4/14/14, listed the following group modalities to be used as treatment interventions: "Life Skills group," "Coping Skills group," "Stress Management," "Anger Management," "Functional Task," "Craft," "Leisure," "Nutrition," "Medication Education," "Relaxation/Meditation," "AM Stretch," "Discharge Issues," "Gym Group," "Psychological Issues," "Goals and Wrap Up," and "Peer Education" groups.

b. The "Treatment/Recovery Plan Review" (treatment plan review) dated 4/10/14 stated "OT update: [Patient 6] attended 7% of referred OT groups this past week. [Patient 6] displayed some mania, interrupting (sic) peers in groups having difficulty remaining on topic. Limited progress." The MTP for Patient 6, updated on 4/10/14 indicated no revision to the interventions to address the needs of Patient 6 despite continued refusal of group therapy.

2. Patient #16

Patient #16 was admitted on 3/1/14 with the diagnosis of "Schizoaffective disorder."

a. The MTP for Patient #16, revised 4/14/14, stated that Patient #16 was admitted on listed the following group modalities to be used as treatment interventions: "Life Skills group," "Coping Skills group," "Stress Management," "Anger Management," "Functional Task," "Craft," "Leisure," "Nutrition," "Medication Education," "Relaxation/Meditation," "AM Stretch," "Discharge Issues," "Gym Group," "Psychological Issues," "Goals and Wrap Up," and "Peer Education" groups.

b. The "Treatment/Recovery Plan Review" (treatment plan review) dated 4/14/14 stated "Nursing update:...[Patient #16] continues with an angry and irritable edge and ignores staff on approach: remaining mute when spoken to...Patient naps a lot during the day and has to be woken up for medications." The "OT [occupational therapy] Update" stated Patient #16 "continues to refused (sic) all referred OT groups and 1:1 activities such as current events; cards, puzzles and music. [S/he] continues to refuse to meet with this therapist for OT/KELS [Kohlman Evaluation of Living Skills] evaluation." The MTP for Patient #16, updated on 4/14/14 indicated no revision to the interventions to address the needs of Patient #16 despite continued refusal of group therapy.

B. Interviews

1. During an interview on 4/15/14 at 4:00 p.m. with OT 1, the therapeutic group leader for most of the therapeutic groups assigned to Patient #6 and Patient #16, she acknowledged that these patients did not usually attend therapeutic groups and that the treatment plans had not been revised to address their lack of attendance.

2. During an interview on 4/15/14 at 11:40 a.m. with the Director of Social Work who was also the social worker assigned to Patient #16, she acknowledged that there were no documented interventions offered to Patient #16 when Patient #16 refused group therapy.

3. During an interview on 4/16/14 at 2:15 p.m. with Psychologist 1, the therapeutic group leader for some of the therapeutic groups assigned to Patient #6 and Patient #16, he acknowledged that these patients did not usually attend therapeutic groups and that the treatment plans had not been revised to address their lack of attendance.

4. During an interview with the Medical Director on 4/16/14 at 4:00 p.m., he acknowledged that the treatment plans for Patient #6 and Patient #16 had not been revised to provide alternative interventions despite the failure of these patients to attend assigned therapeutic groups.

Based on record review and interview, the facility failed to provide a Master Treatment Plan (MTP) that contained short and long-term goals that addressed the individualized needs of eight (8) of eight (8) active sample patients (3, 5, 6, 7, 9, 12, 14, and 16). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions, based on changes in patient's behaviors.

Findings include:

A. Record reviews (MTP dates in parentheses)

1. Patient #3, presenting problem was: "medication non adherence...decrease in ability to perform ADLS, increased smoking...increased intake of sweets (patient is diabetic) ...increasingly psychotic."

The long-term goal dated (MTP 4/10/14) was; "Patient will have a decrease in psychotic symptoms of paranoia, delusional ideation and responding to internal stimuli and will able to have a reality based conversation about issues related to admissions. Patient will agree to discuss/participate in a plan of aftercare to include, medication and outpatient treatment and recovery community supports."

The short-term goal was; "Patient will remain safe on the unit, be organized able to participate in basic self care tasks independently for 5 consecutive days."

2. Patient #5, presenting problem was; "non-compliance with medications....psychotic, agitated, paranoid, unable to care for self."

The long-term goal dated (MTP 4/15/14) was; "Patient will remain safe on the unit without threats or plans to harm self or others (maintaining personal boundaries without any aggressive behaviors) for seven (7) consecutive days. Patient will be organized in thoughts and without complaints or paranoia interfering with ability to have a reality based discussion or performs ADLS prior to her discharge. Patient will participate in a plan or aftercare to include medication and treatment."

The short-term goal was; "Patient will be organized in thoughts and mood, remain safe on the unit, maintaining personal boundaries (Remaining arms length from others, no verbal threatening statement, no punching, no kicking or other aggressive or sexualized behaviors)) for 5 consecutive days."

3. Patient #6, presenting problem was: "decompensating, non-adherent with medications, poor safety skill, lighting his cigarette by the stove burner, threatening to stab eye with a knife."

The long-term goal dated (MTP 4/10/14) was; "Patient will have a stable mood and will remain safe on the unit without threats or plans to harm self for 7 consecutive days. Patient will agree to discuss/participate in a plan of aftercare to include and identify 1-2 ways to ways to increase personal safety returning to the community."

The short-term goal was; "Patient will remain safe on the unit, be organized and be able to participate in basic self care tasks independently for 5 consecutive days."

4. Patient #7, presenting problem was; "thoughts to kill self if s/he is discharged to new community group home....involvement of reported abuse by father (under investigation)."

The long-term goal dated (MTP 4/14/14) was; "Patient will have a stable mood and will remain safe on the unit without threats or plans to harm self for 7 consecutive days."

The short-term goal was; "Patient will remain safe on the unit with a have a stable mood without thoughts or plans for self harm for 5 consecutive days on the inpatient unit, and Will be able to come to staff if feeling unsafe."

5. Patient #9, presenting problem was; "feeling overwhelmed in recent dates with worsening depression, paranoia, anxiety, and per sister bizarre behaviors including pacing, talking to himself and singing inappropriately and pacing in the house."

The long-term goal dated (MTP 4/9/14) was; "Patient will have a stable mood without harm to self or others for five consecutive days. Patient will agree to participate in a plan of how he can remain safe in the community after discharge."

The short-term goal was; "Patient will remain free from self injurious or assaultive behaviors for five consecutive days, and will come to staff if he is feeling unsafe or depressed."

6. Patient #12, presenting problem was; "non adherent with medication with increased paranoia aggression...inability to care for self at apartment even with community supports in place."

The long-term goal dated (MTP 4/9/14) was; "Patient will have a decrease in psychotic symptoms of and will able to have a reality based conversation about issues related to admission (patient) will remain safe on the unit, maintain personal boundaries with any threatening or aggressive behaviors (patient) will agree to discuss/participate in a plan of aftercare to include outpatient care and placement."

The short-term goal was; "Patient will be organized in thoughts and mood, remain safe on the unit, maintaining personal boundaries (remaining arms length from others, no verbal threatening statements, no punching, no kicking or other aggressive behaviors) for 5 consecutive days."

7. Patient #14, presenting problem was;..."reported suicidal ideation in part due to lack of access to treatment for mood and pain symptoms."

The long-term goal dated (MTP 4/14/14) was; "Patient will have a stable mood and will remain safe on the unit without threats of plans to harm self for 7 consecutive days and will identify 1-2 ways to increase personal safety returning to the community. Patient will agree to discuss/participate in a plan of aftercare to include benefits, medication, treatment and recovery community supports."

The short-term goal was; "Patient will remain safe on the unit and take medications as prescribed to help stabilize his depressed mood for 5 consecutive days and will come to staff if feeling unsafe."

8. Patient #16, presenting problem was; "...non-adherent with medication ...increased paranoia aggression...inability to care for self at apartment even with community supports in place."

The long-term goal dated (MTP 4/14/14) was "Patient will remain safe on the unit maintaining personal boundaries without any threatening or aggressive behaviors towards others. Patient will be organized, able to participate in ADL self care tasks on the unit prior to discharge (patient) will agree to discuss/participate in a plan of aftercare to include community supports, medication and treatment."

The short-term goal was; "Patient will have a stable mood and be able to maintain personal boundaries (remain arms length from others without yelling, threatening, hitting or other aggressive behaviors) for 7 consecutive days."

B. Interview

1. In an interview on 4/ 14/14 at 2:20 p.m. RN1 acknowledged that the goals did not give the staff guidance. She went on to say; "we seem to use the 5 or 7 consecutive days often, I'm not sure how we get to those numbers."

Based on record review and interview, the facility failed to ensure that the treatment plans for eight (8) of eight (8) active sample patients (3, 5, 6, 7, 9, 12, 14 and 16) identified active treatment measures that addressed the individual patient's specific problems and treatment. Instead, the treatment plans either listed routine and generic discipline functions inappropriately written as treatment interventions or listed general groups/activities to be provided for the patients as the interventions. These deficiencies result in treatment plan that fail to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions needed and the purpose for each. This failure potentially results in inconsistent and/or ineffective treatment.

Findings include

1. Routine, generic discipline functions.

A. Record Review

1. Patient #3 was admitted 3/8/14. The treatment plan dated 4/10/14 noted the following routine, generic discipline functions: "...RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression." Patient 3 was scheduled to attend the following occupational therapy groups: Life skills, Coping Skills, Stress Management, Functional Task group, Craft group, and Leisure group.

2. Patient #5 was admitted 3/28/14. The treatment plan dated 4/15/14 noted the following routine, generic discipline functions: "...RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression." Patient 5 was scheduled to attend the following occupational therapy groups: Life skills, Coping Skills, Anger Management, Functional Task group, Craft group, and Leisure group.

3. Patient #6 was admitted 3/5/14. The treatment plan dated 4/10/14 noted the following routine, generic discipline functions: "...RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression."

4. Patient #7 was admitted 2/24/14. The treatment plan dated 4/14/14 noted the following routine, generic discipline functions: "...RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression." Patient 7 was scheduled to attend the following occupational therapy groups: Coping Skills, Stress Management, Functional Task group, Craft group, and Leisure group.

5. Patient #9 was admitted 4/9/14. The treatment plan dated 4/11/14 noted the following routine, generic discipline functions: "...RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression."

6. Patient #12 was admitted 2/20/14. The treatment plan dated 4/9/14 noted the following routine, generic discipline functions: "...RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression."

7. Patient #14 was admitted 4/7/14. The treatment plan dated 4/9/14 noted the following routine, generic discipline functions: "...RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression."

8. Patient #16 was admitted 3/1/14. The treatment plan dated 4/14/14 noted the following routine, generic discipline functions: "...RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression."

2. General group therapy interventions.

1. Patient 3, 5, 6, 14, and 16 all had the following general group therapy sessions assigned to them on their treatment plans: Life skills group; Coping skills; Stress and/or Anger Management, Functional Task group, Craft group, and Leisure group and other special groups like meditation group, psychological issues group, nutrition group, etc.

2. During ward rounds on 4/15/14 at 12:50 p.m., Patient #5 was observed sitting in a chair in the dayroom area. S/he was asked to attend the 1:00 p.m. group on psychological issues. S/he did not respond to the staff person. Approximately five minutes after the start of the psychological issues group, s/he came into the group, sat down away from the group and then left the group after 5-10 minutes. S/he did this entrance-exit 6 times during the 45-minute session. No problems, goals, or interventions were related to the refusal of Patient #5 to attend group therapy. No alternative treatment was identified to be provided despite the refusal of Patient #5 to attend or participate in group therapy.

B. Interview

In an interview with RN 3 while reviewing the computerized MTPs and treatment notes (4/15/14 at approximately 11:00 a.m. and 3:30 p.m.) it was observed that the treatment notes did not specifically refer to the "10-15 minutes twice daily staff/patient meetings/interventions to assess mental status", as recorded in the MTP nursing intervention for the patients. The RN Coordinator said, "we should not record this intervention, it's not accurate or specific on a daily basis."

Based on observation, interview, and record review, it was determined that the facility failed to:

I. Ensure that patients attended programming or received alternative treatment based on individualized treatment needs for two (2) of eight (8) active patients (6 and 16). These patients spent much of their time in their bedroom, sitting in the hallway, or sitting alone in a unit room, often missing assigned programming. This prevented patients from achieving their optimal level of functioning during hospitalization.

II. Provide individualized active treatment for eight (8) of eight (8) sample patients (3, 5, 6, 7, 9, 12, 14, and 16) sample patients on evenings and weekends. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion potentially delaying improvement.

III. Assess and treat the medical problems of one (1) discharged patient (D6) reviewed for medical care, in order to identify potentially treatable medical etiologies of mental status changes, and identify potential concurrent medical illnesses. Failure to address medical issues and obtain a correct diagnosis and treatment results in a potential risk to patients' lives/health and prevents patients from achieving an optimal level of functioning.
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I. Failure to provide individualized treatment

A. Patient #6

1. Observations and Interview

During ward rounds on 4/15/14 at 9:40 a.m., Patient #6 was observed sitting alone in a chair in the dayroom area during the time of his/her scheduled group therapy, "Life Skills." At that time, Patient #6 stated that s/he only attended group therapy "once in a while. I don't have to go... Basically, I know what goes on in them [the groups]." On 4/15/14 at 10:25 a.m., Patient #6 was observed sitting alone in the dayroom area during the time of his/her scheduled group therapy, "Medication Ed (education)." On 4/15/14 at 1:15 p.m. during his/her scheduled group therapy, "Psychological Issues," Patient #6 was observed sitting alone in a unit room with his/her head on the table asleep.

2. Record Review

a. The psychiatric assessment for Patient #6 dated 3/5/14 at 8:14 p.m. stated that Patient 6 was admitted "due to SI (suicidal ideation) with plan of stabbing [him/herself] in the eyes and problematic behaviors including unsafe use of oven, smoking in non-permitted areas..." Diagnoses were "Schizoaffective d/o (disorder) vs (versus) schizophrenia paranoid type" and "antisocial personality disorder with antisocial and narcissistic traits."

b. Review of the master treatment plan dated 4/10/14 revealed a list of general group modalities for the treatment of Patient #6 including "Life Skills group," "Coping Skills group," "Stress Management," "Self Esteem," "Functional Task," "Craft," "Leisure," "Discharge Issues," and "Psychological Issues" groups. No problems, goals, or interventions were related to the refusal of Patient #6 to attend group therapies. No alterative treatments were identified to be provided despite the refusal of Patient #6 to attend or participate in group therapy.

c. The "Group Progress Notes" listing all groups attended and refused by Patient #6 during the period of 4/1/14 to 4/15/4 indicated that Patient #6 attended only one therapeutic group session, "Life Skills" on 4/7/14 at 9:30 a.m., in which s/he "attended briefly." Only one "alternative activities," a "one to one," was documented on 4/10/14 at 11:00 a.m. and the "Time Person Spent in Activity" was "0-15 Minutes."

B. Patient #16

1. Observations and Interviews

During ward rounds on 4/15/14 between 9:40 a.m. and 10:00 a.m., Patient #16 was observed lying in the bed or sitting alone in a chair in the dayroom area during the time of his/her scheduled "Life Skills" group. Patient 16 refused to answer any questions at these times.

2. Record Review

a. The psychiatric assessment for Patient #16 dated 3/1/14 at 2:28 a.m. stated that Patient #16 was admitted "due to agitated, angry...uncooperative...chronic paranoia." Diagnosis was "Schizoaffective disorder."

b. Review of the MTP dated 4/14/14 revealed a list of general group modalities for the treatment of Patient #16 including "Life Skills group," "Coping Skills group," "Stress Management," "Anger Management," "Functional Task," "Craft," "Leisure," "Nutrition," "Medication Education," "Relaxation/Meditation," "AM Stretch," "Discharge Issues," "Gym Group," "Psychological Issues," "Goals and Wrap Up," and "Peer Education" groups. No problems, goals, or interventions were related to the refusal of Patient 16 to attend group therapies. No alterative treatments were identified to be provided despite the refusal of Patient #16 to attend or participate in group therapy.

c. The "Group Progress Notes" listing all groups attended and refused by Patient #16 during the period of 4/1/14 to 4/15/14 indicated that Patient #16 attended only one therapeutic group session, "Crafts" on 4/6/14 at 10:15 a.m. Only one "alternative activities," a "meditation," was documented on 4/7/14 at 10:15 a.m. and the "Time Person Spent in Activity" was "16-30 Minutes."

C. Staff Interviews

a. During an interview on 4/15/14 at 4:00 p.m. with OT 1, the therapeutic group leader for most of the therapeutic groups assigned to Patient #6 and Patient #16, she acknowledged that these patients did not usually attend group therapy. She stated that she was not responsible for providing alterative treatments for patients who did not attend therapeutic groups. She stated that Patient #6 only attended therapeutic groups one time in the previous two weeks. She stated that Patient #16 did not attend therapeutic groups and "refused almost everything since [s/he] came in."

b. During an interview with Patient #6 on 4/15/14 at 9:45 a.m., s/he stated that s/he attended groups "once in a while. I don't have to go [to group therapy]...basically, I know what goes on in them [the groups]."

c. During an interview with the Director of Social Work on 4/16/14 at 11:15 a.m., she stated that "Group is seen as the primary modality...don't see one-to-one [therapy] as being the major treatment [for patients in the facility]."

d. During an interview on 4/16/14 at 2:15 p.m. with Psychologist 1, the therapeutic group leader for some of the therapeutic groups assigned to Patient #6 and Patient #16, he acknowledged that these patients did not usually attend therapeutic groups.

e. During an interview with the Medical Director on 4/16/14 at 4:00 p.m., he acknowledged that Patient #6 and Patient #16 did not attend their assigned therapeutic groups and no alterative treatments were provided other than medication management.

II. Failure to provide individualized therapeutic modalities on evenings and/or weekends.

A. Record Review

A review of the following MTP's (dates in parenthesis) revealed that no therapeutic activities were listed for evenings and weekends: Patient #3 (revised 4/10/14), Patient #5 (revised 4/15/14), Patient #6 (revised 4/10/14), Patient #7 (revised 4/14/14), Patient #9 (revised 4/11/14), Patient #12 (revised 4/9/14), Patient #14 (revised 4/9/14), and Patient #16 (revised 4/14/14).

B. Document Review

A review of the "IPU Group Schedule" presented as the current group schedule for the facility did not include therapeutic programming on the weekends or evenings.

C. Interviews

1. During an interview on 4/15/14 at 4:00 p.m. with OT 1, the therapeutic group leader for most of the therapeutic groups, she stated that she did not conduct therapeutic groups at night or on weekends. She stated that night and weekend activities were leisure-focused activities conducted by the charge nurses and the recreational therapist.

2. During an interview on 4/16/14 at 2:15 p.m. with Psychologist 1, the therapeutic group leader for some of the therapeutic groups, he stated that he did not conduct therapeutic groups at night or on weekends.

3. During an interview on 4/17/14 at 9:30 a.m. with the DON, she acknowledged that nursing did not conduct therapeutic groups at night and on weekends related to the treatment plans for the patients.

III. Medical Care

A. Musculoskeletal system

1. Historical information available to the facility during the hospitalization

a. The "Outpatient Vascular Surgery Consultation Report" dated 10/18/13 stated that Patient D6 had a "Past Medical History" of "Factor V Leiden deficiency with a history of 2 deep venous thrombosis of the right calf, one subsequently had contributed to a pulmonary embolism."

b. The outpatient evaluation of Patient D6 by "Foot and Ankle Services" dated 10/28/13 stated that "November 2012, patient was in a MVA [motor vehicle accident] with multiple injuries: fractures of both 'legs', right fractured talus, tibia, fibula and metatarsals 1-4. [S/he] also fractured [his/her] back, arm. At one point at least one fasciotomy was performed on the right leg. In December, [s/he] developed an infection in the right foot (pseudomonas and 'staph'). [S/he] also developed osteomyelitis in the thigh and pelvis." The evaluation stated "Trauma: 2012: MVA, fractures: back, arm, both 'legs', right ankle (tib/fib/talus), MT 1-4. ORIF, osteomyelitis in pelvis and thigh, fasciotomy right leg, revascularization right leg. 2011: MVA (hit by a snow plow): left hip fracture, loss of kidney."

c. Emergency department records dated 12/27/13 at 12:35, reportedly available at the time of the admission of Patient D6, stated "currently in pain: yes L [left] knee from MVA."

2. Hospital course

a. The "History and Physical" examination dated 1/4/14 at 1:33 p.m. stated that Patient D6 had a history of "2013 motor vehicle accident, orthopedic surgery metnal (sic) in right forearm, had left knee injury and stroke." The review of symptoms stated, "The patient has a limp of the right leg which significantly affects [his/her] ambulation. [S/he] reports pain in the right knee." The examination stated, "The patient has an unsteady gait due to a limp from a motor vehicle accident." The "Summary and Formulation" stated that Patient D6 "has suffered orthopedic injury due to MVA [motor vehicle accident]. [S/he] has a gait abnormality and claims to have chronic pain as a result." The "History and Physical" examination did not include an examination or assessment of Patient D6's lower extremities other than to note "[s/he] has bilateral scars down both legs."

b. The "Nursing Bio-Physical Screening" dated 12/30/13 at 7:17 p.m. completed at the time of admissions stated "prob [problem] w/ [with] wt [weight] bearing joints" and "chronic left knee pain."

c. The "Prescribers New Orders" on 1/29/14 at 12:45 a.m. stated "Apply heat pack to L [left] leg q[every] 2 [hours] prn [as needed]." No assessment of the left leg by a physician or physician extender was documented at that time.

d. The RN "Daily Note Nursing" on 1/31/14 at 7:31 a.m. stated that Patient D6 "complains of knee pain; continues to utilize heat packs."

e. The "Prescribers New Orders" on 1/31/14 at 11:40 p.m. stated "Apply ice pack to left knee for 15 min [minutes] q[every] 2 [hours] for pain." No assessment of the left leg by a physician or physician extender was documented at that time.

f. The RN "Pain/Function Progress Note" on 2/1/14 at 5:14 a.m. stated that on 1/31/14 at 11:55 p.m. and 1/31/14 at 2:00 a.m., Patient D6 reported pain that was "constant, at rest with ambulation 'I can't even lay my leg down in the bed without pain.' " The "Pain Rating" was "7/10, knee is hot and erythemic at the ankle/shin. [Physician on-call] notified." "Patient stated 'nothing helps, nothing make (sic) a difference.' "

g. The RN "Daily Note Nursing" on 2/1/14 at 7:37 a.m. stated that Patient D "complains of knee pain...Left leg is swollen and reddened from knee down to ankle."

h. The RN "Special Occurrence Note" on 2/1/14 at 12:05 p.m. stated that "[Patient D] was seen by the DOC (doctor on call), who determined that [Patient D6] needed to go to [outside medical facility] ER (emergency room) for evaluation and possible treatment of left knee." The RN note on 2/1/14 at 10:31 p.m. stated that Patient D6 returned from the outside facility on 2/1/14 at 5:30 p.m.

i. A review of the medical record indicated that vital signs were only documented on 12/30/13 at 6:45 p.m., 1/1/14 at 6:00 p.m., 1/4/14 at 1:33 p.m. (no blood pressure), 2/18/14 at 6:30 p.m., and 2/25/14 at 6:15 a.m. and no vital signs were obtained on 1/31/14 or 2/1/14.

j. The only physician note during this period was on 2/1/14 at 5:49 p.m. The note stated "the patient was evaluated and found to have a hot left knee. [S/he] also was complaining of pain. Due to the findings on the physical examination there was concern that the knee could be septic. The patient was subsequently sent to [outside medical facility] ED (emergency department). The ED felt that [s/he] had a cellulitis in the left knee."

k. No physical examination of Patient D6's lower extremities by a medical provider at the facility was documented on 1/31/14 or 2/1/14 prior to transfer to the emergency department despite the concern that Patient D6 might have a septic knee. No examination of the left knee by a physician or physician extender was documented until 2/4/14 at 10:30 a.m.

3. Staff Interview

During interviews with the Medical Director on 4/16/14 at 4:00 p.m. and with the Medical Director and NP 1, the primary medical provider for these patients, they acknowledged that there was no documented examination of the left leg of Patient D6 from the time admission until 2/4/14 at 10:30 a.m. despite a history of serious trauma and surgery and complaints of pain. He acknowledged that there was no documented examination of the left leg of Patient D6 despite serious symptoms resulting in transfer to an emergency department.

B. Thyroid Status

1. Historical information available to the facility during the hospitalization

Emergency department records dated 12/27/13 at 12:35, reportedly available at the time of the admission of Patient D6, stated Laboratory studies completed in the emergency department included "thyroid stim horm [thyroid stimulating hormone] L [low] 0.090 uIU/mL [International milliunits/milliliter] 0.358-3.740 [reference normal range]."

2. Hospital course

a. The "History and Physical" examination dated 1/4/14 at 1:33 p.m. stated that Patient D6 had a history of The "Recent Laboratory Findings" stated "TSH [thyroid stimulating hormone] low 0.090 [milliunits/liter]." The "Summary and Formulation" stated that Patient D6 "Of note is possible hyperthyroidism. Consider endocrine consult."

b. A review of the orders and laboratory reports did not indicate a repeat TSH level or further laboratory studies to further evaluate the possibility of hyperthyroidism were completed during this hospitalization. A review of the medical record did not indicate an endocrinology consult was considered or obtained during this hospitalization.

3. Staff Interview

During interviews with the Medical Director on 4/16/14 at 4:00 p.m. and with the Medical Director and NP 1, the primary medical provider for these patients, they acknowledged that the facility was aware of the low TSH level of Patient D6 at the time of admission but that there was no documented follow-up to repeat the abnormal level or consider an endocrinology consultation as stated in the admission physical examination.

C. Coagulation status

1. Historical information available to the facility during the hospitalization

a. The outpatient evaluation of Patient D6 by "Foot and Ankle Services" dated 10/28/13 stated that "Factor V Leiden deficiency, (DVT x 2 of R(right)/calf, PE [pulmonary embolism] (patient refuses Coumadin)."

b. The "Outpatient Vascular Surgery Consultation Report" dated 10/18/13 stated that Patient D6 had a "Past Medical History" of "Factor V Leiden deficiency with a history of 2 deep venous thrombosis of the right calf, one subsequently had contributed to a pulmonary embolism."

c. Emergency department records dated 12/27/13 at 12:35, reportedly available at the time of the admission of Patient D6 stated "Factor V (Leiden) deficiency - noncompliant with Coumadin treatment."

2. Hospital course

A review of the orders and laboratory reports did not indicate further evaluation, assessment, or laboratory studies were completed during this hospitalization to determine if Patient D6 had or required treatment for a hypercoagulable state.

3. Staff Interview

During interviews with the Medical Director on 4/16/14 at 4:00 p.m. and with the Medical Director and NP 1, the primary medical provider for these patients, on 4/17/14 at 9:30 a.m., they acknowledged that the facility noted a possible hypercoagulable state at the time of admission with a possible history of multiple blood clots and noncompliance with treatment. He acknowledged that no further assessment including laboratory studies to determine the diagnosis or consideration of specialty consultation was documented during this hospitalization.

Based on interview and document review, the Medical Director failed to provide adequate medical oversight to ensure quality medical services. Specifically, the Medical Director failed to:

I. Ensure that the MTP's for two (2) of two (2) active sample patients (Patients #6 and Patients #16) were revised when the patients failed to participate in the prescribed treatment. Master treatment plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

II. Provide a Master Treatment Plan (MTP) that contained short and long-term goals that addressed the individualized needs of eight (8) of eight (8) active sample patients (3, 5, 6, 7, 9, 12, 14, and 16). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions, based on changes in patient's behaviors. (Refer to B121)

III. Ensure that patients attended programming or received alternative treatment based on individualized treatment needs for two (2) of eight (8) active patients (6 and16). These patients spent much of their time in their bedroom, sitting in the hallway, or sitting alone in a unit room, often missing assigned programming. This prevented patients from achieving their optimal level of functioning during hospitalization. (Refer to B125 Part I)

IV. Provide individualized active treatment for eight (8) of eight (8) sample patients (3, 5, 6, 7, 9, 12, 14, and 16) sample patients on evenings and weekends. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion potentially delaying improvement. (Refer to B125 Part II)

V. Assess and treat the medical problems of one (1) discharged patient (D6) reviewed for medical care, in order to identify potentially treatable medical etiologies of mental status changes, and identify potential concurrent medical illnesses. Failure to address medical issues and obtain a correct diagnosis and treatment results in a potential risk to patients' lives/health and prevents patients from achieving an optimal level of functioning. (Refer to B125 Part III)

Based on record review and interview, the Director of Nurses failed to assure quality and appropriateness of nursing care of eight (8) of eight (8) active sample patients (3. 5, 6, 7, 9, 12, 14, and 16). Specifically the DON failed to:

1. Ensure that the short and long-term goals that were recorded in the MTPs were stated in behavioral measurable terms for 8 of 8 active sample patients (3, 5, 6, 7, 9, 12, 14, and 16). (Refer to B121)

2. Ensure that the MTPs for eight (8) of eight (8) active sample patients (3, 5, 6, 7, 9, 12, 14, and 16) had nursing interventions that included a focus, frequency and duration. The nursing interventions were generic functions of the discipline. (Refer to B122)

3. Ensure that patients participate in therapeutic activity and that nurses plan ways to effectively involve patients. Failure to ensure that patients receive active treatment results in potential delay of the patients' recovery and/or discharge from the hospital. (Refer to B122)

Findings include

A. Lack of specific Nursing Interventions in the Master Treatment Plans

1. Active sample Patient #3, admitted 3/8/14, MTP dated 4/10/14: Intervention for Problem 1; "medication non adherence...decrease in ability to perform ADLS, increased smoking...increased intake of sweets (patient is diabetic)...increasingly psychotic." Interventions - "RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression." These are generic nursing tasks and are not specific treatment modalities.

2. Active sample Patient #5, admitted 3/18/14, MTP dated4/15/14: Intervention for Problem 1; "non-compliance with medications....psychotic, agitated, paranoid, and unable to care for self." Interventions - "RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression." These are generic nursing tasks and are not specific treatment modalities.

3. Active sample Patient #6 admitted 3/5/14, MTP dated 4/10/14: Intervention for problem 1; "decompensating, non-adherent with medications, poor safety skill, lighting his cigarette by the stove burner, threatening to stab eye with a knife." Interventions - "RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression." These are generic nursing tasks and are not specific treatment modalities.

4. Active sample Patient #7 admitted2/24/14, MTP dated 4/14/14: Intervention for problem 1; "thoughts to kill self if s/he is discharged to new community group home.... involvement of reported abuse by father (under investigation)." Interventions - "RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression." These are generic nursing tasks and are not specific treatment modalities.

5. Active sample Patient #9 admitted 4/9/14, MTP dated 4/11/14: Intervention for problem1; "feeling overwhelmed in recent dates with worsening depression, paranoia, anxiety, and per sister bizarre behaviors including pacing, talking to himself and singing inappropriately and pacing in the house." Interventions - "RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression." These are generic nursing tasks and are not specific treatment modalities.

6. Active sample patient #12 admitted 2/20/14, MTP dated 4/9/14: Intervention for problem 1; "non adherent with medication with increased paranoia aggression ...inability to care for self at apartment even with community supports in place." Interventions - "RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression." These are generic nursing tasks and are not specific treatment modalities.

7. Active sample patient #14 admitted 4/7/14, MTP dated 4/9/14: Intervention for problem1; ..."reported suicidal ideation in part due to lack of access to treatment for mood and pain symptoms." Interventions - "RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression." These are generic nursing tasks and are not specific treatment modalities.

8. Active sample patient #16 admitted 3/1/14, MTP dated 4/14/14: Intervention for problem 1; ..."reported suicidal ideation in part due to lack of access to treatment for mood and pain symptoms." Interventions - "RN and other nursing staff will meet with (patient) for at least 10-15 minutes twice daily to assess mental status, thought process, mood, ability to maintain boundaries and personal safety. Staff will encourage (patient) to attend medication group at least twice weekly. Staff will also provide medication education at each med administration: and will offer PRN medications if needed for complaints of agitation, irritability, paranoia or hallucinations or increased depression." These are generic nursing tasks and are not specific treatment modalities.

B. Interviews

1. In an interview 4/15/14 at approximately 8:45 am, RN3 who was checking the active sample patients on the computerized medical record noted and said; "we have not individualized these MTPs, we have to do better."

In an interview 4/17/14 at 9:30 am with the DON and RN3 acknowledged that the MTP did not include specific psychiatric nursing interventions that were measurable and specific to each patient's needs.