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I. The facility failed to provide focused, active treatment throughout the waking hours for 8 of 8 sample patients (R1, R2, R3, R4, P5, P6, P7 and P8) and no alternative treatment for 1 of 8 sample patients (R4). A treatment plan not updated when a patient ' s clinical condition changes. This failure resulted in individuals being hospitalized without all interventions provided based on individual patient needs/presenting behaviors, not receiving active treatment and potentially delaying their recovery. (Refer to B125)

II. The facility failed to address significant psychiatric disabilities identified during the assessment process for 7 of 8 sample patients (R1, R2, R3, R4, P5, P6, and P8). This failure resulted in Master Treatment Plans that were not individualized for the patient and there was no specific direction to staff as to how to intervene regarding the disabilities cited. (Refer to B119)

III. The facility failed to ensure that the Master Treatment Plans for 8 of 8 sample patients (R1, R2, R3, R4, P5, P6, P7 and P8) identified active treatment interventions that addressed the individual patient ' s specific problems. This failure resulted in lists of routine and generic discipline functions or lists of general groups/activities without a specific focus for the individual patient which compromises treatment. (Refer to B122)

Based on record review and staff interviews, the facility failed to ensure that the social service assessments included individualized recommendations for social work services from the data gathered for 1 of 8 active sample patients (R2). As a result, the treatment team did not have current baseline social functioning on these patients for establishing treatment goals and interventions and social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams.


Findings include:


A. Record Review

Patient R2 was admitted on 08/29/14. The psychosocial assessment, done on 08/31/14, did not include individualized social services specific recommendations. The recommendations documented were generic in nature describing routine unit activities, reason for the admission, and routine outpatient follow up care. The recommendations were "Pt. is 20 yr old F [Female] presents with paranoia responding to internal stimuli, bizarre statements about her body, not slept 4 days, not eating, drug and alcohol use, loose associations. Pt. stuck on traumatic event happened 4 yrs ago. Pt. to benefit from safe and supportive environment, group therapy to release feelings and learn coping skills for depressed mood. Pt. to f/u with outpatient MD for medication management and outpatient therapist."


B. Staff Interviews

During an interview on 09/17/14 at 03:00PM, the supervising SW1 stated, "I get your point. It is very short (referring to social service recommendations). The social assessments do not include individualized recommendations. This particular therapist does not work here full time. I need to spend more time with her. It is a concern with this therapist. I need to address this with her."

Based on record review, policy review and staff interview, it was determined that the facility failed to perform and document a psychiatric evaluation for 1 of 8 active sample patient (R2). The absence of this patient information hinders the clinician's ability to make an accurate diagnosis and plan appropriate treatment.


Findings Include:


Record Review:

Patient R2 was admitted on 08/29/2014. There was no psychiatric evaluation documented in the medical record. Instead, there was a physician progress note dated 08/30/2014 which was labelled "see psych eval dated 7/29/14 (referring to this patient's previous admission to the facility). This is a addendum to psych evaluation."


Policy Review:

The medical staff rules and regulations dated 06/26/2014, stated, "The psychiatric evaluation and mental status examination shall, in all cases, be completed within 24 hours after admission of the patient and the admission note will be entered in the progress notes at the time of evaluation. Dictation of such must be completed and in the patient's chart within 48 hours. The admission note will include a DSM IV five axis diagnoses and preliminary plan of treatment. The complete psychiatric evaluation, in all cases, will be completed and recorded in the chart within 24 hours after admission of the patient, unless one has been performed within 30 days prior to admission, in which case a durable, legible copy of the report may be used in the patient ' s medical record provided that the physician reviews such copy, indicates any changes on the report copy in the chart, and signs and dates his review. If the psych eval is dictated, a progress note shall be entered at the time of examination documenting any relevant medical conditions and recommendations. When the patient is readmitted within 30 days for the same or related problem, an "interval" psych eval reflecting any changes may be used, provided that the original physical exam is readily available.


Interview:

During an interview on 09/17/2014 at 02:30PM, the CEO stated, "Psychiatric evaluation is being completed now. It is late but it will be done. Medical staff by laws will also be amended."

Based on record review, policy review and staff interview, it was determined that the facility failed to perform and document psychiatric evaluations for 1 of 8 active sample patients (P7) in a timely manner as per the medical staff rules and regulations. This failure hinders the treatment team's ability to effectively formulate treatment plans in a timely manner.


Findings Include:


Record Review:

Patient P7 was admitted on 09/11/2014. The psychiatric evaluation was not completed within 24 hours of the admission as per the hospital medical staff rules and regulations.


Policy Review:

The medical staff rules and regulations dated 06/26/2014, stated, "The psychiatric evaluation and mental status examination shall, in all cases, be completed within 24 hours after admission of the patient and the admission note will be entered in the progress notes at the time of evaluation. Dictation of such must be completed and in the patient's chart within 48 hours. The admission note will include a DSM IV five axis diagnoses and preliminary plan of treatment. The complete psychiatric evaluation, in all cases, will be completed and recorded in the chart within 24 hours after admission of the patient, unless one has been performed within 30 days prior to admission, in which case a durable, legible copy of the report may be used in the patient ' s medical record provided that the physician reviews such copy, indicates any changes on the report copy in the chart, and signs and dates his review. If the psych eval is dictated, a progress note shall be entered at the time of examination documenting any relevant medical conditions and recommendations. When the patient is readmitted within 30 days for the same or related problem, an "interval" psych eval reflecting any changes may be used, provided that the original physical exam is readily available.


Interview:

During an interview on 09/17/2014 at 02:30PM, the CEO stated, "I see psych eval (psychiatric evaluation) is not done within 24 hours."

Based on record review and staff interview, it was determined that the facility failed to perform and document an estimate of memory functioning in the psychiatric evaluation for 1 of 8 active sample patients (R2) and failed to perform an estimate of intellectual functioning in the psychiatric evaluation for 1 of 8 active sample patients (R2). These failures potentially result in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromise future comparative re-examinations to assess patient's response to treatment interventions.

Findings include:

Record Review:
Patient R2 was admitted on 08/29/14. The addendum to psychiatric evaluation, done on 08/30/14 did not document an estimate of memory functioning and an estimate of intellectual functioning.

Interview:
During an interview on 09/17/14 at 11:25AM, the Medical Director stated, "We are going through massive overhaul, we are making changes. You guys came a little bit earlier. Over next 2 or 3 weeks we will be looking at effectiveness changes. I know we still need to improve."

Based on record review and interview, the facility failed to address significant psychiatric disabilities identified during the assessment process for 7 of 8 active sample patients (R1, R2, R3, R4, P5, P6, and P8). This failure resulted in Master Treatment Plans that were not individualized for the patient and there was no specific direction to staff as to how to intervene regarding the disabilities cited.

Findings include:

A. Record Reviews:
1. Patient R1 had the following liabilities listed in the Master Treatment Plan dated 9/6/14: "Limited or poor social support," "Limited social skills," "Traumatic Event" and "Family Conflict." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

2. Patient R2 had the following liabilities listed in the Master Treatment Plan dated 8/31/14: "Treatment/Medication Non-compliance" and "Traumatic Event." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

3. Patient R3 had the following liabilities listed in the Master Treatment Plan dated 9/7/14: "Limited ability to read and write" and "Traumatic Event." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

4. Patient R4 had the following liabilities listed in the Master Treatment Plan dated 9/4/14: "Substance Abuse" and "No insight into current situation/illness." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

5. Patient P5 had the following liabilities listed in the Master Treatment Plan dated 9/11/14: "Limited or poor social support," "Limited social skills," " Family conflict," and "No insight into current situation/illness." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

6. Patient P6 had the following liabilities listed in the Master Treatment Plan dated 9/11/14: "Educational or school conflicts," "Recent loss," "Traumatic event" and "Family conflict." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

7. Patient P8 had the following liabilities listed in the Master Treatment Plan dated 9/12/14: "Past history of unsuccessful treatment," "Traumatic Event," and "No insight into current situation/illness." There were no individualized interventions to address these liabilities in the Master Treatment Plan.

B. Interviews:
1. On 9/16/14 at 1:10PM, the Director of Clinical Services for the facility stated, "I see what you mean about the interventions not being related to the liabilities mentioned."

2. On 9/16/14 at 1:40PM, the Chief Executive Officer of the facility stated, "No, the interventions are not individualized. We are a work in progress."

3. On 9/17/14 at 10:00AM, the Director of Nursing, "I see that the interventions are not specific to each patient."

Based on record review and interviews, the facility failed to ensure that the Master Treatment Plans for 8 of 8 active sample patients (R1, R2, R3, R4, P5, P6, P7 and P8) identified active treatment interventions that addressed the individual patient's specific problems. The list of preprinted interventions was identical on each patient's record, from the child unit to the adult units, and was written as to what the patient would do instead of how the staff would treat the patient. This failure resulted in lists of routine and generic discipline functions or lists of general groups/activities without a specific focus for the individual patient which compromises treatment.

Findings include:

A. Record Review:
1. Patient R1 (Master Treatment Plan dated 9/6/14), for the problems of "SI [suicidal ideation], command AH [auditory hallucinations] and aggression towards family and increased paranoia," had the following interventions listed: "Compliance with the following medications as prescribed by assigned psychiatrist: Clozapine," "Attend daily nursing education groups," "Patient will meet with unit nurse twice a shift daily," "Take a minimum of three showers within a one week period," "Practice journaling affirmations daily," "Talk to a trusted staff daily when having thoughts of harming others," "Participate in process groups daily," "Provide feedback a minimum of one time a day in groups," " Participate in 5-6 recreational therapy groups per week," "Patient will identify areas of strength and interest by participating in recreational therapy groups daily," and "Patient will practice calm telephone conversations." The focus of the modality or activity is listed as "nursing" or "clinical." These are generic discipline functions without individualization.

2. Patient R2 (Master Treatment Plan dated 8/31/14), for the problems of "depression, paranoid, delusional, internal stimuli," had the following interventions listed: "Compliance with the following medications prescribed by assigned psychiatrist: Abilify, Depakote," "Attend daily nursing education groups," "Patient will be oriented to reality with unit nursing staff at least twice a shift daily," "Nursing staff will educate patient each shift on the importance of medication to decrease hallucinations/psychosis," "Patient will brush teeth, wash hands after toileting daily, and shower 3x per week," "Talk to trusted staff daily when having thoughts of harming self," "Patient will attend and attempt to participate in one process group per day" and "Participate in 5-6 recreational therapy groups per week." The focus of the modality or activity is listed as "RN service" or "Clinical services." These are generic discipline functions without individualization.

3. Patient R3 (Master Treatment Plan dated 9/7/14), for the problems of "depressed, suicide thoughts," had the following interventions listed: "Compliance with the following medication as prescribed by the assigned psychiatrist: Lexapro, Neurontin," "Attend daily nursing education groups," "Patient will meet with unit nurse twice a shift daily," "Take a minimum of three showers within a one week period," "Participate in 60 minute spirituality group one time weekly" and "Patient will identify areas of strength and interest by participating in recreational therapy groups daily." The focus of the modality or activity is "clinical services." These are generic discipline functions without individualization.

4. Patient R4 (Master Treatment Plan dated 9/4/14), for the problems of "danger to self, opioid dependence," had the following interventions listed: "Compliance with the following medications prescribed by assigned psychiatrist: Suboxone, Clonidine," "Attend daily nursing education groups," "Patient will meet with unit nurse twice daily," "Talk to a trusted staff daily when having thoughts of harming self," "Participate in one process group daily," "Participate in 5-6 recreational therapy groups per week," "Patient will identify areas of strength and interest by participating in recreational therapy groups daily." These are generic discipline functions without individualization.

5. Patient P5 (Master Treatment Plan dated 9/11/14), for the problems of "danger to self, danger to others, and family history of mental illness," had the following interventions listed: "Compliance with the following medication as prescribed by assigned psychiatrist: Abilify, Tenex, Trileptel," "Attend daily nursing education groups " "Patient will meet with unit nurse twice a shift daily," "Practice journaling affirmations daily," "Talk to a trusted staff daily when having thoughts of harming self," "Participate in one process group daily," "Provide feedback a minimum of one time a day in groups," "Participate in 5-6 recreational therapy groups per week" and "Patient will identify areas of strength and interest by participating in recreational therapy groups daily." These are generic discipline functions without individualization.

6. Patient P6 (Master Treatment Plan dated 9/11/14), for the problems of "danger to others, danger to self," had the following interventions listed: "Compliance with the following medication as prescribed by assigned psychiatrist: Patient to see [doctor] 6xs per week," "Attend daily nursing education groups," "Patient will meet with unit nurse twice a shift daily," "Participate in process groups daily," "Provide feedback a minimum of one time a day in groups" and "Participate in 5-6 recreational therapy groups per week." These are generic discipline functions without individualization.

7. Patient P7 (Master Treatment Plan dated 9/12/14), for the problem "danger to self," had the following interventions listed: "Compliance with the following medication as prescribed by assigned psychiatrist: Cymbalta," "Attend daily nursing education groups," "Patient will meet with unit nurse twice a shift daily," "Participate in one process group daily" and "Participate in 5-6 recreational therapy groups per week." These are generic discipline functions without individualization.

8. Patient P8 (Master Treatment Plan dated 9/12/14), for the problems "depression, urges to cut," had the following interventions listed: "Attend daily nursing education groups," "Patient will meet with unit nurse twice a shift daily," "Participate in one process group daily," "Participate in 5-6 recreational therapy groups per week," and "Patient will participate in family therapy session." These are generic discipline functions without individualization.

B. Interviews
1. On 9/17/14 at 10:00AM, the Director of Nursing stated, "I see that the interventions are not specific to each patient."

2. On 9/17/14 at 11:30AM, the Clinical Director stated, "I can see where the interventions are the same, like cookie cutter ones."

3. On 9/1714 at 1:05PM, the Director of Clinical Services stated, "Yes, the interventions are the same for all the units."

18054

Based on document review, observation and patient and staff interviews, the facility failed to provide focused active treatment throughout the waking hours for 8 of 8 sample patients, (R1, R2, R3, R4, P5, P6, P7 and P8) and no alternative treatment/intervention for 1 of 8 sample patients (R4). This failure resulted in individuals being hospitalized without all interventions provided based on individual patient needs/presenting behaviors, not receiving active treatment and potentially delaying their recovery.

A. Document Review
1. There were no clinical groups noted on the weekly schedule for the 7 units after 5:00PM each day. There were only "Music Therapy" and "Spirituality" (on one ward) noted on the schedule for Saturday and Sunday.

2. The schedule for the 7 units revealed similar generic groups regardless of the age, diagnosis or gender of patients. Examples of generic groups listed were, "Orientation/Goals Group, Discharge Group, MHT [Mental Health Technician] Group, Nursing Education, Process Group, Rec [Recreation] Group and Peer Led Group."

3. The review of group attendance notes for patient R4 indicated that the patient R4 did not attend group on 9/6/14, 9/9/14, and 9/12/14. The treatment plan for patient R4 was not updated to address patient ' s non-attendance in the group activities and to address providing any alternative interventions.

B. Observation
1. On 9/16/14 at 9:40AM, the adolescent females were split into two "process" groups with nine females in one group and twelve females in the other. Both groups covered the same material which entailed a set of questions related to opinions. There was no focus on individual symptoms or coping strategies and the therapist did not foster interaction between the participants.

2. On 9/16/14 at 10:40AM, there were twenty girls in a nursing group discussing what they wished to be doing in ten years. The girls were divided into two groups after the discussion had started. There was no focus on individual symptoms or coping strategies and the nurse did not foster interaction between the participants.

3. On 9/17/14 at 9:40AM, the Child unit was divided into two sections for a "process" group. The children colored for the first fifteen minutes and the second group did the same. There was no focus on individual symptoms or coping strategies and the therapist did not foster interaction between the participants.

4. Patient R4 did not attend chemical dependency group on 9/15/14 and 9/16/14. Patient was observed sitting alone in the day room, not engaged in any active treatment. One of the active diagnoses for this patient was Opioid Dependence as per the psychiatric evaluation dated 09/04/14.

C. Patient Interviews:
1. Patient P5 stated on 9/15/14 at 11:15AM that, "I am so bored here. Especially on the weekends, I just want to cry."

2. Patient P8 stated on 9/15/14 at 11:45AM that, "There is not much to do here. Other hospitals have more activities."

3. Patient P7 stated on 9/15/14 at 1:30PM that, "It is the same thing every day, very boring. The groups are the same every day. But there is very little to do on the weekend."

4. Patient P6 stated on 9/15/14 that, " It is too boring here. I wish there was more to do. "
5. Patient R4 stated on 9/15/14 at 11:30AM, "I don't go to chemical dependency group; there are a lot of people in the group. They bring patients from other units. I become anxious. I got bad anxiety. Everyone stares at me."

D. Staff Interviews
1. On 9/16/14 at 1l: 00AM, Therapist 1 stated "The patients are divided up according to which kids get along better together" in response to a query from the surveyor about what clinical criteria are used to separate the patients into groups.

2. On 9/17/14 at 1:05PM, the Director of Clinical Services stated, "No, there are no clinical groups after 5PM and there are only music groups on the weekends."

3. On 9/16/14 at 1:10PM, the Director of Clinical Services stated, "I agree that 8-10 is the ideal number for a clinical group."

4. On 9/17/14 at 10:15AM, the Director of Nursing state, "Yes, the groups are not specific to the individual or their diagnosis."

Based on record review and interviews, it was determined that the Medical Director failed to adequately monitor and evaluate the care provided to patients at the facility. Specifically the Medical Director failed to assure that:

I. Social service assessments included individualized recommendations for social work services from the data gathered for 1 of 8 active sample patients (R2). As a result, the treatment team did not have current baseline social functioning on these patients for establishing treatment goals and interventions and social work specific recommendations regarding treatment of patient ' s psychosocial problems were not described for the treatment teams. (Refer to B108)


II. Physicians performed and documented a psychiatric evaluation for 1 of 8 active sample patients (R2). The absence of this patient information hinders the clinician ' s ability to make an accurate diagnosis and plan appropriate treatment. (Refer to B110)


III. Physicians performed and documented psychiatric evaluations for 1 of 8 active sample patients (P7) in a timely manner as per the medical staff rules and regulations. This failure hinders the treatment team ' s ability to effectively formulate treatment plans in a timely manner. (Refer to B111)


IV. Physicians performed and documented an estimate of memory functioning in the psychiatric evaluation for 1 of 8 active sample patients (R2) and failed to perform an estimate of intellectual functioning in the psychiatric evaluation for 1 of 8 active sample patients (R2). These failures potentially result in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromise future comparative re-examinations to assess patient's response to treatment interventions. (Refer to B116)

V. The facility provided focused, active treatment throughout the waking hours for 8 of 8 sample patients (R1, R2, R3, R4, P5, P6, P7 and P8) and no alternative treatment for 1 of 8 sample patients (R4). A treatment plan not updated when a patient ' s clinical condition changes. This failure resulted in individuals being hospitalized without all interventions provided based on individual patient needs/presenting behaviors, not receiving active treatment and potentially delaying their recovery. (Refer to B125)

VI. The facility addressed significant psychiatric disabilities identified during the assessment process for 7 of 8 sample patients (R1, R2, R3, R4, P5, P6, and P8). This failure resulted in Master Treatment Plans that were not individualized for the patient and there was no specific direction to staff as to how to intervene regarding the disabilities cited. (Refer to B119)

VII. The facility ensured that the Master Treatment Plans for 8 of 8 sample patients (R1, R2, R3, R4, P5, P6, P7 and P8) identified active treatment interventions that addressed the individual patient ' s specific problems. This failure resulted in lists of routine and generic discipline functions or lists of general groups/activities without a specific focus for the individual patient which compromises treatment. (Refer to B122)

Based on observation, interview and document review, the Director of Nursing failed to:
1. Ensure that Master Treatment Plans for 7 of 8 sample patients (R1, R2, R3, R4, P5, P6, and P8) identified active treatment interventions that addressed the individual patient's specific problems. (Refer to B 119)

2. Ensure that the Master Treatment Plans for 8 of 8 sample patients (R1, R2, R3, R4, P5, P6, P7 and P8) identified active nursing treatment interventions that address in the individual patient's specific problems. The list of preprinted interventions was identical on each patient's record, from the child unit to the adult units, and was written as to what the patient would do instead of how the staff would treat the patient. The nursing interventions listed were generic discipline functions and were: "Attend daily nursing education groups," "Patient will meet with unit nurse twice a shift daily," "Take a minimum of three showers within a one week period," "Patient will brush teeth, wash hands after toileting daily," "Patient will be oriented to reality with unit nursing staff at least twice a shift daily." These interventions were not specific and individualized for each patient. (Refer to B122)

3. Provide focused active treatment throughout the waking hours for 8 of 8 sample patients, (R1, R2, R3, R4, P5, P6, P7 and P8) and to provide alternative treatment for 1 of 8 sample patients (R ). The schedule for the 7 units revealed similar generic nursing groups regardless of the age, diagnosis or gender of patients. Examples of generic nursing groups were, Orientation/Goals Group, Discharge Group, MHT [Mental Health Technician] Group and Nursing Education. (Refer to B 125)