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Based on record review, hospital policy review, staff and patient interviews and observations, the facility failed to:

I. Provide Master Treatment Plans (MTPs) for 7 of 8 active sample patients (A1, A2, A4, A5, A6, A7 and A8) on Pavilion 4 that included individualized interventions which reflected actual patient activity on the unit, and that were reviewed (and updated) in a timely way to address current patient needs. The MTPs did not reflect the patients' actual participation in programming, or in some instances, lack of participation. For Patient A1, there was no evidence that the treatment plan was reviewed every 14 days as required by hospital policy; for the other patients, the reviews did not result in needed revisions. Failure to develop and document individualized interventions for patients and do timely reviews of treatment plans (and revisions if needed) hampers staff's ability to provide effective treatment for patients. (Refer to B118-III)

II. Provide Master Treatment Plans for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) that included measurable short-term goals. This deficiency results in treatment plans that fail to identify expected treatment outcomes in a manner that is clearly understood by treatment staff and patients. (Refer to B121)

III. Provide MTPs that included Activity Therapy interventions for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Although there were preprinted treatment plan forms containing spaces for activity therapy interventions, none of these were completed. Failure to list all treatment intervention offerings on patients' treatment plans inhibits communication between staff members regarding the care of patients. (Refer to B122)

IV. Provide appropriate active treatment to address the individual needs of 7 of 7 active sample patients present throughout the survey (A1, A2, A4, A5, A6, A7 and A8) on Pavilion 4. There was inconsistency between assignments listed on these patients' treatment plans and actual schedule of groups offered on the unit. Staff also failed to keep a list of individual patient assignments to modalities as required by hospital policy. Instead of encouraging patients to go to their assigned treatment groups, staff allowed patients to attend (or not attend) offered group(s) at their own discretion. This resulted in patients not consistently attending their assigned groups, attending non-assigned groups with no treatment plan goals for participation, or, as in the case of one patient (A4), refusing to participate in programming. There was no documented evidence of staff attempts to offer alternative interventions when/if patients did not attend their assigned groups, or to revise the treatment plans to address the patients' current needs. Failure to provide appropriate active treatment can lead to delays in improvement of the patient's condition, potentially prolonging the hospitalization. (Refer to B125)

Based on record review and interview, the facility failed to provide comprehensive interdisciplinary Master Treatment Plans (MTPs) that:

I. included measurable short-term goals for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This deficiency results in treatment plans that fail to identify expected treatment outcomes in a manner that is clearly understood by treatment staff and patients. (Refer to B121)

II. specified Activity Therapy interventions for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Although there were preprinted treatment plan forms containing spaces for activity therapy interventions, none of these were completed. Failure to list all treatment intervention offerings on patients' treatment plans inhibits communication between staff members regarding the care of patients. (Refer to B122)

III. contained individualized interventions which reflected actual patient activity on the unit and were reviewed (and updated) in a timely way to address the current needs of 7 of 8 active sample patients (A1, A2, A4, A5, A6, A7 and A8). The MTPs for these patients did not reflect the patients' actual participation in programming, or in some instances, lack of participation. For Patient A1, there was no evidence that the treatment plan was reviewed every 14 days as required by hospital policy; for the other patients, the reviews did not result in needed revisions. Failure to develop individualized interventions for patients and do timely reviews of treatment plans (and revisions if needed) hampers staff's ability to provide effective treatment for patients.

A. Specific Patient Findings (MTP dates in parentheses)

1. Patient A1

Patient A1 was admitted on 12/16/2010 for depression with suicidal ideation. According to the MTP (12/17/2010), the patient was assigned to "Symptom Management Group 2 times weekly", "Health Education Group 2 times weekly" and "Medication Education Group 2 times weekly." Review of Group Progress Notes showed that, since admission, Patient A1 had only attended one of the assigned health education sessions (12/26/2010). There was no evidence of the patient's attendance in the Symptom Management Group or the Medication Education groups. The Group Progress Notes also showed that the patient had attended the following treatment modalities not listed in the MTP: Community Meeting (12/20/2010), Relaxation Group (12/26/10) and Cognitive Behavioral Therapy (CBT) Groups (12/17/2010, 12/20/2010, 12/27/2010, unreadable date, 01/10/2011, 01/06/2011, 01/10/2011 and 01/11/2011). The treatment plan was not revised to address the patient's non-attendance in the assigned treatment groups or to list the additional groups. The target date listed for all the short-term goals on Patient A1's MTP was 12/23/2010. There was no evidence that the goals had been met or that any new target dates were set. In addition, the hospital policy states that treatment plans are to be updated every 14 days. Patient A1's treatment plan of 12/17/2010 had not been up-dated as of 1/11/2011.

2. Patient A2

Patient A2 was admitted on 12/08/2010 with a diagnosis of Schizoaffective Disorder. According to the MTP (12/09/2010), the patient was assigned to "Symptom Management Group q shift (every shift)", "Health Education Group 1 times weekly" and "Medication Education Group 1 times weekly." Review of the Group Progress Notes revealed that since admission, the patient had only attended one health education group session (12/26/2010). There was no evidence that the patient had attended any of the Symptom Management Groups or the Medication Education sessions. The Group Progress Notes also showed that the patient attended the following groups not listed on the MTP: 2 Relaxation Groups (12/26/2010; other unreadable date), Community Meeting (12/26/2010) and CBT Group (unreadable date). The MTP was not updated to reflect the patient's participation in these groups.

Patient A2 was not observed attending any group during the time of the survey, nor was attendance at any group recorded on the Group Progress Notes sheets for this time period. Observations on Pavilion 4 revealed that Patient A2 was in bed on.1/11/2011 at 2:50p.m. and 1/12/11 at 10:15a.m. During these times, open groups (groups available to all patients) were in progress on the unit (Community Meeting 10:00-10:30a.m.; Fitness Instruction 2:30-3:30p.m.).

Review of Social Work and Physician progress notes for Patient A2 revealed the following: Social Worker notes: (12/16/10): "Stays in his room comes out for meals;" (12/23/10): "...isolates himself from others"; (1/06/2011)"...continues to isolate himself in room." Physician Notes: (12/20/2010): "(Patient) continues to remain isolative in his room, only coming out for meals and medications"; (1/04/2011): "The patient is not getting out of bed in the day."

In an interview on 1/12/2011 at 10:20a.m., RN2 stated that Patient A2 liked to stay in bed and that the staff has "to really encourage him to get out of bed."

Review of the treatment plan revealed no evidence that that new interventions were considered for Patient A2, nor was the problem of isolating himself in his room identified and addressed.

3. Patient A4.

Patient A4 was admitted 12/29/2010 with Psychosis NOS (not otherwise specified) and Cannabis Abuse. According to the MTP (01/03/2011), the patient was assigned to the "Symptom Management Group 3 times weekly", "Health Education Group 3 times weekly and Medication Education Group 3 times weekly." Although Patient A4 had a history of substance abuse, this was not addressed in the MTP, and he was not assigned to the MISA (Mental Illness/Substance Abuse) group.

Review of Group Progress Notes provided by the DON on 1/11/2011 at 3:15p.m. revealed that Patient A4 had not attended any groups since his admission on 1/29/2011.

In an interview on 1/10/2011 at 11:15a.m., Patient A4 stated, "I don't go to groups. I do crossword puzzles or read the Bible and chat with people around me."

4. Patient A5 was admitted on 11/23/2010. The MTP (11/29/2010) listed the problem as "Substance induced mood disorder, ETOH (alcohol) dependence." According to the MTP, the patient was assigned to the "Mental Illness Substance Abuse (MISA) group 1 time weekly", "Fitness Instruction Group (blank) times weekly", "Relaxation Group (blank) times weekly", "Leisure Education Group 1 times weekly", "Art Expression 1 times weekly" and "MISA Leisure Group 1 times weekly".

Review of the Group Progress Notes sheets maintained in the Group Binder revealed that since admission, Patient A5 had not attended the Fitness Instruction Group, the Relaxation Group, or the Leisure Education Group, or the Art Expression group. There was nothing in the treatment plan to address the non-participation in these assigned groups. The Group Progress Notes also revealed that Patient A5 had attended 2 CBT groups (1/10/2011 and 1/11/2011). The patient was not assigned to the CBT group,.

5. Patient A6 was admitted on 12/14/2010. The MTP (12/17/2010) listed the problem as "paranoid." According to the MTP, the patient was assigned 3 nursing groups, "Symptom Management 2 times weekly", "Health Education 2 times weekly" and "Medication Education 2 times weekly". In addition, he was assigned to the "MISA group 1 time weekly". Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group and the Medication Education Group were offered once weekly and not twice weekly.

Review of the Group Progress Notes sheets maintained in the Group Binder revealed no documentation that Patient A6 had attended the Symptom Management Group or the Medication Education Group. There was nothing in the MTP that addressed this non-participation. The Group Progress Notes also showed that the patient had attended several non-assigned groups -- 3 Community Meetings (12/15/2010, 12/22/2010 and 12/26/2010), 4 Relaxation Groups (12/15/2020, 12/22/2010, 12/26/2010), 2 MISA groups (12/20/2010 and 1/10/11), 2 CBT groups (12/17/2010 and 1/10/2011). However, the treatment plan was not updated to reflect the patient's participation in these modalities, or to formulate any goals for his participation in these modalities.

6. Patient A7 was admitted on 12/23/2010. The MTP (12/27/2010) identified the problem as "aggressive towards wife and other family members." According to the MTP, Patient A7 was assigned to three nursing groups; Symptom Management Group 2 times weekly, Health Education Group 2 times weekly and Medication Education Group 2 times weekly. Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group and the Medication Education Group were offered once weekly and not twice weekly.


Review of the Group Progress Notes sheets maintained in the Group Binder revealed that since admission, Patient A7 had not attended the Symptom Management Group or the Medication Education Group. He had only attended 2 Health Education Groups (12/24/2010 and 12/26/2011). There was nothing in the MTP to address his lack of participation in the assigned groups. The Group Progress Notes also showed that Patient A7 had attended 3 Relaxation Groups (12/24/2010, 12/26/2010 and 1/11/2011), 3 Community Meetings (12/24/2010, 12/26/2010 and 1/11/2011), and 6 CBT Groups (12/27/2010, 12/28/2010, 12/30/2010, 1/3/2011, 1/04/2011 and 1/06/2011). The MTP was not updated to reflect the patient's actual participation in these groups. The CBT group was not added to the treatment plan. Although anger and subsequent aggression was directly related to Patient A7's hospitalization, he was not assigned to the Anger Management Group.

7. Patient A8 was admitted on 12/31/2010. On the MTP (01/03/2011) the problems of "Depression" and "ETOH (alcohol) Dependence" were identified, and the patient was assigned to three nursing groups; Symptom Management Group 2 times weekly, Health Education Group 2 times weekly and Medication Education Group (blank) times weekly and to the MISA group. Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group was offered once weekly and not twice weekly.


Review of the Group Progress Notes sheets maintained in the Group Binder revealed that since admission, Patient A8 had not attended the Symptom Management Group or the Medication Education Group. He had only attended 1 Health Education Group (12/26/2010). There was nothing on MTP to address his non-participation in these assigned groups. The Group Progress Notes also showed that the patient had attended several non-assigned groups: 1 Community Meeting (12/26/2010), 1 Relaxation Group (12/26/2010) and 3 CBT Groups (12/26/2010, 1/07/2011 and 1/10/2011). The MTP was not updated to reflect the patient's participation in these groups.

Based on record review and interview, the facility failed to provide Master Treatment Plans that identified patient related short term goals in observable, measurable, behavioral terms for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This deficiency results in treatment plans that fail to identify expected treatment outcomes in a manner that is clearly understood by staff and patients.

Findings include:

A. Record Review

1. Patient A1's Master Treatment Plan dated 12/17/10 had the following non measurable short term goals for the problem "depression c [with] SI [suicidal ideation]" as manifested by "c/o [complains of] having depressive episode and loneliness and feel like hurting myself": "Pt will report a decrease in depressed feeling and have a brighter affect at least 3 days prior to discharge"; "Pt will no longer experience feeling to hurt self (others) and will be future oriented for at least 3 days prior to discharge."

2. Patient A2's Master Treatment Plan dated 12/09/10 had the following non measurable short term goals for the problem "Depression with SI; psychosis" as manifested by "c/o feeling depressed c [with] suicidal ideation"; "Pt will report a decrease in depression c [with] brighter affect 3 days prior to discharge"; "pt will seek out staff and verbalize feeling [sic] of hurting self"; "pt will report there is no longer SI present."

3. Patient A3's Master Treatment Plan dated 10/29/10 had the following non measurable short term goals for the problem "mood disorder NOS [not otherwise specified]; R/O [rule out] schizophrenia R/O MDD [major depressive disorder]." as manifested by "hearing voices, non-compliant with meds": "Pt will no longer have hallucinations"; "pt will verbalize that the voices have ceased or are minimal and not threatening three days prior to discharge.

4. Patient A4's Master Treatment Plan dated 01/03/2011 had the following non measurable short term goals for the problem "Psychosis NOS [not otherwise specified] and Cannabis Abuse manifested by "Hearing voices-Religiously Focused": "pt will verbalize orientation, place, time, person, and situation on the unit"; "pt will no longer exhibit psychotic feature of hearing voices, delusional."

5. Patient A5's Master Treatment Plan dated 11/29/10 had the following non measurable short term goals for the problem "substance induced mood disorder; ETOH depen [dependence]" as manifested by "c/o feeling depressed, suicidal, and complained [sic] withdrawal": "Pt will no longer use alcohol and seek out assistance for his ETOH dependent tendencies"; "Pt will [illegible] that he is not depressed and has no self injurious thoughts."

6. Patient A6's Master Treatment Plan dated 12/17/10 had the following non measurable short term goal for the problem "Paranoid" as manifested by "Patient has obsession of getting hurt, killed or robbed; Also depressed": "Pt will verbalize the importance and benefit of taking his medications and report to staff not having the feelings of hurting self or others. Also will no longer be paranoid."

7. Patient A7's Master Treatment Plan dated 12/27/10 had the following non measurable short term goals for the problem "Bipolar, Manic-lability" as manifested by "aggressive towards wife and other family members": "Pt will respond to staff directions when agitated and will learn to self soothe"; "Pt will identify and express feelings appropriately when upset or angry."

8. Patient A8's Master Treatment Plan dated 1/3/11 had the following non measurable short term goals for the problem "Depression; ETOH Dependence/Abuse" as manifested by "Depression, suicidal ideations, auditory hallucinations": "Pt will comply c [with] medication during and after hospitalization and will verbalize an understanding"; "Pt will seek out staff and verbalize any feeling to harm self."

B. Interviews

1. In an interview on 1/11/11 at 2:30PM, the Director of Nursing concurred that the above treatment plan short term goals were not observable or measurable.

2. In an interview on 1/12/11 at 10:00AM, the Medical Director concurred that the treatment plan short term goals were not observable or measurable.

Based on record review and interview, the facility failed to ensure that the Master Treatment Plans of 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) included Activity Therapy treatment modalities/interventions. Although there were preprinted treatment plan forms containing spaces for activity therapy interventions, none of these were completed. Failure to list all treatment intervention offerings on patients' treatment plans inhibits communication between staff members regarding the care of patients.

Findings include:

A. Record Review (MTP dates in parentheses)

1. The following patient's treatment plans failed to document Activity Therapy interventions:
Patient A1 (12/17/10); Patient A2 (12/09/2010); Patient A3 (10/29/10); Patient A4 1/3/11); Patient A5 (11/29/10); Patient A6 (12/17/10); Patient A7 (12/27/10); and Patient A8 (1/3/11).

B. Interview

In an interview on 1/11/2011 at 11:00a.m., the Activity Therapy Supervisor stated that all the groups conducted by Activity Therapy on Pavilion 4 (7 groups per week) were open to any patient. He further stated that the groups "used to be specific to patients but now are open for everyone." When asked about individual patient goals that could be focused on during his groups, he stated that he didn't have time "to assess each patient."

Based on document and record reviews, observations and interviews, the facility failed to provide appropriate active treatment to address the individual needs of 7 of 7 active sample patients present throughout the survey (A1, A2, A4, A5, A6, A7 and A8) on Pavilion 4. There was inconsistency between assignments listed on these patients' treatment plans and actual schedule of groups offered on the unit. Staff also failed to keep a list of individual patient assignments to modalities as required by hospital policy. Instead of encouraging patients to go to their assigned treatment groups, staff allowed patients to attend (or not attend) offered group(s) at their own discretion. This resulted in patients not consistently attending their assigned groups, attending non-assigned groups with no treatment plan goals for participation, or, as in the case of Patient A4, refusing to participate in programming. There was no documented evidence of staff attempts to offer alternative interventions when/if patients did not attend their assigned groups or to revise the treatment plans to address the patients' current needs. Failure to provide appropriate active treatment can lead to delays in improvement of the patient's condition, potentially prolonging the hospitalization.

Findings include:

A. Document Review

1. Review of the "Procedure for Group Progress Notes" (revision 5/17/2010) revealed the following statement: "Treatment Coordinators and Activity Therapy will maintain an ongoing list of patients who are to attend the specific prescribed groups." The procedure also said that the Group Binder was to include "A list of patients who are to attend each prescribed group."

2. Review of the group assignment sheets found in the Group Binder revealed blank sheets (no patient names) for the following groups: Anger Management, Art Expression, MISA, CBT and Trauma. There were no other group sheets in the binder that listed patient names for any of the other groups.

B. Specific Patient Findings

1. Patient A1 was admitted on 12/16/2010 for "depression with suicidal ideation". According to her Master Treatment Plan dated 12/17/2010, Patient A1 was assigned to "Symptom Management Group 2 times weekly", "Health Education Group 2 times weekly" and "Medication Education Group 2 times weekly." Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group and Medication Education Group were offered only once a week.

Review of the Group Progress Notes maintained in the Group Binder revealed no evidence that that Patient A1 had attended the Symptom Management Group (12/20/10, 12/27/10, 01/03/10 and 01/10/11) or the Medication Education Group (12/22/10, 12/29/10 and 01/05/11). The treatment plan did not address the non-attendance of Patient A1 in the assigned Medication Education Groups or the Symptom Management Groups. The Group Progress Notes also showed that the patient had attended the following non-assigned groups -- 1 Community Meeting (12/20/2010), 1 Relaxation Group (12/26/10) and 8 Cognitive Behavioral Therapy (CBT) Groups. (12/17/2010, 12/20/2010, 12/27/2010, unreadable date, 01/03/2011, 01/06/2011, 01/10/2011 and 01/11/2011) The CBT group was not added to the treatment plan.

2. Patient A2 was admitted on 12/09/2010. Review of the Comprehensive Psychiatric Evaluation dated 12/08/2010, revealed a diagnosis of "Schizoaffective Disorder". Problems on his Master Treatment Plan dated 12/09/2010 were listed as "Depression with Suicidal Ideation and Psychosis." The treatment plan revealed that Patient A2 was assigned to "Symptom Management Group q shift (every shift)", "Health Education Group 1 times weekly" and "Medication Education Group 1 times weekly." Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group was offered once weekly (Monday from 1:30p.m. - 2:30p.m.), not every shift.

Review of the Group Progress Notes maintained in the Group Binder revealed no evidence that Patient A2 had attended the Symptom Management Group (12/13/10, 12/20/10, 12/27/10, 01/03/11 and 01/10/11) or the Medication Education Group (12/15/10, 12/22.10, 12/29/10 and 01/05/11). The Group Progress Notes also showed that since admission, the patient had attended the following non-assigned groups -- 2 Relaxation Groups (12/26/2010 and a second unreadable date), 1 Community Meeting (12/26/2010) and 1 CBT Group (unreadable date). The CBT group was not mentioned on the treatment plan.

The progress notes written by the Social Worker and the Physician for Patient A2 revealed the following:

"Stays in his room comes out for meals." -Social Worker note 12/16/2010.
"(Patient) continues to remain isolative in his room, only coming out for meals and medications." -Physician note 12/20/2010.
"...isolates himself from others." -Social Worker note 12/23/2010.
"The patient is not getting out of bed in the day." -Physician note 1/04/2011.
"...continues to isolate himself in room." -Social Worker note 1/06/2011.

In an interview on 1/12/2011 at 10:20a.m., RN2 stated that Patient A2 liked to stay in bed and that the staff has "to really encourage him to get out of bed."

Patient A2 was not observed attending any group or being offered alternative interventions during the time of the survey, nor was attendance at any group recorded on the Group Progress Notes sheets for this time period.

Observations on Pavilion 4 revealed that Patient A2 was in bed on 1/11/2011 at 2:50p.m., and 1/12/11 at 10:15a.m. During these times, open groups (open to all patients) were in progress: Community Meeting 9:00-9:30a.m.; Fitness Instruction 2:00-3:00 p.m.

Review of the treatment plan revealed that no new interventions were considered for Patient A2 nor was the problem of isolating himself in his room identified and addressed.

3. Patient A4, according to the Master Treatment Plan dated 01/03/2011 was admitted 12/29/2010 with a diagnosis of "Psychosis NOS (not otherwise specified) and Cannabis Abuse". This was the first psychotic break for this patient and his first psychiatric hospitalization. The MTP showed that Patient A4 was assigned to the "Symptom Management Group 3 times weekly", "Health Education Group 3 times weekly and Medication Education Group 3 times weekly." Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group met only one time weekly (Monday from 1:30-2:30p.m.) and that the Medication Education Group met only one time weekly (Thursday 1:45p.m. - 2:30p.m.). Although Patient A4 had a history of substance abuse, this was not addressed in the Master Treatment Plan and he was not assigned to the MISA (Mental Illness/Substance Abuse) group.

Review of the Group Progress Notes maintained in the Group Binder revealed that since admission on 12/29/10, Patient A4 had not attended any groups nor was there evidence that any alternative interventions had been offered. The Group Progress Notes sheet obtained by the DON on 1/12/11 at 3:15p.m. revealed a blank page.

In an interview on 1/10/11 at 11:15a.m., Patient A4 stated, "I don't go to groups. I do crossword puzzles or read the Bible and chat with people around me." There was no evidence that the treatment plan was updated to address the patient's treatment needs.

4. Patient A5 was admitted on 11/23/2010. The Master Treatment Plan dated 11/29/2010 listed as problems, "Substance induced mood disorder, ETOH (alcohol) dependence." The MTP revealed that Patient A5 was assigned to the "MISA group 1 time weekly", "Fitness Instruction Group (blank) times weekly", Relaxation Group (blank) times weekly", "Leisure Education Group 1 times weekly", "Art Expression 1 times weekly" and "MISA Leisure Group 1 times weekly."

Review of the Group Progress Notes sheets maintained in the Group Binder revealed no evidence that Patient A5 had attended the assigned Fitness Instruction Group, the Relaxation Group, the Leisure Education Group, or Art Expression. There was nothing in the treatment plan to address the patient's non-participation in these groups. The Group Progress Notes also showed that the patient had attended 2 CBT groups (1/10/2010 and 1/11/2011). However, he was not assigned to the CBT group. The patient was observed attending a MISA group from 4:00-4:30p.m. but this was not documented on the Group Progress Notes.

5 Patient A6 was admitted on 12/14/2010. The Master Treatment Plan dated 12/17/2010 identified the problem as "paranoid." The MTP revealed that Patient A6 was assigned the nursing groups, "Symptom Management 2 times weekly", "Health Education 2 times weekly" and "Medication Education 2 times weekly". In addition, he was assigned to the "MISA group 1 time weekly." Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group and the Medication Education Group were offered once weekly and not twice weekly.

Review of the Group Progress Notes maintained in the Group Binder revealed no documentation that Patient A6 had attended the assigned Symptom Management group (12/15/10, 12/22/10, 12/29/10 and 01/05/11) or the Medication Education Group (12/20/10, 12/27/10, 01/03/11 and 01/10/11). There was nothing in the treatment plan to address his non-participation in these groups. The Group Process Notes showed that the patient had attended the following non-assigned groups: 3 Community Meetings (12/15/2010, 12/22/2010 and 12/26/2010), 3 Relaxation Groups (12/15/2020, 12/22/2010, 12/26/2010), and 2 CBT groups (12/17/2010 and 1/10/2011).

6. Patient A7 was admitted on 12/23/2010. The Master Treatment Plan dated 12/27/2010 identified the problem as "aggressive towards wife and other family members." On the MTP, the patient was assigned to three nursing groups: "Symptom Management Group 2 times weekly", "Health Education Group 2 times weekly" and "Medication Education Group 2 times weekly". Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group and the Medication Education Group were offered once weekly and not twice weekly.

Review of the Group Progress Notes maintained in the Group Binder revealed no evidence that Patient A7 had attended the Symptom Management Group (12/27/10, 01/03/11 and 01/10/11) or the Medication Education Group (12/29/10 and 01/05/11). Since admission, the patient had attended the following non-assigned groups: 3 Relaxation Groups (12/24/2010, 12/26/2010 and 1/11/2011), 3 Community Meetings (12/24/2010, 12/26/2010 and 1/11/2011), and 6 CBT Groups ( 12/27/2010, 12/28/2010, 12/30/2010, 1/3/2011, 1/04/2011and 1/06/2011). The CBT group was not added to the treatment plan. In addition, although anger and subsequent aggression was directly related to Patient A7's hospitalization, he was not assigned to the Anger Management Group.

Observations on Pavilion 4 on 1/10/10 at 1:30p.m. (when Symptom Management Group was being offered) revealed that patient A7 was resting in bed.

7. Patient A8 was admitted on 12/31/2010. The Master Treatment Plan dated 01/03/11 listed as problems, "Depression" and "ETOH (alcohol) Dependence" and revealed that Patient A8 was assigned to three nursing groups; Symptom Management Group 2 times weekly, Health Education Group 2 times weekly and Medication Education Group (blank) times weekly and to the MISA group. Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group was offered once weekly and not twice weekly.

Review of the Group Progress Notes maintained in the Group Binder revealed no evidence that Patient A8 had attended the Symptom Management Group (01/10/11), the Medication Education Group (01/05/11) or the Health Education Group (offered 5 times weekly 01/03/11, 01/05/11, 01/07/11, 01/08/11 and 01/09/11). The MTP did not address the patient's non-participation in the assigned modalities. The Group Progress Notes also showed that, since admission, Patient A8 had attended 2 CBT Groups (1/07/2011 and 1/10/2011). The CBT group was not added to the treatment plan.

C. Additional Observations

1. Observations on 1/11/2011 at 10:30a.m. revealed a patient census of 26 patients on Pavilion 4. Ten patients, including Patient A1 and A5 were in the CBT Group. (Patients A1 and A5 were not assigned to the CBT group). The locations of the remaining patients were: 3 patients sitting at a table talking, 1 patient sitting at a table talking with a LPN, 9 patients in bed (including Patient A2 and A6), 1 patient on the phone, Patient A7 was walking around the dayroom and Patient A4 was standing in the dayroom talking with a Mental Health Technician.
Although the Group Progress Notes documented that Patient A5 had attended the CBT group from 10:30-11:15a.m. on 1/11/2010, the patient was observed at 11:00a.m., sitting in the dayroom.

2. Observations on 1/11/2011 at 2:30p.m. revealed a patient census of 26 patients on Pavilion 4. Six patients (including A1) were participating in the Fitness Instruction Group. This group was not on Patient A1's MTP. The locations of the remaining patients were: 6 patients (including Patient A8) sitting together at a table in the dayroom watching the group (these patients did not stay at the table during the entire group but instead walked around the dayroom or went into their bedrooms), 1 patient working on a puzzle, Patient A4 was playing with cards, 1 patient coloring a picture, 2 patients on the phones and 9 patients (including A2) in bed.

3. Observations on 1/12/2011 at 10:00a.m. revealed a patient census of 26 patients on Pavilion 4. Fifteen patients (including A1) were in the Community Group Meeting. The locations of the remaining patients were: 11 patients in bed (including A2 and A4).

4. Observations on 1/12/2011 at 10:30a.m. revealed a census of 26 patients on Pavilion 4. Eleven patients (including A1) were in the Relaxation Training Group. The location of the remaining patients were: 11 patients in bed, 1 patient sitting in dayroom with hood pulled over head and 3 patients (including Patient A4 and A7) sitting at a table with RN2.

D. Staff Interviews

1. In an interview on 1/11/2011 at 11:00a.m., the Activity Therapy Supervisor stated that all the groups conducted by Activity Therapy on Pavilion 4 (7 groups per week) were open to any patient. He further stated that the groups "used to be specific to patients but now are open for everyone." When asked about individual patient goals that could be focused on during his groups, he stated that he didn't have time "to assess each patient."

2. In an interview on 1/11/2011 at 2:15p.m., the Director of Nursing stated that groups were divided into "Prescribed Groups and "Open Groups." According to the DON, the "Prescribed Groups" are those groups assigned during treatment team meetings to address specific patient goals, and are conducted primarily by social work and psychology staff. The "Open Groups," conducted primarily by nursing and Activity Therapy staff, are available to anyone wanting to attend. When asked how the patients and staff know the group assignments, the DON stated that there is a binder in the nurses' station that has a listing of patients in each prescribed group and a progress note sheet to record the patient's participation in all groups. The DON stated that she was aware that staff was not always compliant with following the required documentation procedure.

3. In an interview on 1/12/11 at 10:20a.m., Social Worker 1 stated that, although his Anger Management Group was supposed to be a "Prescribed Group," he encouraged everyone to attend. Social Work 1 also stated "Everybody has problems with anger." In the same interview, Activity Therapist 1 further stated that he did not have a list of who was to be in his group and that it didn't "make sense to keep a list from week to week because it changes." In addition, he stated that the patients who were assigned to the Anger Management Group on their treatment plans would not come to the group anyway because they were usually "too angry and paranoid." When asked if alternative treatment measures were offered to those patients who refused to attend, he stated "no." He stated that nursing did a good job of keeping up with patient group assignments. RN 2, who was at the table and heard the Social Worker's comments, stated "We don't really keep up with it."

4. In an interview on 1/12/2011 at 10:25a.m., Psychologist 1 stated that patients not assigned to CBT could attend the group if they wanted to attend.

Based on record review, observations and interviews, the Medical Director failed to:

I. Assure that the Master Treatment Plans for 7 of 8 active sample patients (A1, A2, A4, A5, A6, A7 and A8) on Pavilion 4 contained individualized interventions which reflected actual patient activity on the unit and were reviewed (and updated) in a timely way to address the current needs of 7 of 8 active sample patients (A1, A2, A4, A5, A6, A7 and A8). The MTPs for these patients did not reflect the patients' actual participation in programming, or in some instances, lack of participation. For Patient A1, there was no evidence that the treatment plan was reviewed every 14 days as required by hospital policy; for the other patients, the reviews did not result in needed revisions. Failure to develop individualized interventions for patients and do timely reviews of treatment plans (and revisions if needed) hampers staff's ability to provide effective treatment for patients. (Refer to B118-III)

II. Assure that the Master Treatment Plans of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) included measurable short-term goals. This deficiency results in treatment plans that fail to identify expected treatment outcomes in a manner that is clearly understood by treatment staff and patients. (Refer to B121)

III. Assure that Activity Therapy interventions were included on the Master Treatment Plans for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Although there were preprinted treatment plan forms containing spaces for activity therapy interventions, none of these were completed. Failure to list all treatment intervention offerings on patients' treatment plans inhibits communication between staff members regarding the care of patients. (Refer to B122)

IV. Assure that appropriate active treatment was provided to address the individual needs of 7 of 7 active sample patients present throughout the survey (A1, A2, A4, A5, A6, A7 and A8) on Pavilion 4. There was inconsistency between assignments listed on these patients' treatment plans and actual schedule of groups offered on the unit. Staff also failed to keep a list of individual patient assignments to modalities as required by hospital policy. Instead of encouraging patients to go to their assigned treatment groups, staff allowed patients to attend (or not attend) offered group(s) at their own discretion. This resulted in patients not consistently attending their assigned groups, attending non-assigned groups with no treatment plan goals for participation, or, as in the case of one patient (A4), refusing to participate in programming. There was no documented evidence of staff attempts to offer alternative interventions when/if patients did not attend their assigned groups or to revise the treatment plans to address the patients' current needs. Failure to provide appropriate active treatment can lead to delays in improvement of the patient's condition, potentially prolonging the hospitalization. (Refer to B125)

Based on record review and interview, the Director of Nursing failed to ensure that appropriate active treatment was provided to address the individual nursing needs of 6 of 8 active sample patients (A1, A2, A4, A6, A7 and A8) on Pavilion 4. There was inconsistency between assignments listed on the patients' treatment plans and actual schedule of nursing groups offered on the unit. Nursing staff failed to document, on the Group Progress Notes, the patients' participation in nursing led groups. Instead of encouraging patients to go to their assigned treatment groups, nursing staff allowed patients to attend (or not attend) offered group(s) at their own discretion. This resulted in patients not consistently attending their assigned groups, attending non-assigned groups with no treatment plan goals for participation, or as in the case of one patient (A4), refusing to participate in programming. There was no documented evidence of nursing staff attempts to offer alternative interventions when patients did not attend the nursing led groups. Failure to consistently offer nursing modalities, and encourage patients to participate in appropriate programming can lead to delays in improvement of patients' recovery, potentially prolonging the hospitalization.

Findings include:

A. Specific Patient Findings

1. Patient A1 was admitted on 12/16/2010 for "depression with suicidal ideation." According to her Master Treatment Plan dated 12/17/2011 his problem was "depression with suicidal ideation." Patient A1 was assigned to the following nursing led groups: "Symptom Management Group 2 times weekly", "Health Education Group 2 times weekly" and "Medication Education Group 2 times weekly" Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group and Medication Education Group were offered only once a week.

Review of the Group Progress Notes sheets maintained in the Group Binder revealed that since admission on 12/16/2010, Patient A1 had not attended the assigned nursing groups: Symptom Management Group (12/20/10, 12/27/10, 01/03/11 and 01/10/11) or the Medication Education Group (12/22/10, 12/29/10 and 01/05/11). The treatment plan did not address the non-attendance of Patient A1 in these groups. There was no revision of the treatment plan to show alternative interventions to meet the patient's goals that could have been achieved by attending the Medication Education and Symptom Management groups.

2. Patient A2 was admitted on 12/08/2010. Review of the Comprehensive Psychiatric Evaluation dated 12/09/2010 revealed a diagnosis of "Schizoaffective Disorder." Problems on his Master Treatment Plan dated 12/09/2010 were "Depression with Suicidal Ideation" and "Psychosis." The treatment plan showed that Patient A2 was assigned to the following nursing-led groups: "Symptom Management Group q shift (every shift)", "Health Education Group 1 times weekly" and "Medication Education Group 1 times weekly." Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group was offered once weekly (Monday from 1:30-2:30p.m.) not every shift.

Review of the Group Progress Notes sheets maintained in the Group Binder revealed that since admission on 12/08/2010, Patient A2 had not attended the assigned Symptom Management Group (12/13/10, 12/20/10, 12/27/10, 1/03/11 and 1/10/11) or the Medication Education Group (12/15/10, 12/22/10, 12/29/10 and 01/05/11).

Progress notes written by the Social Worker and the Physician for Patient A2 revealed the following:

"Stays in his room comes out for meals." -Social Worker note 12/16/2010.
"(Patient) continues to remain isolative in his room, only coming out for meals and medications." -Physician note 12/20/2010.
"...isolates himself from others." -Social Worker note 12/23/2010.
"The patient is not getting out of bed in the day." -Physician note 1/04/2011.
"...continues to isolate himself in room." -Social Worker note 1/06/2011.

In interview on 1/12/2011 at 10:20a.m., RN2 stated that Patient A2 liked to stay in bed and that the staff has "to really encourage him to get out of bed."

Patient A2 was not observed attending any nursing group or being offered alternative interventions during the time of the survey, nor was attendance at any nursing group recorded on the Group Progress Notes for this time period.

Observations on Pavilion 4 revealed that Patient A2 was in bed on 1/11/2011 at 2:50p.m., and 1/12/11 at 10:15a.m. when open groups (groups open to all patients) were being provided.

Review of the treatment plan revealed no new interventions for Patient A2, nor was the problem of isolating himself in his room identified and addressed. There was no evidence that nursing staff offered alternative interventions to address patient goals to be achieved in the unattended Symptom Management, and Medication Education groups.

3. Patient A4, according to the Master Treatment Plan dated 01/03/2011, was admitted 12/29/2010 with a diagnosis of "Psychosis NOS (not otherwise specified) and Cannabis Abuse." According to the MTP, the patient was assigned to the nursing-led "Symptom Management Group 3 times weekly", "Health Education Group 3 times weekly, and Medication Education Group 3 times weekly." Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group met only one time weekly (Monday from 1:30-2:30p.m.) and that the Medication Education Group met only one time weekly (Thursday 1:45-2:30p.m.)

Review of the Group Progress Notes sheets maintained in the Group Binder revealed that since admission on 12/29/2010, Patient A4 had not attended any groups. The Group Progress Notes sheet obtained by the DON on 1/12/11 at 3:15p.m. revealed a blank page.

In an interview on 1/10/11 at 11:15a.m., Patient A4 stated, "I don't go to groups. I do crossword puzzles or read the Bible and chat with people around me." There was no evidence of attempts by the nursing staff to modify the treatment plan or to provide alternative interventions to address patient's goals to be achieved in the un-attended nursing groups.

4. Patient A6 was admitted on 12/14/2010. The Master Treatment Plan dated 12/17/2010 identified the problem as "paranoid." The MTP revealed that Patient A6 was assigned the nursing groups, "Symptom Management 2 times weekly", "Health Education 2 times weekly" and "Medication Education 2 times weekly." Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group and the Medication Education Group were offered once weekly and not twice weekly.

Review of the Group Progress Notes maintained in the Group Binder revealed no documentation that Patient A6 had attended the Symptom Management group (12/15/10, 12/22/10, 12/29/10 and 01/05/11) or the Medication Education Group (12/20/10, 12/27/10, 01/03/11 and 01/10/11). There was nothing in the treatment plan to address his non-participation in these groups, nor was there evidence that alternative interventions were attempted.

5. Patient A7 was admitted on 12/23/2010. The Master Treatment Plan dated 12/27/2010 identified the problem as "aggressive towards wife and other family members." The MTP revealed that Patient A7 was assigned to three nursing groups: "Symptom Management Group 2 times weekly", "Health Education Group 2 times weekly" and "Medication Education Group 2 times weekly." Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group and the Medication Education Group were offered once weekly and not twice weekly.

Review of the Group Progress Notes maintained in the Group Binder revealed no evidence that Patient A7 had attended the Symptom Management Group (12/27/10, 01/03/11 and 01/10/11) or the Medication Education Group (12/29/10 and 01/05/11).

Observations on Pavilion 4 on 1/10/10 at 1:30p.m. (when the Symptom Management Group was being offered) revealed that patient A7 was resting in bed. There was no revision of the treatment plan to show alternative interventions to meet the patient's goals that could have been achieved by attending the Medication Education and Symptom Management groups.

6. Patient A8 was admitted on 12/31/2010. The Master Treatment Plan dated 01/03/11 listed the problems as "Depression" and "ETOH (alcohol) Dependence." According to the MTP, the patient was assigned to three nursing groups: Symptom Management Group 2 times weekly, Health Education Group 2 times weekly and Medication Education Group (blank) times weekly. Review of the Pavilion 4 Program Schedule revealed that the Symptom Management Group was offered once weekly and not twice weekly.

Review of the Group Progress Notes maintained in the Group Binder revealed no evidence that Patient A8 had attended the Symptom Management Group (01/10/11), the Medication Education Group (01/05/11) or the Health Education Group (offered 5 times weekly 01/03/11, 01/05/11, 01/07/11, 01/08/11 and 01/09/11). The Master Treatment Plan did not address the patient's non-participation in these assigned modalities. There was no evidence that nursing staff offered alternative interventions, nor was the non-attendance noted on the treatment plan.

B. Additional Observations

1. Observations on 1/11/2011 at 10:30a.m. revealed a patient census of 26 patients on Pavilion 4. Ten patients, including Patient A1 and A5 were in the CBT Group. (Patients A1 and A5 were not assigned to the CBT group). The locations of the remaining patients were: 3 patients sitting at a table talking, 1 patient sitting at a table talking with a LPN, 9 patients in bed (including Patient A2 and A6), 1 patient on the phone, Patient A7 was walking around the dayroom and Patient A4 was standing in the dayroom talking with a Mental Health Technician.

2. Observations on 1/11/2011 at 2:30p.m. revealed a patient census of 26 patients on Pavilion 4. Six patients (including A1) were participating in the Fitness Instruction Group. The locations of the remaining patients were: 6 patients (including Patient A8) sitting together at a table in the dayroom watching the group (these patients did not stay at the table during the entire group but instead walked around the dayroom or went into their bedrooms), 1 patient working on a puzzle, Patient A4 was playing with cards, 1 patient coloring a picture, 2 patients on the phones and 9 patients (including A2) in bed.

3. Observations on 1/12/2011 at 10:00a.m. revealed a patient census of 26 patients on Pavilion.

4. Fifteen patients (including A1) were in the Community Group Meeting. The locations of the remaining patients were: 11 patients in bed (including A2 and A4).

5. Observations on 1/12/2011 at 10:30a.m. revealed a census of 26 patients on Pavilion 4. Eleven patients (including A1) were in the Relaxation Training Group (not an assigned group for Patient A1). The location of the remaining patients were: 11 patients in bed, 1 patient sitting in dayroom with hood pulled over head and 3 patients (including Patient A4 and A7) sitting at a table with RN2.

C. Staff Interviews

1. In an interview on 1/11/2011 at 2:15p.m., the Director of Nursing stated that groups were divided into "Prescribed Groups" and "Open Groups." According to the DON, the "Prescribed Groups" are those groups assigned during treatment team meetings to address specific patient goals, and are conducted primarily by social work and psychology staff. The "Open Groups," conducted primarily by nursing and Activity Therapy staff, are available to anyone wanting to attend. When asked how the patients and staff know the group assignments, the DON stated that there is a binder in the nurses' station that has a listing of patients in each prescribed group and a progress note sheet to record the patient's participation in all groups. The DON stated that she was aware that staff was not always compliant with following the required documentation procedure.

2. In an interview on 1/12/2011 at 10:20a.m., Social Worker 1 stated that, nursing did a good job of keeping up with patient group assignments. RN2 who was at the table and heard the Social Worker's comments, stated, "We don't really keep up with it."