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Based on record review and interview, the hospital failed to ensure the implementation of an effective grievance process for 1 of 3 patients (Patient #2) whose records were reviewed for the effective operation of the grievance process out of a total sample of 12 patients. This was evidenced by the hospital's failure to ensure that a patient grievance relating to alleged abuse was reviewed to include the hospital's conduction of a thorough investigation as indicated in the hospital approved policies/procedures relating to patient complaints/grievances and relating to allegations of abuse. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 was an 18 year old female admitted to Greenbrier Hospital on 3/20/10. Review of the medical record revealed that Patient #2 was initially admitted on a PEC (physician emergency certificate) on 3/20/10 at 5:30 p.m. after being assessed to be "dangerous to self" and "gravely disabled". Further review of the medical record revealed that Patient #2 signed a Formal Voluntary Admission form on 3/21/10 at 12:20 a.m. and remained on a formal voluntary admission status until her discharge from Greenbrier Hospital on 3/24/10. The Psychiatric Evaluation, dated 3/22/10, documents Patient #2's Axis I diagnosis as "There is a wide differential for this patient. It does appear that she is presenting in a depressed manner, and given the history, as well as symptoms, bipolar disorder could not be completely ruled out at this point in time. In fact, it does seem that there is quite a bit of criteria for bipolar disorder, however, the drug problem does complicate the picture, and again, drug induced psychosis should be considered". The Psychiatric Evaluation documents Patient #2's Axis II diagnosis as "Personality disorder, not otherwise specified, should be taken into consideration". Review of the admission orders dated 3/20/10 revealed that Patient #2 was initially placed on a "Visual Contact" observational status (line of sight of a staff member at all times). Review of the physician's orders dated 3/21/10 at 1:30 p.m. revealed orders to discontinue the "Visual Contact" observational status and place Patient #2 on a "Special Observation" status (checks every 30 minutes). Review of the "Patient Observation Log" revealed that S14 (mental health technician) conducted the 30 minute checks on Patient #2 on the p.m. shift that began on 3/22/10 and 3/23/10. Review of the medical record revealed that Patient #2 remained on the "Special Observation" status until her discharge from Greenbrier Hospital on 3/24/10. The Psychiatric Discharge Summary, dated 3/25/10, documents Patient #1's Axis I diagnoses as Major Depression, recurrent, severe; Rule out Bipolar Disorder; Generalized Anxiety Disorder; and History of Substance Abuse. The Psychiatric Discharge Summary documents Patient #2's Axis II diagnoses as "Consider Borderline Personality Disorder". Review of the medical record revealed no documentation relating to Patient #2 alleging that she had been treated inappropriately or sexually abused during her hospitalization at Greenbrier Hospital.

S16 (Licensed Clinical Social Worker) was interviewed on 5/28/10 at 10:05 a.m. S16 reviewed the medical record of Patient #2. S16 reported that she is the Director of Outpatient Services for both Greenbrier Hospital and for Facility A Partial Hospitalization Program. S16 reported that Patient #2 was discharged from Greenbrier Hospital on 3/24/10 and admitted to Facility A Partial Hospitalization Program on 3/25/10. S16 reported that on 4/19/10 one of the outpatient therapists from Facility A informed her that the mother of Patient #2 was verbalizing allegations of inappropriate sexual behavior and harassing phone calls against a male employee who works at Greenbrier Hospital. S16 reported that a meeting was held with Patient #2 and Patient #2's mother at the Partial Hospitalization Program on 4/19/10 at 2:30 p.m. to discuss the allegations. S16 reported that Patient #2 reported that S13 (mental health technician) had came into her assigned room on the night of 3/23/10 and exposed himself and asked her to perform oral sex on him. S16 reported that there were also allegations of S13 making harassing phone calls to Patient #2's phone following her discharge from Greenbrier Hospital. S16 reported that she informed the Corporate Compliance Officer of Facility A of the allegations made against S13 on 4/19/10 after becoming aware of the allegations. S16 indicated that the Corporate Compliance Officer for Facility A is the Corporate Compliance Officer for Greenbrier Hospital as both Facility A and Greenbrier Hospital are managed by the same entity.

The hospital's complaint/grievance log for the time frame of 1/01/10 thru 5/26/10 was reviewed. This review revealed no evidence to indicate that any complaints/grievances/allegations of abuse had been reported by or on behalf of Patient #2.

The hospital's policy/procedure titled "Patient Abuse and/or Neglect" was reviewed. The policy/procedure documents in part "It is the policy of Greenbrier, in accordance with state and federal law, that suspected cases of abuse and or neglect of adults will be reported to the appropriate protective services agency". The policy/procedure defines abuse as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another". The policy/procedure defines sexual abuse as "any unwanted sexual activity, without regard to contact or injury; any sexual activity with a person whose capacity to consent or resist is limited". The policy/procedure indicates that an investigation into allegations of abuse will be conducted and the hospital's Grievance Committee will review all data in relation to allegations of patient abuse and/or neglect. The policy/procedure documents that the Grievance Committee shall consist of the Director of Nursing, the Administrator, the Director of Social Services, and the Director of Human Resources. The policy/procedure documents "The Committee shall submit their written report to the Administrator in a timely manner, the entire investigation should not span longer than thirty (30) days, unless an extension is granted by the Administrator. Request for an extension must be in writing, by the Committee, and submitted to the Administrator prior to the 29th day of the 30 day period".

The hospital's policy/procedure titled "Patient Complaints and Grievances" was reviewed. The policy/procedure documents in part "all complaints and/or grievances are addressed in a timely manner and an appropriate intervention or response is provided to the patient and/or family member". The policy/procedure indicates that a "Care Connection Representative" will discuss problems and/or concerns with the patient and formulate a statement of grievance. The policy/procedure further indicates that this "Care Connection Representative" will attempt to resolve the problem or concern and if the "Care Connection Representative" and the patient come to a resolution of the problem or concern, a written response will be provided to the patient that includes the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. The policy/procedure indicates that unresolved grievances are handled as follows:
? Step 1- The Care Connection Representative will conduct a meeting of the Grievance Committee to present all known information regarding the patient's grievance within ten working days of the Grievance/Complaint Report. (Composition of the Grievance Committee includes the Administrator, Director of Nursing, Director of Social Services, Human Resources Director, Compliance Officer)
? Step 2- The Grievance Committee will review and further investigate the substance of the patient's grievance to assist in the provision of a response and work toward resolution.
? Step 3- Within five working days of the Grievance Committee Meeting, a response will be provided to the patient or his/her legal representative with a written notice of determination regarding the committee's decision communicated in a manner and language the patient or his/her representative understands. The response will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
The policy/procedure further documents "Grievances about situations that endanger the patient, such as neglect or abuse, shall be reported immediately to the Director of Nursing and to the Administrator. DHH must also be notified".

S1 (Administrator) was interviewed on 6/01/10 at 2:00 p.m. S1 confirmed that the same corporate entity manages both Facility A and Greenbrier Hospital. S1 reported that she received a phone call from the Corporate Compliance Officer on 4/19/10 at approximately 5:30 p.m. and was informed of allegations made against S13 (mental health technician) involving Patient #2. S1 reported that the Corporate Compliance Officer informed her that the corporate office would handle the investigation. S1 reported that she contacted S2 (Director of Nursing) immediately after receiving the call from the Corporate Compliance Officer to ensure S13's suspension pending an internal investigation. S1 reported that S13 did not return to work at Greenbrier Hospital after the hospital was made aware of the allegations on 4/19/10. S1 reported that a request was made for S13 to submit his phone records for review but stated that S13 failed to submit the requested phone records. S1 reported that the hospital's policy/procedure titled "Patient Complaints and Grievances" was not followed in relation to this alleged abuse as she was unable to provide data to indicate that a thorough investigation had been conducted into the allegations of patient abuse and to indicate that a written response was provided to the patient that included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. S1 reported that the hospital's policy/procedure titled "Patient Abuse and/or Neglect" was not followed as she was unable to provide data to indicate that the results of the allegations of abuse had been reviewed by the Grievance Committee or to indicate that the Grievance Committee had submitted a written report to the Administrator as documented in the policy/procedure. S1 reported that she did not notify the Health Standards Section of the Department of Health & Hospitals. S1 reported that notification to the Department of Health & Hospitals was made by an attorney representing MMO on 4/29/10 which was 10 days after the hospital was made aware of the allegations of patient abuse. S1 reported that she was not aware of any other law enforcement agencies being informed of the allegations of patient abuse made against S13.

S2 (Director of Nursing) was interviewed on 5/27/10 at 10:40 a.m. S2 reviewed the medical record of Patient #2. S2 reported that she was not directly involved in Patient #2 ' s care during her hospitalization. S2 reported that she was informed by the Administrator that Patient #2 had alleged that S13 (mental health technician) had attempted to fondle her (Patient #2) breast, had exposed himself and requested that she perform oral sex on him during her (Patient #2) hospitalization and then made harassing phone calls to her (Patient #2) after being discharged from Greenbrier Hospital. S2 reported that she was first made aware of these allegations on the evening of 4/19/10. S2 reported that she contacted S13 by telephone on 4/19/10 and informed him that there has been some allegations made against him. S2 reported that she asked S13 if he had made any phone calls to any patients who had been discharged from Greenbrier Hospital and indicated that his initial response was silence and then he stated " I don ' t recall " . S2 reported that she informed S13 that he was suspended until further notice. S2 reported that she contacted S13 again on 4/28/10 and requested that he bring his phone records in for review. S2 reported that S13 did not bring his phone records in for review as requested. S2 reported that S13 ' s employment was terminated on 5/03/10. S2 reported that she did not conduct any further interviews or investigation into the alleged patient abuse due to her (Director of Nursing) being told by the Administrator that the corporate office was going to conduct an investigation into this matter. S2 reported that she was not aware of any direct care staff members being interviewed in regards to the allegations made by Patient #2. S2 reported that she was not aware of any regulatory or law enforcement agencies being informed of the allegations made against S13. S2 reported that her main concern was ensuring that S13 did not return to work around patients until an investigation was completed. S2 indicated that S13 refused to comply with the hospital ' s request to review his phone records and his employment was terminated on 5/03/10.

The nurse staffing records were for the dates of 3/20/10 through 3/24/10 were reviewed with the Director of Nursing as these were the dates that Patient #2 was hospitalized at Greenbrier Hospital. This review revealed that S13 worked the p.m. shifts that began on 3/22/10 and 3/23/10. Review of the staffing records for the p.m. shifts that began on 3/22/10 and 3/23/10 revealed that S8 was the charge nurse working on the unit on both dates, S10 was the licensed practical nurse working on the unit on both dates, S13 & S14 were the two mental health technicians working on the unit on both dates. A request was made to the Director of Nursing to set up interviews with the Director of Outpatient Services, with Patient #2 ' s attending physician, with Patient #2 ' s advanced practice nurse, with Patient #2 ' s case manager, and with all staff members who worked on the p.m. shifts that began on 3/22/10 and 3/23/10.

S11 (Medical Director and attending Psychiatrist) was interviewed on 5/27/10 at 2:40 p.m. S11 reviewed the medical record of Patient #2. S11 reported that the administrator had recently told him that Patient #2 had informed one of the outpatient therapists that a male staff member had treated her inappropriately while hospitalized at Greenbrier Hospital. S11 reported that the administrator told him that the male staff member was no longer employed at Greenbrier Hospital. S11 reported that he was not aware of any details regarding the hospital ' s internal investigation into this matter other than remembering that the employee was interviewed and had either denied the accusations or did not answer. S13 reported that he was not aware of any regulatory or law enforcement agencies being informed of the allegations made against S13.

S12 (Advanced Practice Registered Nurse) was interviewed on 5/28/10 at 9:25 a.m. S12 reviewed the medical record of Patient #2. S12 reported that she was the Clinical Nurse Specialist who provided care for Patient #2. S12 reported that she was not aware of Patient #2 alleging that she had been treated inappropriately during her hospitalization or following her discharge from Greenbrier Hospital. S12 reported that she was not aware of the hospital conducting any investigation in regards to allegations made by Patient #2.

S9 (Licensed Professional Counselor) was interviewed on 5/27/10 at 9:45 a.m. S9 reviewed the medical record of Patient #2. S9 reported that she was Patient #2's case manager during her hospitalization. S9 reported that she was not aware of Patient #2 alleging that she had been treated inappropriately during her hospitalization or following her discharge from Greenbrier Hospital. S9 reported that she was not aware of any investigation being conducted in relation to allegations made by Patient #2.

S14 (Mental Health Technician) who conducted the 30 minute checks on Patient #2 on the night shifts that began on 3/22/10 and 3/23/10 was unavailable for interview during this investigation. The Director of Nursing reported that S14 was on vacation in Jamaica and could not be reached by telephone.

S13 (Mental Health Technician) was unavailable for interview as he was no longer employed at Greenbrier Hospital.

S10 (Licensed Practical Nurse) was interviewed on 5/27/10 at 11:40 a.m. S10 reviewed the medical record of Patient #2. S10 reported that she worked as the medication nurse on the p.m. shift on 3/23/10. S10 reported that she was not aware of Patient #2 alleging that she had been treated inappropriately during her hospitalization or following her discharge from Greenbrier Hospital. S10 reported that she was not aware of any investigation being conducted in relation to allegations made by Patient #2.

S8 (Registered Nurse) was interviewed on 5/27/10 at 12:50 p.m. S8 reviewed the medical record of Patient #2. S8 reported that she worked on the p.m. shift on 3/23/10 as the charge nurse on the unit that Patient #2 was hospitalized. S8 reported that S14 (Mental Health Technician) was assigned to conduct the 30 minute visual checks on Patient #2 on the night shifts that began on 3/22/10 and 3/23/10. S8 reported that she was not aware of Patient #2 alleging that she had been treated inappropriately during her hospitalization or following her discharge from Greenbrier Hospital. S8 reported that she was not aware of any investigation being conducted in relation to allegations made by Patient #2.

S14 (Mental Health Technician) who conducted the 30 minute checks on Patient #2 on the night shifts that began on 3/22/10 and 3/23/10 was unavailable for interview during this investigation. The Director of Nursing reported that she (S14) was on vacation in Jamaica and could not be reached by telephone.

Based on record review and interview, the hospital failed to ensure the effective implementation of the grievance process for 1 of 3 patients (Patient #2) whose records were reviewed for the effective operation of the grievance process out of a total sample of 12 patients. This was evidenced by the hospital's failure to provide the patient and/or patient representative with a written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 was an 18 year old female admitted to Greenbrier Hospital on 3/20/10. Review of the medical record revealed that Patient #2 was initially admitted on a PEC (physician emergency certificate) on 3/20/10 at 5:30 p.m. after being assessed to be "dangerous to self" and "gravely disabled". Further review of the medical record revealed that Patient #2 signed a Formal Voluntary Admission form on 3/21/10 at 12:20 a.m. and remained on a formal voluntary admission status until her discharge from Greenbrier Hospital on 3/24/10. Review of the medical record revealed no documentation relating to Patient #2 alleging that she had been treated inappropriately or sexually abused during her hospitalization at Greenbrier Hospital.

S16 (Licensed Clinical Social Worker) was interviewed on 5/28/10 at 10:05 a.m. S16 reviewed the medical record of Patient #2. S16 reported that she is the Director of Outpatient Services for both Greenbrier Hospital and for Facility A Partial Hospitalization Program. S16 reported that Patient #2 was discharged from Greenbrier Hospital on 3/24/10 and admitted to Facility A Partial Hospitalization Program on 3/25/10. S16 reported that on 4/19/10 one of the outpatient therapists from Facility A informed her that the mother of Patient #2 was verbalizing allegations of inappropriate sexual behavior and harassing phone calls against a male employee who works at Greenbrier Hospital. S16 reported that a meeting was held with Patient #2 and Patient #2's mother at the Partial Hospitalization Program on 4/19/10 at 2:30 p.m. to discuss the allegations. S16 reported that Patient #2 reported that S13 (mental health technician) had came into her assigned room on the night of 3/23/10 and exposed himself and asked her to perform oral sex on him. S16 reported that there were also allegations of S13 making harassing phone calls to Patient #2's phone following her discharge from Greenbrier Hospital. S16 reported that she informed the Corporate Compliance Officer of Facility A of the allegations made against S13 on 4/19/10 after becoming aware of the allegations. S16 indicated that the Corporate Compliance Officer for Facility A is the Corporate Compliance Officer for Greenbrier Hospital as both Facility A and Greenbrier Hospital are managed by the same entity.

The hospital's complaint/grievance log for the time frame of 1/01/10 thru 5/26/10 was reviewed. This review revealed no evidence to indicate that any complaints/grievances/allegations of abuse had been reported by or on behalf of Patient #2.

The hospital's policy/procedure titled "Patient Abuse and/or Neglect" was reviewed. The policy/procedure documents in part "It is the policy of Greenbrier, in accordance with state and federal law, that suspected cases of abuse and or neglect of adults will be reported to the appropriate protective services agency". The policy/procedure defines abuse as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another". The policy/procedure defines sexual abuse as "any unwanted sexual activity, without regard to contact or injury; any sexual activity with a person whose capacity to consent or resist is limited". The policy/procedure indicates that an investigation into allegations of abuse will be conducted and the hospital's Grievance Committee will review all data in relation to allegations of patient abuse and/or neglect. The policy/procedure documents that the Grievance Committee shall consist of the Director of Nursing, the Administrator, the Director of Social Services, and the Director of Human Resources. The policy/procedure documents "The Committee shall submit their written report to the Administrator in a timely manner, the entire investigation should not span longer than thirty (30) days, unless an extension is granted by the Administrator. Request for an extension must be in writing, by the Committee, and submitted to the Administrator prior to the 29th day of the 30 day period".

The hospital's policy/procedure titled "Patient Complaints and Grievances" was reviewed. The policy/procedure documents in part "all complaints and/or grievances are addressed in a timely manner and an appropriate intervention or response is provided to the patient and/or family member". The policy/procedure indicates that a "Care Connection Representative" will discuss problems and/or concerns with the patient and formulate a statement of grievance. The policy/procedure further indicates that this "Care Connection Representative" will attempt to resolve the problem or concern and if the "Care Connection Representative" and the patient come to a resolution of the problem or concern, a written response will be provided to the patient that includes the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. The policy/procedure indicates that unresolved grievances are handled as follows:
? Step 1- The Care Connection Representative will conduct a meeting of the Grievance Committee to present all known information regarding the patient's grievance within ten working days of the Grievance/Complaint Report. (Composition of the Grievance Committee includes the Administrator, Director of Nursing, Director of Social Services, Human Resources Director, Compliance Officer)
? Step 2- The Grievance Committee will review and further investigate the substance of the patient's grievance to assist in the provision of a response and work toward resolution.
? Step 3- Within five working days of the Grievance Committee Meeting, a response will be provided to the patient or his/her legal representative with a written notice of determination regarding the committee's decision communicated in a manner and language the patient or his/her representative understands. The response will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
The policy/procedure further documents "Grievances about situations that endanger the patient, such as neglect or abuse, shall be reported immediately to the Director of Nursing and to the Administrator. DHH must also be notified".

S1 (Administrator) was interviewed on 6/01/10 at 2:00 p.m. S1 confirmed that the same corporate entity manages both Facility A and Greenbrier Hospital. S1 reported that she received a phone call from the Corporate Compliance Officer on 4/19/10 at approximately 5:30 p.m. and was informed of allegations made against S13 (mental health technician) involving Patient #2. S1 reported that the Corporate Compliance Officer informed her that the corporate office would handle the investigation. S1 reported that she contacted S2 (Director of Nursing) immediately after receiving the call from the Corporate Compliance Officer to ensure S13's suspension pending an internal investigation. S1 reported that S13 did not return to work at Greenbrier Hospital after the hospital was made aware of the allegations on 4/19/10. S1 reported that a request was made for S13 to submit his phone records for review but stated that S13 failed to submit the requested phone records. S1 reported that the hospital's policy/procedure titled "Patient Complaints and Grievances" was not followed in relation to this alleged abuse as she was unable to provide data to indicate that a thorough investigation had been conducted into the allegations of patient abuse and to indicate that a written response was provided to the patient that included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. S1 reported that the hospital's policy/procedure titled "Patient Abuse and/or Neglect" was not followed as she was unable to provide data to indicate that the results of the allegations of abuse had been reviewed by the Grievance Committee or to indicate that the Grievance Committee had submitted a written report to the Administrator as documented in the policy/procedure. S1 reported that she did not notify the Health Standards Section of the Department of Health & Hospitals. S1 reported that notification to the Department of Health & Hospitals was made by an attorney representing MMO on 4/29/10 which was 10 days after the hospital was made aware of the allegations of patient abuse. S1 reported that she was not aware of any other law enforcement agencies being informed of the allegations of patient abuse made against S13.

Based on observation, record review and interview the hospital failed: 1) to ensure patient bed assignments were made taking into consideration the care and safety of female patients as evidenced by assigning a sexually active male patient with orders for visual contact and two female patients in an area containing two rooms off an anti-room, farthest away from the nurses' station and not visible unless standing in the doorway leading to the rooms and failing to follow MD orders for visual contact throughout the night (Patients #6, #11 and R12) and 2) to follow their policy and procedure for employment as evidenced by failing to ensure a background check had been performed on 1 of 3 Mental Health Technicians personnel files reviewed (S13). Findings:

1) to ensure patient bed assignments were made taking into consideration the care and safety of female patients
Observation of the layout of room for Unit B of the hospital revealed Rooms "a" and "b" were configured within an "anti" room which contained the entrance to the bathrooms for room "a" and room "b". Because of being set back off of this anti-room, neither room was visible from the nursing station and in order to have visual contact it would be necessary to station one Mental Health Technician directly outside of the door leading to the room. Because of the remote location, and not being able to be visualized form the nursing station set back off of this anti room, neither room was visible from the nursing station and in order to have visual contact it would be necessary to station one Mental Health Technician directly outside of the door leading to the room.

Observation of the layout for Room "c" which contained two beds revealed this room was situated the far end from the nursing station to the right in hall by itself. Because of the remote location, and not being able to be visualized form the nursing station in order to have visual contact it would be necessary to station one Mental Health Technician directly outside of the door leading to the room.

Review of the Nursing Assignment Sheet for May 25, 2010 revealed 1 RN, 1LPN and 2MHT had been assigned to Unit B.

Review of the Census for Unit B on May 25, 2010 revealed a census of 20 patients. Further review revealed 18 patients were on visual contact (line of sight at all times), 1 was on modified visual contact (lines of sight while awake) and 1 was on special observation (location of patient every thirty minutes).

Review of the bed assignments for May 25, 2010 revealed in Room "a" Patient #6 with orders for visual contact and Room " b Patients #11 and R12 which were located in the rooms off of an anti-room. Further review revealed Patient R7 and R9 located in Room "b" at the far end of the hall to the right also had orders for visual contact.

Observation on 05/26/10 at 2:00pm on Unit B revealed Room "a" and Room "b" located off of the anti-room at the end of Unit B housed men in one room and women in the other. Further review of the area revealed a sign on the bathroom door for Room " a " that the males were not to use the bathroom.

In a face to face interview on 05/27/10 at 1:05pm RN S8 (nurse assigned to Unit B) indicated it was a common practice to put males and female in such close proximity when using Rooms "a" and "b". Further she indicated that unless you go into the anti-room of Rooms "a" and "b" , you cannot visualize the patients. S8 indicated the unit is usually staffed with 2 MHT which are used to staff both sides of Unit B.

In a face to face interview on 05/27/10 at 3:00pm RN S6 (nurse assigned to Unit B) indicated having a male and female mix on the same unit has been a problem at times and patients have had to be moved to another unit. Further she indicated that when the hospital was first established, it was determined that a staff member would be assigned at all times for the end of the hall containing Rooms "a", "b" and "c". S6 indicated she had even spoken with MD S11 about getting the males and female separated, but changes were never implemented. Further S6 indicated she had suggested putting one staff member on each side of the nursing station (Unit B split into 2 wings); however a plan was developed to put like patients together, but not implemented.

A group interview was conducted on 05/26/10 at 1:45pm with 7 cognitively intact patients chosen by the hospital and the social worker assigned to Unit B. At that time, Patient #11 (a psychiatric nurse hospitalized for depression) indicated her room was located at the end of the hall next door to two men. Further #11 indicated she did not feel safe because no staff member was watching her and one of the men was constantly going to the bathroom and using hers. Patient R12, roommate of Patient #11 indicated she was also frightened, especially since Patient #11 was being transferred to another hospital and she would be left alone in that room. R6 indicated Patient #6 would follow her around and stand right in back of her. Further she indicated on several occasions #6 would try to grab her hand. R9 indicated Patient #6 was always asking her if she wanted a boyfriend.

Review of the bed assignment sheet for May 25, 2010 revealed Patient #6 had been assigned to Room "b" and had orders for visual contact (to be in the line of staff at all times, even when asleep).


2) to follow their policy and procedure for employment as evidenced by failing to ensure a background check had been performed. Findings:

The personnel record of S13 was reviewed. This review revealed that S13 was employed as a mental health technician and his date of hire was 6/25/09. This review revealed documentation to indicate that a hospital orientation including a unit based orientation was provided to S13. This review revealed that information relating to abuse/neglect was included in the training and orientation process. This review failed to reveal that a criminal background check had been conducted on S13 relating to his 6/25/09 employment.

The hospital's policy/procedure titled "Patient Abuse and/or Neglect" was reviewed. The policy/procedure documents in part " he hospital maintains several policies and procedures geared towards abuse and/or neglect prevention and patient advocacy which include but are not limited to: b. Criminal Background Checks on all Potential New Hires".

The Human Resources Director was interviewed on 5/27/10 at 2:00 p.m. The Human Resources Director reported that a criminal background check should have been conducted on S13 but indicated that the results of the criminal background check were not available secondary to problems that the hospital was having with the company who provides the information relating to the criminal background checks. When asked by the surveyor for a copy of the policy/procedure relating to criminal background checks as referenced in the policy/procedure titled "Patient Abuse and/or Neglect", the Human Resources Director reported that there was no hospital approved policy/procedure that addresses criminal background checks. The Human Resources Director then presented a copy of the "MMO Employee Handbook" and referenced a section under " Compliance Information" which documents "For certain positions, criminal background checks will be conducted". The Human Resources Director reported that the results of the criminal background check should have been included in the personnel record of S13.

Based on record review and interview, the hospital failed to ensure that a patient has the right to be free from all forms of abuse and/or harassment and failed to assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 was an 18 year old female admitted to Greenbrier Hospital on 3/20/10. Review of the medical record revealed that Patient #2 was transferred from Hospital B and initially admitted at Greenbrier Hospital on a PEC (physician emergency certificate) on 3/20/10 at 5:30 p.m. after being assessed to be "dangerous to self" and "gravely disabled" at Hospital B. Further review of the medical record revealed that Patient #2 signed a Formal Voluntary Admission form on 3/21/10 at 12:20 a.m. and remained on a formal voluntary admission status until her discharge from Greenbrier Hospital on 3/24/10. The Psychiatric Evaluation, dated 3/22/10, documents Patient #2's Axis I diagnosis as "There is a wide differential for this patient. It does appear that she is presenting in a depressed manner, and given the history, as well as symptoms, bipolar disorder could not be completely ruled out at this point in time. In fact, it does seem that there is quite a bit of criteria for bipolar disorder, however, the drug problem does complicate the picture, and again, drug induced psychosis should be considered". The Psychiatric Evaluation documents Patient #2's Axis II diagnosis as "Personality disorder, not otherwise specified, should be taken into consideration". Review of the admission orders dated 3/20/10 revealed that Patient #2 was initially placed on a "Visual Contact" observational status (line of sight of a staff member at all times). Review of the physician's orders dated 3/21/10 at 1:30 p.m. revealed orders to discontinue the "Visual Contact" observational status and place Patient #2 on a "Special Observation" status (checks every 30 minutes). Review of the "Patient Observation Log" revealed that S14 (mental health technician) conducted the 30 minute checks on Patient #2 on the night shift that began on 3/22/10 and 3/23/10. Review of the medical record revealed that Patient #2 remained on the "Special Observation" status until her discharge from Greenbrier Hospital on 3/24/10. The Psychiatric Discharge Summary, dated 3/25/10, documents Patient #1's Axis I diagnoses as Major Depression, recurrent, severe; Rule out Bipolar Disorder; Generalized Anxiety Disorder; and History of Substance Abuse. The Psychiatric Discharge Summary documents Patient #2's Axis II diagnoses as "Consider Borderline Personality Disorder". Review of the medical record revealed no documentation relating to Patient #2 alleging that she had been treated inappropriately or sexually abused during her hospitalization at Greenbrier Hospital.

S16 (Licensed Clinical Social Worker) was interviewed on 5/28/10 at 10:05 a.m. S16 reviewed the medical record of Patient #2. S16 reported that she is the Director of Outpatient Services for both Greenbrier Hospital and for MMO (Medical Management Options) Partial Hospitalization Program. S16 reported that Patient #2 was discharged from Greenbrier Hospital on 3/24/10 and admitted to MMO Partial Hospitalization Program on 3/25/10. S16 reported that on 4/19/10 one of the outpatient therapists from MMO informed her that the mother of Patient #2 was verbalizing allegations of inappropriate sexual behavior and harassing phone calls against a male employee who works at Greenbrier Hospital. S16 reported that a meeting was held with Patient #2 and Patient #2 ' s mother at the Partial Hospitalization Program on 4/19/10 at 2:30 p.m. to discuss the allegations. S16 reported that Patient #2 reported that S13 (mental health technician) had came into her assigned room on the night of 3/23/10 and exposed himself and asked her to perform oral sex on him. S16 reported that there were also allegations of S13 making harassing phone calls to Patient #2 ' s phone following her discharge from the hospital. S16 reported that she informed the Compliance Officer at MMO of the allegations made against S13 on 4/19/10 after becoming aware of the allegations.

Review of the Louisiana Revised Statutes revealed the following in relation to the reporting of abuse/neglect:
Title 40. Public Health and Safety, Chapter 11. State Department of Health and Hospitals
?2009.20.
"Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report".

S2 (Director of Nursing) was interviewed on 5/27/10 at 10:40 a.m. S2 reviewed the medical record of Patient #2. S2 reported that she was not directly involved in Patient #2 ' s care during her hospitalization. S2 reported that she was informed by the Administrator that Patient #2 had alleged that S13 (mental health technician) had attempted to fondle her (Patient #2) breast, had exposed himself and requested that she perform oral sex on him during her (Patient #2) hospitalization and then made harassing phone calls to her (Patient #2) after being discharged from Greenbrier Hospital. S2 reported that she was first made aware of these allegations on the evening of 4/19/10. S2 reported that she contacted S13 by telephone on 4/19/10 and informed him that there has been some allegations made against him. S2 reported that she asked S13 if he had made any phone calls to any patients who had been discharged from Greenbrier Hospital and indicated that his initial response was silence and then he stated " I don ' t recall " . S2 reported that she informed S13 that he was suspended until further notice. S2 reported that she contacted S13 again on 4/28/10 and requested that he bring his phone records in for review. S2 reported that S13 did not bring his phone records in for review as requested. S2 reported that S13 ' s employment was terminated on 5/03/10. S2 reported that she did not conduct any further interviews or investigation into the alleged patient abuse due to her (Director of Nursing) being told by the Administrator that the corporate office was going to conduct an investigation into this matter. S2 reported that she was not aware of any direct care staff members being interviewed in regards to the allegations made by Patient #2. S2 reported that she was not aware of any regulatory or law enforcement agencies being informed of the allegations made against S13. S2 reported that her main concern was ensuring that S13 did not return to work around patients until an investigation was completed. S2 indicated that S13 refused to comply with the hospital ' s request to review his phone records and his employment was terminated on 5/03/10.

S1 (Administrator) was interviewed on 6/01/10 at 2:00 p.m. S1 indicated that MMO (Medical Management Options) is the entity that manages Greenbrier Hospital. S1 reported that she received a phone call from MMO's Corporate Compliance Officer on 4/19/10 at approximately 5:30 p.m. and was informed of allegations made against S13 (mental health technician) involving Patient #2. S1 reported that MMO's Corporate Compliance Officer informed her that MMO would handle the investigation (which was not in accordance with Greenbrier Hospital's policy/procedure relating to the investigation of abuse). S1 reported that she contacted S2 (Director of Nursing) immediately after receiving the call from MMO's Corporate Compliance Officer to ensure S13's suspension pending an internal investigation. S1 reported that S13 did not return to work at Greenbrier Hospital after the hospital was made aware of the allegations on 4/19/10. S1 reported that a request was made for S13 to submit his phone records for review but stated that S13 failed to submit the requested phone records. S1 reported that S13 was terminated from Greenbrier Hospital. S1 reported that the hospital's policy/procedure titled "Patient Complaints and Grievances" was not followed in relation to this alleged abuse as she was unable to provide data to indicate that a thorough investigation had been conducted into the allegations of patient abuse and to indicate that a written response was provided to the patient that included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. S1 reported that the hospital's policy/procedure titled "Patient Abuse and/or Neglect" was not followed as she was unable to provide data to indicate that the results of the allegations of abuse had been reviewed by the Grievance Committee or to indicate that the Grievance Committee had submitted a written report to the Administrator as documented in the policy/procedure. S1 reported that she did not notify the Health Standards Section of the Department of Health & Hospitals. S1 reported that notification to the Department of Health & Hospitals was made by an attorney representing MMO on 4/29/10 which was 10 days after the hospital was made aware of the allegations of sexual abuse. S1 reported that she was not aware of any other law enforcement agencies being informed of the allegations of abuse made against S13.

Based on record review and interview the hospital failed to perform a thorough investigation which should have included a review of the observation status of all involved patients, census on the unit at the time of the incidents, acuity of the patients at the time of the incidents, the staffing assignments, additional duties assigned to the mental health technicians responsible for the observation of the patients, policies and procedures or trending of complaints for 4 of 9 complaints concerning sexual abuse allegations. Findings:

In a face to face interview on 05/27/10 at 10:30am S2 DON indicated she does not keep a log of her grievances but rather keeps all of the documentation received in a folder; however she informed the survey team a list of the grievances could be typed and submitted to the team.

Review of the typed list of grievances submitted by S2 DON revealed the following: January 2010 (1); February (1); March (2); April (2); and May (3). Further review revealed 4 of the 9 reported grievances dealt with sexual abuse allegations.

Review of the Performance Improvement Report and Analysis and Plan for Improvement dated January 2010 revealed ..... " Results: January 22, 2010 - Letter received per fax from DHH regarding an allegation concerning male patient RB, admitted 01/04/10 and discharged 01/15/10. The complaint alleges that while and inpatient, RB stated that his roommate forced him to have oral and anal sex with him. Investigation occurred with response to DHH. Letter faxed back to hospital January 29, 2010 from DHH thanking for our prompt response to the internal administrative review and DHH did not identify any deficient practices on part of our facility. Discussion - Staff were inservices on Complaints and Grievances in the month of October. Modify or Revise Plan - .... DHH mailed information regarding recommendations and resources for investigations and self-reports of abuse. Staff will be inserviced on this in February. Review of the one grievance submitted for February 2010 revealed a patient felt he had not been explained his admit paperwork and his family had not been given a patient telephone code. Further review revealed the results documented as .... " Patient was met with and issues resolves. Staff was met with and issues discussed " . Discussion was documented as " Staff were inservices on Complaints and Grievances in the month of October. Modify or Revise Plan - .... DHH mailed information regarding recommendations and resources for investigations and self-reports of abuse. Staff will be inserviced on this in February " . There were no Grievances documented in Performance Improvement for the month of March, even though two (1 from a patient patient ' s mother concerning discharge issues and one from a patient who admits to having problems deciding what situations in her life are fact and which are delusions had been reported to administration. Review of April PI (Performance Improvement) and the documentation submitted to DHH by the hospital concerning Patients #9 and #10 which took place on April 28, 2010 revealed no documented evidence concerning the observation status of either patient, the acuity of the patients on Unit A at the time of the incident, the number of staff assigned to the unit at the time of the incident, or the other duties the mental health techs were responsible for besides direct patient care.

Review of the Physician ' s Orders for Patient #9 and #10 revealed both had orders to be on visual contact which meant that a staff member should have had them in his/her sight at all times. Because Patient #8 and #9 were found in Patient #10 ' s room, there had been an obvious breakdown in the system for observation of patients.

Review of the nursing assignment sheet for April 28, 2010 revealed 1RN, 1LPN and 2MHT (Mental Health Technicians) had been assigned to the more acute psychiatric wing (Unit A) to care for
Of the 15 patients on Unit A, seven patients had orders for VC (Visual Contact: The patient must be in sight of a staff member at all times); and 15 minute checks documented; five patients had orders for MVC (Modified Visual Contact: The patient is observed within the line of sight of staff during all waking hours); and 3 patients had orders for SO (Special Observation: The patient is observed with visual checks every 30 minutes). In addition review of the "Assignment Sheet" dated 04/28/10 revealed the Mental Health Technicians were responsible for the following: 1. Smoking (accompanying the patient to the smoke area); 2. Unit cleanliness; 3. Room checks; 4. Group exercise times three; 5. Group: Priority and Goals; 6. Group: OT/RT; 7. Group: Nursing; 8. Group: Life skills; 9. Group: Community; 10. Group: Current Events; 11. Group: Wrap-Up; 12. Performing EKGs; 13. Meals; 14. Admits (paperwork, faxes, etc); 15. Discharge (paperwork completed including patient satisfaction survey); 16. Delinquent: assessments; 17. Weekend recreation; 18. Vital signs; 19. Location graph; 20. Sharps; 21. Transportation; 22. Make up chart packets; 23. Stuff charts; 24. Trash; 25. Dirty linen; 26. Refrigerator; 27. Patient hygiene; 28. Diet/snack sheet; and 29. Order supplies which verified the additional tasks the MHT were responsible for besides direct patient care. Because there was 1 MHT per 6 patients needing direct visual line of sight at all times a systems breakdown in staffing might have been identified.

Review of the policy and procedure for staffing, the daily staffing assignment sheets, and the acuity assessment for patients would have revealed that the hospital was not following their policy and procedures for assessment or assignment of staff according to patient need and acuity.

Further review of the PI submitted for April 2010 revealed .... " Discussion - the staff were inserviced on Complaints and Grievances in the month of October. Modify or Revise the Plan - d. DHH mailed information regarding recommendations and resources for investigations and self-reports of abuse. Staff will be inservices on this in February.

Further review revealed no documented evidence of any corrective action taken since the first reported allegation of sexual abuse in January.

In a face to face interview on 05/27/10 at 10:30am S2 DON indicated no corrective had been needed because DHH said the hospital had conducted a thorough investigation and the matter was closed.

Based on review of medical records, review of policies/procedures, review of nurse staffing reports, observations and interviews with staff, the hospital failed to ensure compliance with the Condition of Participation relative to Nursing Services by:

Failing to provide adequate numbers of nursing staff to ensure that the observational level needs of patients hospitalized on the acute care psychiatric unit are met based on ongoing assessments and the orders of the attending psychiatrist/practitioner. (Cross reference to findings cited at A0392)

An Immediate Jeopardy Situation was identified on 5/28/10 at 3:00 p.m. relative to the responsibilities of Nursing Services. The Immediate Jeopardy Situation was relating to the hospital's failing to ensure that patients hospitalized in the psychiatric hospital were monitored/supervised in accordance with hospital approved policies/procedures and with the orders of the attending psychiatrist/practitioner. This was evidenced by the hospital's failure to ensure that patients who were ordered to be on a "visual contact" observational status were actually within visual contact of a staff member at all times (per hospital policy/procedure for "visual contact") during their hospitalization while the "visual contact" orders were active. This failure resulted in at least three (3) identified incidents of male and female patients being together in a patient room without being in the line of sight of a staff member. This immediate jeopardy situation has the potential to affect all patients who are on a "visual contact" observational status.

The hospital's Administrator (S1) was notified of the Immediate Jeopardy Situation on 5/28/10 at 3:00 p.m. S1 verbalized understanding and indicated that the hospital's leadership team would immediately formulate and implement a corrective action plan to ensure that patients hospitalized in the psychiatric hospital were monitored/supervised in accordance with hospital approved policies/procedures and with the orders of the attending psychiatrist/practitioner. The corrective action plan included documentation indicating that the hospital would implement a system that utilizes levels of observation for patients to determine patient acuity & required staffing needs and to provide for patient care assignments. The corrective action plan indicated that training in relation to this system that utilizes levels of observation for patients to determine patient acuity & required staffing needs and to provide for patient care assignments including the definitions of the observational levels has been provided to all registered nurses who have worked on the nursing units since the date and time of the identified Immediate Jeopardy situation and that ongoing training will continue with regard to this requirement.

The Immediate Jeopardy Situation was lifted on 6/01/10 at 1:50 p.m., which was prior to the completion of this survey. The Condition of Participation relative to Nursing Services was no longer out of compliance once the Immediate Jeopardy Situation was resolved.

Based on record review and interview, the hospital failed to ensure that nursing services were being provided in a safe and effective manner by failing to provide nursing staff to ensure that the needs of patients hospitalized on the acute care psychiatric unit were met based on ongoing assessments of the patient's needs and the orders of the attending psychiatrist/practitioner as evidenced by two female patients ordered to be on visual contact being found in male rooms one of which also had orders for visual contact (#7, #9, #10). Findings:

Review of the census for Unit A for 04/28/10 revealed a census of 15 patients. Of the 15 patients on Unit A, seven patients had orders for VC (Visual Contact: The patient must be in sight of a staff member at all times); and 15 minute checks documented; five patients had orders for MVC (Modified Visual Contact: The patient is observed within the line of sight of staff during all waking hours); and 3 patients had orders for SO (Special Observation: The patient is observed with visual checks every 30 minutes).

Review of the Nursing Staffing Report for 04/28/10 7a-7p shift for Unit A revealed the following staffing: 1RN, 1LPN, and 2 MHT who were responsible for observing 12 patients at all times.

Review of the "Assignment Sheet" dated 04/28/10 revealed the Mental Health Technicians were responsible for the following: 1. Smoking (accompanying the patient to the smoke area); 2. Unit cleanliness; 3. Room checks; 4. Group exercise times three; 5. Group: Priority and Goals; 6. Group: OT/RT; 7. Group: Nursing; 8. Group: Life skills; 9. Group: Community; 10. Group: Current Events; 11. Group: Wrap-Up; 12. Performing EKGs; 13. Meals; 14. Admits (paperwork, faxes, etc); 15. Discharge (paperwork completed including patient satisfaction survey); 16. Delinquent: assessments; 17. Weekend recreation; 18. Vital signs; 19. Location graph; 20. Sharps; 21. Transportation; 22. Make up chart packets; 23. Stuff charts; 24. Trash; 25. Dirty linen; 26. Refrigerator; 27. Patient hygiene; 28. Diet/snack sheet; and 29. Order supplies.

Patient #7
Review of the medical record for Patient #7 revealed she had been admitted to the hospital (Unit A) on 03/01/10 for schizophrenia and suicidal ideation after having sex with a man she met over the internet and a fight with her boyfriend. Review of the Physicians' Orders dated/timed 03/01/10 at 0010 (12:10am) revealed patient #7 was placed on suicide precautions and seizure precautions due to a history of epilepsy.

Review of Policy # NU.432 titled "Levels of Observation - Therapeutic Safety Measures" effective date of 09/01/03 and submitted by the hospital as the one currently in use revealed ... " 2. d. The following precautions must have a V.C. (Visual Contact) status ordered: Suicide precautions ... " .

Review of the Observation Log for Patient #7 dated 03/01/10 revealed she was on visual precautions which meant that #7 should have been in the line of sight of the staff at all times. Further review revealed the following observations: 2:00pm-3:15pm (Group); and 3:30pm-4:15pm (Dayroom); however the Daily Nursing Notes revealed an entry which indicated Patient #7 had been found in Patient #8's room on 03/01/10 at 1520 (3:20pm).


Patient #9
Review of the medical record for Patient #9 revealed she had been admitted to the hospital on 04/27/10 with the diagnosis of mood disorder and Asperger ' s Disorder. Review of the Physician's Admit Orders and Treatment Plan dated/timed 04/27/10 at 2025 (8:25pm) revealed an order for "Modified VC (Visual Contact) due to psychosis".

Review of Policy # NU.432 titled "Levels of Observation - Therapeutic Safety Measures" effective 09/01/03 and submitted by the hospital as the one currently in use revealed ... "4. Modified Visual Contact (M.V.C.) a. The patient is observed within the line of sight of staff during all waking hours, with documentation on location graph every 15 minutes. b. The patient is allowed to sleep in his/her room at night with door ajar. Staff checks patient every 15 minutes and documents checks on location graph".

Review of the Daily Interdisciplinary Group Notes dated 04/28/10 at 10:30 (am/pm not documented) revealed patient displays poor boundaries with others, wants intimacy with male peer. Further review of the medical record revealed no documented evidence the display of poor boundaries had been communicated to any other member of the health care team.

Review of the Daily Nursing Documentation dated 04/28/10 at 1430 (2:30pm) for Patient #9 revealed ... "Pt (Patient) is anxious, hyper-verbal pacing on unit. Pt. also with hypersexual behavior. Reminded to maintain distance from males" . Further review revealed a late entry made on 04/30/10 at 1800 (6:00pm) for 04/28/10 at 11:30 (no documentation of am or pm) revealed Patient #9 was being observed due to possible physical contact because she had been found in a male s room. Review of the nursing entry for 04/29/10 at 1600 (4:00pm) revealed no documented evidence of any reported sexual behavior observed by Patient #9. Review of the nursing entry for 04/30/10 at 1100 (am or pm not documented) indicated the patient had been out of her room for most of the morning and required limit setting due to sexual behaviors of sticking her tongue out at males and not wearing a bra. According to the notes acceptable and unacceptable behavior had been discussed with the patient and an order was obtained to transfer Patient #9 to Unit B.

Review of the Observation Log for Patient #9 dated 04/28/10 revealed the precautions as VC (visual contact) which meant she was to be in the line of sight of a staff member at all times. Further review revealed Patient #9 was observed and documented as having been in the dayroom (DR) from 06:45am through 11:45am, outside for a walk from 12:01pm through 12:15pm, eating in the cafeteria from 12:30pm through 12:45pm and then back to the dayroom until 1:30pm. According to the observation log Patient #9 was in her room from 1:45pm through 2:00pm with the next documentation at 2:15pm which revealed Patient #9 was in the dayroom.

Patient #10
Review of the medical record for Patient #10 dated 04/27/10 revealed he had been admitted to the hospital with the diagnosis of bipolar disorder. Review of the Physicians' Admit Orders dated/timed 04/27/10 at 12:50pm revealed an order for visual contact due to a history of violence.

Review of Policy # NU.432 titled "Levels of Observation - Therapeutic Safety Measures" Effective date 09/01/03 and submitted as the one currently in use revealed ... "Visual Contact (V.C.) a. The patient must be in sight of a staff member at all times and 15 minute checks documented".

Review of the Daily Nursing Documentation dated/timed 04/38/10 at 1540 (3:40pm) for Patient #10 revealed he had to be reminded to keep a distance from a female peer. Further review revealed a late entry dated 04/30/10 1800 (6:00pm) for 04/28/10 which revealed Patient #10 had been found in a female patient's room (Patient #9) and that he was told to keep his distance and not invade another patient's private space.

Review of the Daily Interdisciplinary Group Notes dated 04/28/10 at 1130 (am/pm not documented) revealed patient #10 while on a nature walk had to be re-directed as to appropriate boundaries with a female patient. Further review of the medical record revealed no documented evidence this information had been communicated to any other member of the health care team.

Review of the Observation Log dated 04/28/10 for Patient #10 revealed the precautions VC (visual contact) which meant he was to be in the line of sight of a staff member at all times. Further review revealed Patient #10 was observed and documented as having been in his room (PR) from 10:00am through 11:30am. Review of the group notes dated 04/28/10 at 10:30am revealed Patient #10 was attending group with social services and that he was restless and anxious.

In a telephone interview on 06/01/10 at 10:50am with S15, the RN on duty at the time Patient #9 was found in the room of male Patient #10 when both were on visual contact indicated she has been a certified psychiatric nurse for 12 years with 15 years of experience. S15 indicated that all patients are placed on visual contact when they are first admitted to the hospital, Unit A, because it is considered a more acute unit. Further S15 indicated afterwards the patients are put on modified visual contact which means they don ' t have to be in the line of sight when they are sleeping. S15 indicated on April 28th Patient #9 and Patient #10 were sitting in the dayroom and she had been at the desk in the nurses ' station when the MHT (Mental Health Tech) came to find her to tell her that Patient #9 and #10 were gone. Further she indicated integrated units (men and women) are always a challenge especially since like in the case of Patient #9 and #10 neither of these patients appeared to be violent and were at the time she had observed them, were just talking. After the incident, S15 indicated she instructed the MHT to remain in the dayroom to monitor the patients. When asked how two patients who were on visual contact and who should have been in the constant sight of a staff member could wind up alone together in a bedroom, S15 could not answer other than to say the hospital tries to ensure the safety of all patients, but situations change.

The registered nurse working on Unit B (S17) as the unit charge nurse was interviewed on 5/28/10 at 11:00 a.m. S17 reported that the patient census for Unit B was fourteen (14) patients. S17 indicated that she (S17) was working as the Unit B registered nurse and reported that the unit staffing currently (5/28/10 at 11:00 a.m.) consisted of four (4) staff members including her as the unit registered nurse (1-Registered Nurse, 1-Licensed Practical Nurse, 2-Mental Health Technicians). S17 reported that eleven (11) of the fourteen (14) patients were ordered to be on a "Visual Contact" observational status. S17 reported that patients placed on a "Visual Contact" observational status are to be within sight of a staff member at all times. S17 reported that her duties as the unit charge nurse and the unit registered nurse include assessing patients, making patient care assignments, charting, completing patient admissions, completing patient discharges, assisting the physicians and/or practitioners as needed, and responding to questions or concerns presented by various treatment team members. S17 reported that the unit registered nurse is usually not assigned to perform "Visual Contact" duties as the registered nurses have other assignments as documented above. S17 reported that the unit licensed practical nurse is usually not assigned to perform "Visual Contact" duties as the licensed practical nurse spends a large portion of time with the medication administration process. S17 reported that the mental health technicians are primarily responsible for ensuring that patients who are on a "Visual Contact" observational status remain within sight of a staff member at all times. When asked if two (2) mental health technicians could meet the needs of fourteen (14) psychiatric patients and ensure that eleven (11) psychiatric patients remain within sight of a staff member at all times, S17 reported that they could not. S17 reported that there are times when patient's assigned to be on a "Visual Contact" observational status are not within sight of a staff member. S17 reported that the unit is not staffed to ensure that all patients assigned to be on "Visual Contact" observational status remain within sight of a staff member at all times. S17 stated "we do what we can with the staff we have". S17 stated "there are times when patients go in different directions on the psychiatric unit with some being in the dayroom, some in the bathroom and some going to their patient room. When asked how does the hospital determine the number of staff members needed to ensure that the patient care needs are being met, S17 reported that with the exception of patients placed on a 1:1 status, decisions relating to staffing are determined by patient census alone. S17 indicated that the hospital does not take into account the acuity level or observational level of patients hospitalized on the psychiatric unit in order to determine what the staffing needs will be. S17 reported that the charge nurses have been completing a daily staffing sheet which indicates the acuity level of patients but stated that she has not seen any adjustments to staffing based on the completion of the daily staffing sheet. S17 explained that the core staffing usually consist of four staff members and rarely changes regardless of how many patients are on a "Visual Contact" observational status.

The registered nurse working on Unit A (S18) as the unit charge nurse was interviewed on 5/28/10 at 12:30 p.m. S18 reported that the patient census for Unit A was fourteen (14) patients. S18 indicated that she (S18) was working as the Unit A registered nurse and reported that the unit staffing currently (5/28/10 at 12:30 p.m.) consisted of five (5) staff members including her as the unit registered nurse (1-Registered Nurse, 1-Licensed Practical Nurse, 3-Mental Health Technicians). S18 reported that one (1) of the fourteen patients was ordered to be on a 1:1 status and eleven (11) of the fourteen (14) patients were ordered to be on a "Visual Contact" observational status. S18 reported that a 1:1 status is when a staff member's only assignment is to monitor the patient on the 1:1 status. S18 reported that patients placed on a "Visual Contact" observational status are to be within sight of a staff member at all times. S18 confirmed that the mental health technicians are primarily responsible for ensuring that patients who are on a "Visual Contact" observational status remain within sight of a staff member at all times due to the registered nurse and the licensed practical nurse having additional assignments and duties as reported by S17. When asked if two (2) mental heath technicians could meet the needs of fourteen (14) psychiatric patients and ensure that eleven (11) psychiatric patients remain within sight of a staff member at all times, S18 reported that they could not. S18 confirmed that there are times when patient's assigned to be on a "Visual Contact" observational status are not within sight of a staff member. S18 confirmed that the unit is not staffed to ensure that all patients assigned to be on "Visual Contact" observational status remain within sight of a staff member at all times. When asked how does the hospital determine the number of staff members needed to ensure that the patient care needs are being met, S18 confirmed that with the exception of patients placed on a 1:1 status, decisions relating to staffing are determined by patient census alone. S18 confirmed that the hospital does not take into account the acuity level of patients hospitalized on the psychiatric unit in order to determine what the staffing needs will be.

The DON (Director of Nursing) was interviewed on 5/28/10 at 12:50 p.m. The DON reported that she does not feel that the psychiatric units are always staffed based on the acuity level or the needs of patients hospitalized on the unit. The DON confirmed that there have been and still are times when there are not enough staff members on the psychiatric unit to ensure that all patients ordered to be on a "Visual Contact" observational status remain in the line of sight of a staff member at all times as ordered. The DON reported that adjustments are made in the staffing levels based on 1:1 status patients but not based on the number of patients ordered to be within visual contact at all times. The DON reported that she has informed the hospital Administrator of the need to adjust staffing based on the acuity level and needs of the patients on the unit, but reported that she has not been told that she could add additional staff to account for the number of patients ordered to be on a visual contact observational status. The DON reported that she could provide no documented evidence to identify the time and content of information discussed in regards to adjusting staffing to meet the needs of the patients.

The Medical Director (Psychiatrist) was interviewed on 5/27/10 at 2:40 p.m. The Medical Director reported that he has had and continues to have concerns about the lack of staffing on the psychiatric units. The Medical Director indicated that he does not feel that the staffing level is adequate to meet the needs of the patients at times when the patient acuity level is high. The Medical Director reported that he has brought this concern to the Administrator in the past but was basically told that there was enough staff on the units provided that every staff member did what was expected of them. The Medical Director reported that he did not push this issue with the Administrator and did not have any documentation to indicate the time and content of the conversation.

Based on record review and interview the registered nurse failed to ensure patients on the hospitalized on the locked acute psychiatric unit with orders for visual contact and modified visual contact were kept in the line of sight at all times as evidenced by female patients with orders to be kept in the line of sight at all times being found in males rooms one of whom had also been ordered to be in the line of sight at all times (#7, #9, #10) for 3 of 13 patients on visual or modified visual contact out of a census of 18 patients on Unit A (Acute Care). Findings:

Patient #7
Review of the medical record for Patient #7 revealed she had been admitted to the hospital (Unit A) on 03/01/10 for schizophrenia and suicidal ideation after having sex with a man she met over the internet and a fight with her boyfriend. Review of the Physicians' Orders dated/timed 03/01/10 at 0010 (12:10am) revealed patient #7 was placed on suicide precautions and seizure precautions due to a history of epilepsy.

Review of Policy # NU.432 titled "Levels of Observation - Therapeutic Safety Measures" effective date of 09/01/03 and submitted by the hospital as the one currently in use revealed ... " 2. d. The following precautions must have a V.C. (Visual Contact) status ordered: Suicide precautions ... " .

Review of the Observation Log for Patient #7 dated 03/01/10 revealed she was on visual precautions which meant that #7 should have been in the line of sight of the staff at all times. Further review revealed the following observations: 2:00pm-3:15pm (Group); and 3:30pm-4:15pm (Dayroom); however the Daily Nursing Notes revealed an entry which indicated Patient #7 had been found in Patient #8's room on 03/01/10 at 1520 (3:20pm).


Patient #9
Review of the medical record for Patient #9 revealed she had been admitted to the hospital on 04/27/10 with the diagnosis of mood disorder and Asperger ' s Disorder. Review of the Physician's Admit Orders and Treatment Plan dated/timed 04/27/10 at 2025 (8:25pm) revealed an order for "Modified VC (Visual Contact) due to psychosis".

Review of Policy # NU.432 titled "Levels of Observation - Therapeutic Safety Measures" effective 09/01/03 and submitted by the hospital as the one currently in use revealed ... "4. Modified Visual Contact (M.V.C.) a. The patient is observed within the line of sight of staff during all waking hours, with documentation on location graph every 15 minutes. b. The patient is allowed to sleep in his/her room at night with door ajar. Staff checks patient every 15 minutes and documents checks on location graph".

Review of the Daily Interdisciplinary Group Notes dated 04/28/10 at 10:30 (am/pm not documented) revealed patient displays poor boundaries with others, wants intimacy with male peer. Further review of the medical record revealed no documented evidence the display of poor boundaries had been communicated to any other member of the health care team.

Review of the Daily Nursing Documentation dated 04/28/10 at 1430 (2:30pm) for Patient #9 revealed ... "Pt (Patient) is anxious, hyper-verbal pacing on unit. Pt. also with hypersexual behavior. Reminded to maintain distance from males" . Further review revealed a late entry made on 04/30/10 at 1800 (6:00pm) for 04/28/10 at 11:30 (no documentation of am or pm) revealed Patient #9 was being observed due to possible physical contact because she had been found in a male s room. Review of the nursing entry for 04/29/10 at 1600 (4:00pm) revealed no documented evidence of any reported sexual behavior observed by Patient #9. Review of the nursing entry for 04/30/10 at 1100 (am or pm not documented) indicated the patient had been out of her room for most of the morning and required limit setting due to sexual behaviors of sticking her tongue out at males and not wearing a bra. According to the notes acceptable and unacceptable behavior had been discussed with the patient and an order was obtained to transfer Patient #9 to Unit B.

Review of the Observation Log for Patient #9 dated 04/28/10 revealed the precautions as VC (visual contact) which meant she was to be in the line of sight of a staff member at all times. Further review revealed Patient #9 was observed and documented as having been in the dayroom (DR) from 06:45am through 11:45am, outside for a walk from 12:01pm through 12:15pm, eating in the cafeteria from 12:30pm through 12:45pm and then back to the dayroom until 1:30pm. According to the observation log Patient #9 was in her room from 1:45pm through 2:00pm with the next documentation at 2:15pm which revealed Patient #9 was in the dayroom.

Patient #10
Review of the medical record for Patient #10 dated 04/27/10 revealed he had been admitted to the hospital with the diagnosis of bipolar disorder. Review of the Physicians' Admit Orders dated/timed 04/27/10 at 12:50pm revealed an order for visual contact due to a history of violence.

Review of Policy # NU.432 titled "Levels of Observation - Therapeutic Safety Measures" Effective date 09/01/03 and submitted as the one currently in use revealed ... "Visual Contact (V.C.) a. The patient must be in sight of a staff member at all times and 15 minute checks documented".

Review of the Daily Nursing Documentation dated/timed 04/38/10 at 1540 (3:40pm) for Patient #10 revealed he had to be reminded to keep a distance from a female peer. Further review revealed a late entry dated 04/30/10 1800 (6:00pm) for 04/28/10 which revealed Patient #10 had been found in a female patient ' s room (Patient #9) and that he was told to keep his distance and not invade another patient's private space.

Review of the Daily Interdisciplinary Group Notes dated 04/28/10 at 1130 (am/pm not documented) revealed patient #10 while on a nature walk had to be re-directed as to appropriate boundaries with a female patient. Further review of the medical record revealed no documented evidence this information had been communicated to any other member of the health care team.

Review of the Observation Log dated 04/28/10 for Patient #10 revealed the precautions VC (visual contact) which meant he was to be in the line of sight of a staff member at all times. Further review revealed Patient #10 was observed and documented as having been in his room (PR) from 10:00am through 11:30am (Review of the group notes dated 04/28/10 at 10:30am revealed Patient #10 was attending group with social services and that he was restless and anxious.), outside for a walk from 11:45am through 12:15pm, eating in the cafeteria from 12:30pm through 1:00pm and then on smoke break from 1:15pm through 1:30pm. According to the observation log Patient #10 was in his room from 1:45pm through 2:30pm with the next documentation at 2:30pm which revealed Patient #10 was in the group room.

In a telephone interview on 06/01/10 at 10:50am with S15, the RN on duty at the time Patient #9 was found in the room of male Patient #10 when both were on visual contact indicated she has been a certified psychiatric nurse for 12 years with 15 years of experience. S15 indicated that all patients are placed on visual contact when they are first admitted to the hospital, Unit A, because it is considered a more acute unit. Further S15 indicated afterwards the patients are put on modified visual contact which means they don ' t have to be in the line of sight when they are sleeping. S15 indicated on April 28th Patient #9 and Patient #10 were sitting in the dayroom and she had been at the desk in the nurses ' station when the MHT (Mental Health Tech) came to find her to tell her that Patient #9 and #10 were gone. Further she indicated integrated units (men and women) are always a challenge especially since like in the case of Patient #9 and #10 neither of these patients appeared to be violent and were at the time she had observed them, were just talking. After the incident, S15 indicated she instructed the MHT to remain in the dayroom to monitor the patients. When asked how two patients who were on visual contact and who should have been in the constant sight of a staff member could wind up alone together in a bedroom, S15 could not answer other than to say the hospital tries to ensure the safety of all patients, but situations change.

Based on record review and interview the hospital failed to revise treatment plans for patients who repeatedly refused to attend group therapy and offer an alternative for 4 of 13 sampled records and for a patient who was frequently having to re-directed by staff for touching other patients (Patient #3) for 1 of 1 patients with the problem of touching others of 13 sampled records. Findings:

Patient #1
Review of the medical record for Patient #1 revealed she had been admitted to the hospital on 05/08/10 for passive suicidal ideation. Review of the treatment plan dated 05/08/10 revealed patient #1 would be encouraged group attendance five times per week and engage in activities/exercise a minimum of five times per week. Review of the Social Service Group Notes dated 05/10/10 and 05/11/10 revealed no documented evidence she had attended the group sessions.

In a face to face interview on 05/26/10 at 4:00pm S5 LPC indicated she was sure that group had been held that day. Further S5 indicated she did not know whether or not Patient #1 had attended group on 05/10/10 and 05/11/10. S5 indicated either way something should have been documented to let the team know whether or not she (Patient #1) was there.

Patient #4
Review of the medical record for Patient #4 revealed she had been admitted to the hospital on 03/15/10 with the diagnoses of obsessive compulsive disorder, bipolar disorder with psychosis and dependent personality disorder. Review of the treatment plan dated 03/15/20 revealed Patient #4 would be encouraged group attendance five times per week and engage in activities/exercise a minimum of five times per week, patient will complete assigned goals in group to address increased anger, poor sleep, visual hallucinations, medication compliance and adjustments.

Review of the Daily Interdisciplinary Group Notes dated 03/15/10 through 03/26/10 (day of admit through day of discharge) revealed Patient #4 was scheduled to attend the following groups: Social Service, Nursing, Wrap-Up and Activities. Further review of the Group Notes revealed Patient #4 attended 10 out of the 41 scheduled groups during his hospitalization (representing 2% attendance).

Review of the Interdisciplinary Treatment Plans, Clinical Progress Notes, and Physician Progress Notes dated 03/15/10 through 03/26/10 for Patient #4 revealed no documented evidence her lack of participation in group therapy and non-compliance in her treatment plan had been identified as a problem or her treatment plan revised.

Patient # 6
Review of the medical record for Patient #6 revealed he had been admitted to the hospital on 05/14/10 with the diagnosis of schizo-effective disorder. Review of the treatment plan dated 05/14/10 revealed Patient #6 would be encouraged group attendance five times per week and engage in activities/exercise a minimum of five times per week.

Review of the Daily Interdisciplinary Group Notes dated 05/15/10 through 05/23/10 revealed Patient #6 was scheduled to attend the following groups: Social Service, Nursing, Wrap-Up and Activities. Further review of the Group Notes revealed Patient #6 missed 11of the 44 scheduled activity groups during his ongoing hospitalization.

Review of the Interdisciplinary Treatment Plans, Clinical Progress Notes, and Physician Progress Notes dated 05/14/10 through 05/23/10 for Patient #6 revealed no documented evidence his lack of participation in group activity therapy and non-compliance in his treatment plan had been identified as a problem or his treatment plan revised.

Patient #8
Review of the medical record for Patient #8 revealed he had been admitted to the hospital on 02/21/10 with the diagnoses of schizophrenia, depression and suicidal ideation. Review of the treatment plan dated 02/23/20 revealed Patient #8 would be encouraged group attendance five times per week and engage in activities/exercise a minimum of five times per week, patient will complete assigned goals in group to address ineffective coping for suicidal ideations.

Review of the Daily Interdisciplinary Group Notes dated 02/21/10 through 03/03/10 (day of admit through day of discharge) revealed Patient #8 was scheduled to attend the following groups: Social Service, Nursing, Wrap-Up and Activities. Further review of the Group Notes revealed Patient #8 attended 26 out of the 41 scheduled groups during his hospitalization (representing 56% attendance).

Review of the Interdisciplinary Treatment Plans, Clinical Progress Notes, and Physician Progress Notes dated 02/21/10 through 03/03/10 for Patient #8 revealed no documented evidence his lack of participation in group therapy and non-compliance in his treatment plan had been identified as a problem or his treatment plan revised.

Review of the medical record for Patient #13 revealed she had been admitted to the hospital on 01/04/10 with the diagnoses of bipolar disorder with psychosis and mental retardation. Review of the treatment plan revealed dated 01/05/10 revealed Patient #13 would be encouraged group attendance five times per week and engage in activities/exercise a minimum of five times per week, patient will complete assigned goals in group to address re-orientation and medication compliance.

Review of the Daily Interdisciplinary Group Notes dated 01/05/10 through 01/18/10 (day of admit through day of discharge) revealed Patient #13 was scheduled to attend the following groups: Social Service, Nursing, Wrap-Up and Activities. Further review of the Group Notes revealed Patient #13 attended 45 out of the 64 scheduled groups during his hospitalization (representing 70% attendance).

Review of the Interdisciplinary Treatment Plans, Clinical Progress Notes, and Physician Progress Notes dated 01/05/10 through 01/18/10 for Patient #13 revealed no documented evidence his lack of participation in group therapy and non-compliance in his treatment plan had been identified as a problem or his treatment plan revised.

In a face to face interview on 05/27/10 at 3:00pm S2 DON and S3 Director of Social Services indicated alternatives are given to those patients who frequently do not attend group therapy; however both verified this is not documented in the treatment plan not is there evidence of this being discussed in the weekly treatment plan meetings.


Patient #3
Review of the medical record for Patient #3 revealed she had been admitted to the hospital on 05/03/10 with Bipolar disorder, Suicidal Ideations with a Plan, and mental retardation. Review of Patient #3 ' s Treatment Plan revealed problems identified as ineffective coping and risk for self-directed violence.

Review of the Group Notes for Patient #3 revealed the following: 05/09/10 at 1400 (2:00pm) Activity Group - " Still have to remind pt. (patient) about touching others " . 05/10/10 at 11:30am Nursing Group - " having to remind her not to touch others " .

Review of the Treatment Plan dated 05/03/10 through 05/15/10 for Patient #3 revealed no documented evidence the treatment plan had been updated to reflect to update problems with touching other patients.

In a face to face interview on 05/27/10 at 9:05am S21 Mental Health Technician indicated Patient #3 is constantly touching other and has to be re-directed frequently. S21 indicated she had to re-direct her again this morning and tried to explain to her that this offends people.

In a face to face interview on 05/27/10 at 10:30am S22, LPN, indicate Patient #3 is constantly touching the other patients as well as the staff. Further S22 who has been employed at the hospital for two months and has had no prior mental health experience, indicated she did not document her behavior in her nursing notes and verified it had not been added to Patient #3 ' s treatment plan.

Based on observation, record review and interviews the hospital failed to provide a therapeutic activities program to meet the needs of the patients as evidenced by: 1) failing to have a designated quiet space resulting in patients attending group sessions in the open area of Unit B which included the dayroom, nurses station, television and to which most of the patient rooms on Unit B opened onto; 2) failing to have adequate supplies and organized activities resulting in written complaints from the patients to administration, observation of games with broken pieces, documentation of a written schedule accounting for 3.5 hours of a patient's day for organized and observed activity; and 3) failing to individualize therapeutic activities for those patients who did not attend group activities for 5 of 13 samples patients (#1, #4, #6, #8, #12). Findings:

1) lack of space for a group/activity room
Observation on 05/26/10 at 11:00am of Unit B revealed one long open area called the day room which contained sofas, chairs and a television. Patient rooms were located all around the dayroom and opened directly into the area. The nurses ' station was located at one end of the dayroom and a long table with chairs was located at the other end.


Observation on 05/27/10 at 10:45am of a Social Service Group on Unit B revealed it was conducted in the open area at the end of the dayroom around the big table with 12 patients in attendance. While the Social Worker was trying to engage the clients in discussion the following occurred: nursing staff interrupted to retrieve three patients (not all at the same time) for a physical assessment; housekeeping proceeded to clean the room closest to the group which required opening and closing the door, removing the trash and using the vacuum cleaner which could be clearly heard by the group; one of the clients used the phone in the dayroom using a very loud voice; the staff in the nursing station was talking loud and at times was laughing and some of the clients were noted to have turned their heads to see what was going on; and two female patients continually coming to the table and then getting up to leave the group.

In a face to face interview on 05/27/10 at 3:00pm S2 DON (Director of Nursing), S3 Director of Social Services, and S9 LPC indicated they were in agreement the use of the open space on Unit B was not the most therapeutic milieu to conduct group therapy. S9 indicated there are times when she tries to take the patients outside on the deck for a quiet setting.


2) lack of supplies and organized activities resulting in written complaints from the patients to administration, observation of games with broken pieces, documentation of a written schedule accounting for 3.5 hours of a patient ' s day with organized and observed activity
Review of the letter dated 05/26/10 signed by 15 clients and submitted to administration revealed the following four concerns: 1) They spend the day feeling like zombies and the highlight for them are meals and smoke breaks; 2) Would like to be taught on a daily basis skills needed to cope with the stresses of daily life; 3) A regular schedule of physical or other activities and would love to have music therapy. I addition would like to have more group meetings; and 4) Would like to have more outdoor time and activities because the grounds are so beautiful and it makes people feel better to breathe fresh air.

Observation on 05/26/10 at 11:35am revealed the " Activity Room " was located off both of the locked units in the hallway across from the cafeteria. Further observation revealed a sign which stated it was to be kept locked on the weekends.

On 05/26/10 the survey team requested to meet with a group of cognitively intact patients/clients from both Unit A and B who would be willing to speak with the team. On 05/26/10 at 11:45am the members of the survey team met with five clients (R1, R2, R3, R4, R5) and the social worker S3 from Unit A. In discussion with the clients, they felt they needed more activities to help focus on something positive instead of dwelling on their problems. When asked if they had games to play R3 indicated the games had pieces missing.

On 05/26/10 at 1:45pm the members of the survey team met with (R6, R7, R8, R9, R10, R11, #11) and the social worker S9. In discussion with the clients, Patients R7 and R9 indicated sometimes the staff forgets to come and get them for groups and they are either late or miss the group session.

Review of the Group schedule for the hospital revealed the following scheduled groups where attendance and participation are documented by the appropriate disciplines and the time allotted for each: Social Services (1 hour); Nursing (1 hour); Activities (1 hour); and Wrap-up (30 minutes) which accounts for 3.5 hours of the patients ' day.

In a face to face interview on 05/27/10 at 10:10am RT (Recreational Therapist) S20 verified the games on the units are missing pieces and indicated she had put in a request to administration for supplies and to implement a monthly budget. Further S20 indicated she also has requested a recreational aide to assist her in assessments, therapy and documentation because she is one person for as many as 40 patients. Further on the weekends, the MHT (Mental Health Techs) are expected to provide activities on the unit.


3) failing to individualize therapeutic activities for those patients who do not attend group activities
Patient #1
Review of the medical record for Patient #1 revealed fshe had been admitted to the hospital on 05/08/10 for passive suicidal ideation. Review of the treatment plan dated 05/08/10 revealed patient #1 would be encouraged group attendance five times per week and engage in activities/exercise a minimum of five times per week. Review of the Social Service Group Notes dated 05/10/10 and 05/11/10 revealed no documented evidence she had attended the group sessions.

In a face to face interview on 05/26/10 at 4:00pm S5 LPC indicated she was sure that group had been held that day. Further S5 indicated she did not know whether or not Patient #1 had attended group on 05/10/10 and 05/11/10. S5 indicated either way something should have been documented to let the team know whether or not she (Patient #1) was there.

Patient #4
Review of the medical record for Patient #4 revealed she had been admitted to the hospital on 03/15/10 with the diagnoses of obsessive compulsive disorder, bipolar disorder with psychosis and dependent personality disorder. Review of the treatment plan dated 03/15/20 revealed Patient #4 would be encouraged group attendance five times per week and engage in activities/exercise a minimum of five times per week, patient will complete assigned goals in group to address increased anger, poor sleep, visual hallucinations, medication compliance and adjustments.

Review of the Daily Interdisciplinary Group Notes dated 03/15/10 through 03/26/10 (day of admit through day of discharge) revealed Patient #4 was scheduled to attend the following groups: Social Service, Nursing, Wrap-Up and Activities. Further review of the Group Notes revealed Patient #4 attended 10 out of the 41 scheduled groups during his hospitalization (representing 2% attendance).

Review of the Interdisciplinary Treatment Plans, Clinical Progress Notes, and Physician Progress Notes dated 03/15/10 through 03/26/10 for Patient #4 revealed no documented evidence her lack of participation in group therapy and non-compliance in her treatment plan had been identified as a problem or her treatment plan revised.

Patient # 6
Review of the medical record for Patient #6 revealed he had been admitted to the hospital on 05/14/10 with the diagnosis of schizo-effective disorder. Review of the treatment plan dated 05/14/10 revealed Patient #6 would be encouraged group attendance five times per week and engage in activities/exercise a minimum of five times per week.

Review of the Daily Interdisciplinary Group Notes dated 05/15/10 through 05/23/10 revealed Patient #6 was scheduled to attend the following groups: Social Service, Nursing, Wrap-Up and Activities. Further review of the Group Notes revealed Patient #6 missed 11of the 44 scheduled activity groups during his ongoing hospitalization.

Review of the Interdisciplinary Treatment Plans, Clinical Progress Notes, and Physician Progress Notes dated 05/14/10 through 05/23/10 for Patient #6 revealed no documented evidence his lack of participation in group activity therapy and non-compliance in his treatment plan had been identified as a problem or his treatment plan revised.

Patient # 8
Review of the medical record for Patient #8 revealed he had been admitted to the hospital on 02/21/10 with the diagnoses of schizophrenia, depression and suicidal ideation. Review of the treatment plan dated 02/23/20 revealed Patient #8 would be encouraged group attendance five times per week and engage in activities/exercise a minimum of five times per week, patient will complete assigned goals in group to address ineffective coping for suicidal ideations.

Review of the Daily Interdisciplinary Group Notes dated 02/21/10 through 03/03/10 (day of admit through day of discharge) revealed Patient #8 was scheduled to attend the following groups: Social Service, Nursing, Wrap-Up and Activities. Further review of the Group Notes revealed Patient #8 attended 26 out of the 41 scheduled groups during his hospitalization (representing 56% attendance).

Review of the Interdisciplinary Treatment Plans, Clinical Progress Notes, and Physician Progress Notes dated 02/21/10 through 03/03/10 for Patient #8 revealed no documented evidence his lack of participation in group therapy and non-compliance in his treatment plan had been identified as a problem or his treatment plan revised.


Patient #13
Review of the medical record for Patient #13 revealed she had been admitted to the hospital on 01/04/10 with the diagnoses of bipolar disorder with psychosis and mental retardation. Review of the treatment plan revealed dated 01/05/10 revealed Patient #13 would be encouraged group attendance five times per week and engage in activities/exercise a minimum of five times per week, patient will complete assigned goals in group to address re-orientation and medication compliance.

Review of the Daily Interdisciplinary Group Notes dated 01/05/10 through 01/18/10 (day of admit through day of discharge) revealed Patient #13 was scheduled to attend the following groups: Social Service, Nursing, Wrap-Up and Activities. Further review of the Group Notes revealed Patient #13 attended 45 out of the 64 scheduled groups during his hospitalization (representing 70% attendance).

Review of the Interdisciplinary Treatment Plans, Clinical Progress Notes, and Physician Progress Notes dated 01/05/10 through 01/18/10 for Patient #13 revealed no documented evidence his lack of participation in group therapy and non-compliance in his treatment plan had been identified as a problem or his treatment plan revised.

In a face to face interview on 05/27/10 at 3:00pm S2 DON and S3 Director of Social Services indicated alternatives are given to those patients who frequently do not attend group therapy; however both verified this is not documented in the treatment plan not is there evidence of this being discussed in the weekly treatment plan meetings.