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Based on medical record review and staff interview, it was determined that for 8 of 8 active sample patients (A1, A6, A12, A17, B2, B6, B10, and B15), the Master Treatment Plans lacked individualized short term goals, lacked individualized treatment interventions and lacked identification of responsible treatment team members. These failures result in Treatment Plans that lack a method to determine if progress is occurring and if interventions need to be changed as well as which staff member is to be held accountable.

Findings are:

1. Inappropriate Short Term Goals: For details, see B121.

2. Interventions written in generic, discipline specific tasks: For details, see B122.

3. Failure to identify responsible treatment team members: For details, see B123.

Based on medical record review and staff interviews, it was determined that the Master Treatment Plans for 8 of 8 active sample patients (A1, A6, A12, A17, B2, B6, B10 and B15) lacked short term goals, stated in observable, measurable or behavioral terms. These failures results in an inability to determine if and when established goals are achieved.

Findings are:

A. Record Review:

1. Goals of patients stated as staff oriented tasks:

In all 8 active sample patient's Master Treatment Plans, the short-term goal on the preprinted MTP form was identical for all patients, regardless of the various problems identified, and was associated with routine patient care. The "Short term Goal" for all patients read "Patient will provide data to assist in formulation of substantiated diagnosis and master treatment plan." Dates of the MTPs were: A1=11/22/09; A6=2/04/10; A12=2/6/10; A17=2/5/10; B2=1/28/10; B6=1/30/10; B10=12/19/10; B15=2/4/10).

2. Goals written as already accomplished:

a. Patient A12: The Master Treatment Plan (dated 2/6/10) included under "Short Term Goals" the following statements "Worker contacted family for collateral information for treatment and discharge planning," "Worker educated pt.(patient) on the importance of taking psychiatric Rx(medications) as prescribed," and "Patient was educated by worker on these community-based resources..." These were staff interventions, not patient goals.

b. Patient A17: The Master Treatment Plan (dated 2/5/10) stated for "Short Term Goals" "worker educated pt. on the importance of taking Rx as prescribed ...," "Patient participated in the development of treatment & discharge plans," and "Worker educated pt. on the following community-based resources..." These goals were staff goals (for patient participation in treatment) or were staff interventions that were already accomplished, not patient goals.

3. Goals preprinted and applied uniformly to the various identified problems for all 8 patients:

Problem 1- "Patient will identify short term treatment goals and discharge goal."
Problem 2- "Patient will remain safe and free from harm...Client will not hurt others."
Problem 3- "Client and caregivers will be educated in the Use [sic] of medications and the need to report [sic] any reactions to staff."
Problem 4- "Client will verbalize any concerns regarding discharge and develop skills to address the issues."

B. Staff Interviews:

1. On 2/8/2010 at 2:05 p.m., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were interviewed about the formulation of the Master Treatment Plans. They described themselves as having developed the format for the plans. They agreed with the findings described in Section I above.

2. On 2/10/2010 at 9:30 a.m., the Clinical Director of Medical Records/Director of Social Services was interviewed. She agreed that the short term goals on the preprinted forms were identical. She also agreed that the short term goals for Patient A17 had been written in the past tense, thus already accomplished.

Based on record review and interview, the facility failed to describe the specific focus of treatment for preprinted modalities listed on the treatment plans in 8 of 8 sample records (A1, A6, A12, A17, B2, B6, B10 and B15). This failure to document specific treatment approaches interferes with the assurance of consistency of approach to each patient's problems and may result in prolonged hospitalization for patients.

Findings:

A: Record Review:

1. Patient A1 (treatment plan dated 1/21/09 [sic]. The preprinted short term goal was "Patient will develop life management skills applicable to their situation." Preprinted interventions listed under the Topic Groups heading included: "Coping skills, Communication, Health Management, Stress Management and Substance Abuse." Additionally, under the Task Groups heading preprinted interventions included "Exercise, Leisure Skill Development, Looking Good and Life Skills Activity."

2. Patient A6 (2/1) the preprinted short term goal is "Patient will develop life management skills applicable to their situation." Preprinted interventions listed under the Topic Groups heading: "Coping skills, Communication, Health Management, Financial Management, Emotion Management and Stress Management." Additionally, under the Task Groups heading preprinted interventions include "Exercise, Leisure Skill Development, Looking Good and ADLS/Life Skills Activity."

3. Patient A12 (2/5/10) the preprinted short term goal is "Patient will develop life management skills applicable to their situation." Preprinted interventions listed under the Topic Groups heading: "Coping skills, Communication, Health Management, Financial Management, Emotion Management and Stress Management." Additionally, under the Task Groups heading preprinted interventions include "Exercise, Leisure Skill Development, Looking Good and ADLS. Activity."

4. Patient A17 (2/4/10) the preprinted short term goal is "Patient will develop life management skills applicable to their situation." Preprinted interventions listed under the Topic Groups heading: "Coping skills, Communication, Health Management, Financial Management, Emotion Management and Stress Management." Additionally, under the Task Groups heading preprinted interventions include "Exercise, Leisure Skill Development, Looking Good and ADLS/Life Skills."

5. Patient B2 (1/25) the preprinted short term goal is "Patient will develop life management skills applicable to their situation." Preprinted interventions listed under the Topic Groups heading: "Coping skills, Communication, Health Management, Financial Management, Emotion Management and Stress Management." Additionally, under the Task Groups heading preprinted interventions include "Exercise, Leisure Skill Development, Looking Good and ADLS/Life Skills Activity."

6. Patient B6 (1/27/10) the preprinted short term goal is "Patient will develop life management skills applicable to their situation." Preprinted interventions listed under the Topic Groups heading: "Coping skills, Communication, Health Management, Financial Management, Emotion Management and Stress Management." Additionally, under the Task Groups heading preprinted interventions include "Exercise, Leisure Skill Development, Looking Good and ADLS/Life Skills Activity."

7. Patient B10 (12/16/09) the preprinted short term goal is "Patient will develop life management skills applicable to their situation." Preprinted interventions listed under the Topic Groups heading: "Coping skills, Communication, Health Management, Financial Management, Emotion Management Stress Management and Substance Abuse." Additionally, under the Task Groups heading preprinted interventions include "Exercise, Leisure Skill Development, Looking Good and Life Skills Activity."

8. Patient B15 (2/3/10) the preprinted short term goal is "Patient will develop life management skills applicable to their situation." Preprinted interventions listed under the Topic Groups heading: "Coping skills, Communication, Health Management, Financial Management, Emotion Management and Stress Management." Additionally, under the Task Groups heading preprinted interventions include "Exercise, Leisure Skill Development, Looking Good and ADLS/Life Skills."

B. Interview:

In a joint interview conducted on 2/10/10 at 10 a.m., the DON and the ADON acknowledged the treatment modalities were non specific.

Based on record review and interview, it was determined the hospital failed to ensure that staff members responsible for treatment modalities were specifically identified by name for 8 of 8 sample patients (A1, A6, A12, A17, B2, B6, B10 and B15). This results in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings are:

A. Record Review:

For all 8 sample patients, under the "responsible staff " column of the Master Treatment Plans, only generic terms were utilized. Terms for responsible staff included, "Dr, Nurse, MHT, AT Staff, SW, and All Staff." The actual names of staff members responsible for specific interventions were not present.

B. Interview
During a joint interview on 2/10/10 at 10:00 a.m., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) both acknowledged that responsible staff was identified by discipline, not by name.

Based on medical record review and staff interview, it was determined that the Medical Director failed to monitor and ensure the quality of Master Treatment Plans for content. He, also, failed to ensure that when deaths occurred, a Mortality/Morbidity conference or a peer review process was conducted or that a Root Cause Analysis was conducted and submitted to the Joint Commission for Hospital Accreditation. These failures result in a lack of opportunity for medical staff to potentially learn or to identify if any preventable events were present.

Findings are:

I. Master Treatment Plans failed to contain appropriate goals, describe individualized treatment modalities, or identify responsible staff. (See B118, B121, B122, and B123 for details)

II. Failure to conduct medical staff peer review activities associated with patient deaths.

Findings are:

1. In an interview on 2/9/10 at 8:45 a.m., the Medical Director acknowledged that a Mortality/Morbidity conference does not occur, and that there is no agenda item at the regularly scheduled Medical or Executive Medical meetings, or an ad hoc peer review process focused on deaths. The Medical Director reported that no documented Root Cause Analysis focused on any of the 7 deaths that have occurred at the facility or within one week of discharge had been submitted to the Joint Commission for Hospital Accreditation since December 2005.

On 2/10/10 at 10:15 a.m., the facility's C.E.O. [Chief Executive Officer] acknowledged to the surveyor that none of the deaths had been reported to the Joint Commission for Hospital Accreditation.

Based on record review and interview, it was determined the Director of Nursing failed to monitor the inclusion of the names of nursing personnel responsible for specific nursing interventions.

Findings are:

A. Record Review

Review of the Master Treatment Plans for all 8 of 8 sample patients (A1, A6, A12, A17, B2, B6, B10 and B15) revealed that responsible nursing staff was not identified by name on any of the treatment plans (See B123)

B. Interview

In a discussion of treatment plans with the DON and the ADON on 2/10/10 at approximately 10:00 a.m., the DON and the ADON both acknowledged that responsible nursing staff was not specified by name on the sample patient's MTPs.