HospitalInspections.org

Based on the seclusion and restraint policy and procedure and staff interviews the hospital procedure of downgrading or trial release allows the staff to discontinue a restraint or seclusion intervention, and then re-start it under the same order. This would constitute a PRN use of restraint or seclusion, and therefore is not permitted under this regulation.

The hospital restraint and seclusion policy and procedure authorizes the RN to gradually release the patient, to give the patient a 'trial' in a less restrictive environment. This 'trial' will not require a new order nor count as a separate incident, even if the patient fails the trial and the intervention must be reinitiated. However, once all restraints have been removed the order is discontinued and a new order is required to put the patient back in restraints, regardless of whether the original order has expired.

While interviewing licensed nursing staff on Mckeldin D, she verbalized that staff slowly down-grade the patient per hospital policy. When asked if the down-grading or trial fails does she get a new order, the answer was "NO", they continue to use the current order. "That's why we do the trial so we don't have to get a new order since the patient is not completely out of restraints."

Based on review of seven medical records, it was determined that in two of the medical records hospital reviewed staff failed to discontinue the restraint at the earliest possible time as evidenced by:

Patient #1 is a 27 year old male on McKeldin D admitted on 08/23/06 with diagnosis Psychotic Disorder NOS, R/O Schizo-typical/Personality Disorder. It is documented in the medical record that on 04/12/10 at 3:15 pm the patient picked up a chair and smashed the glass day hall door. The patient stated he wanted to leave and would do it again. At 3:15 pm the patient was placed in belt wrist and ankle restraints and given haldol 10mg, Benadryl 50mg and Ativan 2mg by mouth. The face-to face was performed by the physician at 3:30 pm. Per the Care and Observation Log Seclusion and Restraint Form from 3:30 pm to 4:30 pm the patient was lying quietly on the bed in the seclusion room.

At 4:45 pm, he continues to lie quietly according to the record. When asked what happened, the patient stated "that he got mad and threw a chair at the door because he didn't like the new guy (patient) on the unit."

At 5:00 pm the patient is documented as being restless and stated he may do it again if not transferred out.

At 5:15 pm the patient was lying in bed, quietly asking questions about dinner.

At 5:25 pm the patient was assessed by the RN and was able to state what behavior was inappropriate, agreed that he would not throw furniture, and would ask for his PRN, if he felt anxious or angry in the future. The patient walked voluntarily to the small day hall for dinner.

At 5:30 pm the patient sat quietly in the day hall awaiting dinner.

At 5:40 pm the records indicate the patient's right hand was released so the patient could feed himself.

At 5:50 pm, the patient finished 90% of his meal, had his right hand placed back in restraint and chose to go back to the seclusion room to lie down according to the records.

Finally at 6:00 pm the nurse explained the criteria for release to the patient, he agreed to comply and the restraints were completely removed.

There were several other times prior to 6:00 pm that the patient had met the criteria for release but remained in restraint for an additional 35 minutes. The hospital policy and procedure of down-grading the restraints when the patient is calm, able to follow directions, and identify a plan to deal with his feelings violates the patient right to be released from restraints at the earliest possible time. Starting at 5:25 pm the patient had met the criteria for release. He was calm, able to discuss the incident and identify inappropriate behavior and his plan to deal with feelings of anxiety and anger. Instead of removing the restraints, the nurse removed the ankle restraints but left the patient in bi-lateral wrist restraints. The patient sat quietly in the day hall waiting for his dinner and when his hand was released he fed himself and allowed staff to place him back in restraints after completing his meal. Again the patient had met the criteria for release but remained in restraints until the RN assessed him at 6:00 pm.


Patient #2 is a 51 year old male admitted to Springfield Hospital Center on 01/30/07.

The patient was placed in four-point restraint after he was asked not to loiter around the nurse's station when he began to yell, scream, threaten staff, did not respond to verbal redirection or to an offer of PRN medication. The patient lunged at a female staff member. The patient was placed in four-point restraint on 01/17/10 at 10:25 am. The restraint was completely removed on 01/18/10 at 5:00 pm for a total of 30.5 hours. The criteria for release listed the following: The patient cannot threaten others verbally or physically, be able to listen to staff redirection and "Contract for Safety".

The Care and Observation Log for Seclusion and Restraint contains ambiguous language. For example, on 01/18/10 at 4:00 am the RN assessment of the patient states: "Remains unpredictable, refusing to take responsibility for earlier actions, refuses to contract for safety. Angry affect. Does not meet the criteria for release." Other than the description of the patient's affect, the assessment does not include the patient's statements or behaviors that would indicate he is still verbally and physically threatening. On 01/18/10 from 5:00 am to 5:30 am on the Care and Observation Log there are blank spaces in the descriptive comment blocks. The RN Assessments are out of sequence for 8:00 am, 10:00 am, 12 noon and 2:00 pm on separate Care and Observation Log Forms on 01/18/10.

The restraint was down-graded with removal of the his right leg on 01/18/10 at 12:15 pm
By 2:15 pm the patient left hand was removed and he remained in two point restraint.
The Care and Observation Log for Seclusion and Restraint on 01/18/10 starting at 9:00 am revealed the patient was calm, asking questions, following directions, discussing his behavior, including the events from the prior day. The following descriptive comments were taken from The Care and Observation Log for Seclusion and Restraints:

On 01/18/10 at 9:45 am until 11:00 am the staff documented that the patient was lying quietly with eyes closed.

01/18/10 at 11:15 am patient states "I feel good" pleasant affect. Acknowledged rude/threatening behavior directed toward this writer during yesterday's events.

01/18/10 at 11:30 am patient still eating lunch without incident, ate 100% meal.

01/18/10 at 11:45 am wrist restraint reapplied to the right wrist, patient cooperative. Conversing appropriate with writer. Patient request lights off to rest.

01/18/10 from 12:00 pm to 1:00pm the observation log reveals the patient was resting quietly with his eyes closed.

At 2:15 pm the patient was still calm, discussing precipitating events leading to restraint, patient receptive to plan. His left wrist restraint was removed. The RN assessments, made at 12:00 pm and 2:00 pm, were out of sequence.

The Care and Observation Log for Seclusion and Restraint revealed that the patient had periods where he was calm, non-threatening, talking about his behavior, and following staff directions, yet the patient remained in restraints. The patient had met the criteria for release but remained in restraints because he was not accountable for his behavior, unpredictable, and could not contract for safety. The initial limb was removed from restraints at 12:15 pm and the next limb removed at 2:15 pm 2 hours later and the patient was removed from all restraints at 5:00 pm on 01/18/10 for a total of 4 hours and 45 minutes.

The patient had behaviorally met the criteria for release but the restraints were not discontinued at the earliest possible time due to the down-grading of restraints, use of subjective/ambiguous language and changing the criteria of release which was not behaviorally focused.

Based on record review, staff interview and observation, it was determined that the facility staff failed to 1) ensure that weights were accurate and obtained in a timely manner; and 2) have an effective system in place to monitor the nutritional status of patients. The findings include:

1) The facility staff failed to ensure that weights were accurate and obtained in a timely manner.

On 04/15/10, the surveyor conducted an in-depth review of the facility's practices with regards to weight and nutritional status monitoring. Review of the patients' monthly weight book on the Hitchman B unit revealed that on 03/01/10, a notation was made that staff were "unable to get monthly wts (weights) on some of the pts (patients) as big scale is not working." As a result, 3 patients had no March weights, and 4 additional patients had still not been weighed since the beginning of February. These patients require the wheelchair scale (which was broken) to be weighed. The surveyor then asked the 2 nurses on duty if the scale had been fixed. They were initially unable to answer the surveyor's question. The surveyor then asked the nursing supervisor if the scale had been fixed. The supervisor stated that she was unaware that it was broken. As of 04/15/10, the wheelchair scale had yet to be repaired.

Further review of the weight book revealed that weights were being obtained without consistent measuring techniques in place. For example, one month, the patient may be heavily clothed and wearing multiple layers, and another month only a nightgown. This practice does not provide a means of accurate weight monitoring. This practice was confirmed upon interview with staff.

It was also noted that the dates when weights were obtained were not being documented. Also, the surveyor was told that all weights were obtained between the 1st and 5th of each month, yet review of the patient's medical records revealed that this was not always the case. Though frequently the dates were not being documented, on occasion, when a date was recorded, it would be after the 5th of the month. It is standard of practice to document the date a weight is obtained. This enables staff to more effectively monitor weight changes and trends.

Continued review of the monthly weight book also revealed that reweights were not being obtained when indicated, such as when a significant weight gain or loss was noted. It was also noted that no follow-up attempts were being made when a patient refused to be weighed (which could likely occur with psychiatric patients).

Another noted concern was the fact that patients were not being weighed upon readmission to the facility, such as after a hospitalization. Weights upon readmission are essential in evaluating a patient's current status.

After multiple requests for the facility's weight policy, it was determined that one did not exist. Weight policies provide direction to staff regarding standard weighing techniques (weighing patients in a consistent state of dress/after toileting/before breakfast, etc.), scale calibration, when to weigh and reweigh patients, etc.

Facility staff must have an effective system in place to monitor patient weights.

2) The facility staff failed to have an effective system in place to monitor the nutritional status of patients.

a) Patient # 1 is a 66 year old female with paranoid schizophrenia. She receives a mechanical soft, no concentrated sweets diet. On 12/20/09, she was started on small portions due to obesity.

Review of the patient's medical record on 04/15/10 revealed the following documented weights:

11/09 - 246 lbs.
12/09 - 231 lbs.
01/10 - 223 lbs.
02/10 - 226 lbs.
03/10 - not obtained
04/10 - 207 lbs.

From 11/09 through 04/10, the patient exhibited a 39 lb. weight loss, equivalent to a 15.9% loss in body weight over a 5 month period. This is indicative of a severe weight loss.

On 03/05/10, she was re-admitted to the facility after a short hospitalization for an infection. No readmission weight was obtained. By 04/10, the patient's weight had dropped another 19 lbs. since 02/10.

Additional record review failed to reveal any reweights when the patient was showing dramatic changes in monthly weights. Furthermore, the dietitian and physician had not been notified of the patient's change in status. While exhibiting a severe weight loss, the patient continued to receive a small portions diet.

Facility staff must monitor and evaluate weight trends, as this is a common indicator of nutritional status.

b) Patient # 2 is a 59 year old female with schizophrenia, dysphagia (difficulty swallowing), depression, Parkinson's disease, mental retardation, and a history of colon cancer status post hemicolectomy (removal of a portion of the colon). She requires a pureed, no concentrated sweets, no added salt diet.

Review of the patient's medical record on 04/15/10 revealed the following documented weights:

12/09 - 146 lbs.
01/10 - 143.9 lbs.
02/10 - 151 lbs.
03/10 - 145 lbs.
04/10 - 134 lbs.

From 02/10 through 04/10, the patient exhibited a 17 lb. weight loss, equivalent to an 11.3% loss in body weight over a 2 month period. This is indicative of a severe weight loss.

On 03/23/10, her Glucerna supplement was decreased from 3 times per day to twice daily. Glucerna is a nutritionally-fortified shake often used for diabetics needing extra calories. Review of the patient's nursing care records failed to reveal that staff were monitoring her Glucerna intake. This monitoring enables staff to determine the effectiveness of interventions, and whether or not changes in interventions (such as times the supplement is given) are indicated. It was also noted that no reweights were being obtained when the patient exhibited significant changes in weight.

c) Patient # 3 is a 74 year old female with schizophrenia. She has a tendency to hoard food and place food items in dresser bureaus and clothes as reported by staff.

Review of the patient's medical record on 04/15/10 revealed the following documented weights:

11/09 - 134 lbs.
12/09 - 139 lbs.
01/10 - 130.7 lbs.
02/10 - 122 lbs.
03/10 - "refused" weight
04/10 - 105 lbs.

From 12/09 through 04/10, the patient exhibited a 34 lb. weight loss, equivalent to a 24.5% loss in body weight over a 4 month period. This is indicative of a severe weight loss.

No reweights had been obtained when the patient was exhibiting dramatic weight changes each month. Furthermore, the patient was never re-approached when she was documented to refuse her March weight. On 04/15/10, after surveyor intervention, a reweight was obtained and her weight was confirmed to be 105.5 lbs.

Additional record review revealed that on 03/24/10, the patient was started on Ensure supplements if she ate less than 50% of her meal. Review of the nursing care records revealed that on 03/25/10 at lunch, 03/26/10 at dinner, 03/27/10 at lunch, 03/31/10 at lunch, and 04/11/10 at dinner, the patient refused her meal but there was no indication that she was offered her supplement. Furthermore, when she was given her supplement, there was no tracking system in place to determine the effectiveness of the intervention, such as how much of the supplement she actually consumed. Staff were only documenting that the supplement was provided.

Facility staff must have effective systems in place to monitor weights and the appropriateness of nutritional interventions.

Based on review of policies and procedures, staff interviews and observation, the hospital failed to ensure that expired/unusable medications and biologicals are not available for patient use.

A review of the hospital's procedure states: SHC staff identifies and returns all unusable medications to the pharmacy. The pharmacy has developed a method of periodic inspections to ensure removal of medications and biologicals that are due to expire. Licensed nursing staff when interviewed stated that they check for expiration dates on the medications, sending expired medications back to the pharmacy and ordering new stock as needed. They also stated that pharmacy performs monthly inspections of the medication rooms.

During the inspection of the medication room on Salomon B on 04/14/10 two vials of injectables (1-vial Vistaril and 1-bottle Sterile Water) were found to be expired with the date March 2010.

On 04/14/10 the surveyor inspection of the medication room on Hitchman A revealed multiple treatment medications for patients were out-dated for topicals that have a 6-month use per hospital policy.
1. Clotrimazole cream antifungal 1% - filled by pharmacy 10/31/2008 and Muscle rub filled by pharmacy 5/28/2008.
2. Flucocinonide filled by pharmacy 8/27/2006.
3. Proctozone HC 2.5 filled by pharmacy 9/8/2009 and Liqitears 1.4% polyvinyl alcohol filled by pharmacy 9/8/2009.

On 04/14/10 the surveyor inspection of the medication room on Hitchman D revealed some treatments were again out of date as follows:
1. Triamcinolone and Carmol 20 cream filled by pharmacy 07/20/2009.
2. Erythromycin 2% solution was opened, but no open date on container, also filled by pharmacy 07/20/2009.
3. Marmol 20 filled by pharmacy 08/11/2009 and Muscle rub filled by pharmacy 9/10/2009.

Based on kitchen and meal service observations, in addition to staff interview, it was determined that the facility staff failed to: 1) date perishable food items upon thawing; and 2) ensure that a trayline supervisor was competent in thermometer calibration. The findings include:

1) The facility staff failed to date perishable food items upon thawing.

On 04/14/10, a kitchen inspection was conducted. During this time, several undated products were observed in the walk-in refrigerators. These included 2 full cases and one partial case of thawed Rich's whipped topping, 4 cases of thawed raw bacon, and 3 cases of thawed raw turkey bacon. These perishable food items must be dated upon thawing to ensure food safety and freshness.

2) The facility staff failed to ensure that a trayline supervisor was competent in thermometer calibration.

On 04/14/10 at 10:50AM, a trayline observation was conducted at lunch. During this time, the surveyor asked the staff which employee would be responsible for taking the trayline food temperatures. After being informed that the trayline supervisor would be responsible for this task, the surveyor then asked this employee to calibrate her thermometer.

The supervisor retrieved a cup of ice that contained predominantly water. The surveyor intervened, and more ice was added to create a bath of mostly ice and some water. The thermometer (a Taylor brand bi-metallic stem thermometer) read 35 degrees Fahrenheit (dF). The surveyor then asked the employee what temperature the thermometer should read. The employee initially responded "20 degrees or below" and then stated that ideally, it should read 0 dF. This is incorrect, because the thermometer should read 32 dF when using the ice bath method for calibration. When asked what she should do to adjust the temperature reading, the employee stated, "add more ice".

Thermometer calibration involves placing the thermometer probe into an ice bath (or boiling water) and manually adjusting the temperature gauge until it reads the correct temperature (32 degrees Fahrenheit when using the ice bath method). Thermometer calibration is necessary to ensure that food temperature readings are accurate.

Facility staff must be proficient in basic food safety principles. This includes the ability to calibrate a thermometer to accurately verify food temperatures.

Based on observation of the hospital physical plant on April 14 and 15, 2010, the physical environment was not arranged and maintained as required as evidenced by:

The following findings:

The direct observation of the rear of the M and S Building on April 14, 2010, the concrete slab roof covering above the loading dock was found to be deteriorating along the perimeter of the roof edge. Details of the deterioration included the loss of some of the concrete from the perimeter and the presence of cracking along this perimeter surface. Based on the observations made, the surveyor had concerns that further deterioration of the perimeter may result in pieces of concrete falling off the roof and onto patients or staff that would be entering or leaving from the rear of the building. The safety of patients, staff and the general public must be assured at all times.

During the observation of the Hitchman Building on April 15, 2010, it was observed that bathing areas were in need of repairs to restore surfaces (i.e. grout, caulk, paint) to a cleanable condition. Further, the presence of mildew in some shower stalls provide evidence for more extensive cleaning procedures and/or improved ventilation.

During observation of the McKeldin Building on April 15, 2010, a concern was discovered within the area where food was served to patients. Meals were delivered to the building via a rear entrance into a dietary service area. Adjacent to this space was another room, formerly used for processing of soiled kitchen ware, where an ice machine had been installed. In addition to the space being used for food service, a janitorial sink and chemical dispensing system had been installed for dietary staff use in cleaning floors within the kitchen and the adjacent two dining rooms. Further, a photocopy machine was placed into this former dish room for use by the entire building's staff. Lastly, recreation staff was provided with folding tables and they conducted administrative functions within this area. The primary purpose of this space was intended for food service, yet janitorial equipment was later added and then office equipment and administrative work was later added as a function for this space. Janitorial service areas should not be located within a food service area. The ice produced within the ice machine must be protected as if it were food. The uses of food service, janitorial service, and office administration were found to be non-complimentary. Office equipment and administrative activities should not be placed/located within a food service area. If janitorial plumbing fixtures must be located within an area intended for food service, food service staff must be carefully trained to understand the potential for contamination of food contact surfaces, food service equipment (i.e. the ice maker) and of food. Procedures that prevent contamination to food, ice, or food contact surfaces must be developed and implemented if the janitorial plumbing equipment would be left within a food service space. The safety of patients, staff and the general public must be assured at all times.

Based on record review, document review, observation and interview, the facility failed to provide psychosocial assessments that described social work roles in treatment, document assessment of memory function on the psychiatric evaluations, and ensure active treatment measures for patients. Specifically, the facility failed to:

I. Provide a psychosocial assessment for 1 of 16 sample patients (K24), resulting in no professional social work input into the treatment planning for the patient. Additionally the facility failed to provide psychosocial assessments for 8 of 16 sample patients, (B16, D5, F10, G18, H15, H22, I14, and J11) that included conclusions and recommendations for social work roles in treatment. This failure results in a lack of professional social work input into treatment team planning. (Refer to B108).

II. Provide documentation of the assessment of memory function on the psychiatric evaluations for 11 of 16 active sample patients (A2, B16, B22, C12, D5, E2, F10, G18, H14, I14 and K24). Additionally, the facility failed to describe the methods utilized in the assessment of memory, orientation and intelligence for 6 of 16 sample patients (C12, E2, F10, G18, H14, and K24). Lack of memory assessments can lead to failure to identify conditions that impact treatment. Failure to describe the methods used for testing results in inability to make comparisons when re-evaluating memory functioning. (Refer to B116).

III. Ensure active treatment for 4 of 16 active sample patients (E1, E20, G18, and J11) and 3 non-sample patients (E13, F9, and F18) who were on a "Privilege Zero" and five four non-sample patients (E10, E11, F12, F15, and F19) who were confined in the Treatment Mall gym because they had refused to attend their assigned groups. The hospital's failure to identify and correct the unjustified withholding of treatment results in patients being hospitalized without benefit of all necessary treatment interventions for recovery. (Refer to B125).

Based on record review and interview, the facility failed to provide a psychosocial assessment for 1 of 16 sample patients (K24), resulting in no professional social work input into the treatment planning for the patient. Additionally the facility failed to provide psychosocial assessments for 8 of 16 sample patients, (B16, D5, F10, G18, H15, H22, I14, and J11) that included conclusions and recommendations for social work roles in treatment. The recommendations were either not present, described interventions by other disciplines, or were generic social work functions rather than being based on each patient's assessed needs. This failure results in a lack of professional social work input into treatment team planning.

A. Record Review:

1. No Psychosocial Assessment Completed for Patient K24
Review of the Social Work Multidisciplinary Admission Assessment for patient K24, admitted 10/14/09, revealed that the assessment had not been completed. The section entitled "Social Work Interventions" identified no recommendations for social work interventions.

2. Psychosocial assessments not including conclusions and recommendations

a. Patient B16. Review of the Social Work Multidisciplinary Admissions Assessment dated 8/21/09 for the patient, admitted on 8/17/09, revealed the following notations under the Social Work Interventions section: "Additional Background Material"; "Liaison with Family/Significant Other(s)." Both activities were routine social work functions, not therapeutic interventions specific to the patient's assessed needs.

b. Patient D5. Review of the Social Work Multidisciplinary Annual Assessment dated 8/13/09 for the patient, admitted on 8/9/04, listed the following: "Social Work Recommendations/planned interventions:" "medication, group therapies, individual meetings, and social worker as needed." These activities were tasks for other disciplines or were generic social work functions instead of individualized treatment based on assessed needs of the patient.

c. Patient F10. Review of the Social Work Multidisciplinary Admission Assessment dated 7/31/07 for the patient, admitted 7/25/07, listed "Additional Background Material and continue offering supportive services in an effort to locate relatives as needed." This activity was a generic social work function, not a therapeutic intervention specific to the patient's assessed needs.

d. Patient G18. Review of the Social Work Multidisciplinary Annual Assessment (undated) for the patient, admitted 1/10/07 listed "medication, TX [sic] mall groups, supportive counseling per tx [sic] team and social work as needed." These activities were tasks for other disciplines or are generic social work functions instead of therapeutic social work interventions specific to the patient's assessed needs.

e. Patient H15. Review of the Social Work Multidisciplinary Annual Assessment dated 7/31/09 for the patient, admitted 7/25/07, listed "Additional Background Material and continue offering supportive services in an effort to locate relatives as needed." This activity was a generic social work function, not a therapeutic intervention specific to the patient's assessed needs.

f. Patient H22. Review of the Social Work Multidisciplinary Admission Assessment (not signed or dated) for the patient, admitted 10/15/10, only included the following Social Work Intervention: "liaison with family/significant other." Liaison with family was a generic social work function, not an individualized treatment intervention.

g. Patient I14. Review of the Social Work Multidisciplinary Admission Assessment dated 1/14/10 for the patient, admitted 1/7/10, found that the section entitled Social Work Interventions identified no recommendations.

h. Patient J11. Review of the Social Work Multidisciplinary Admission Assessment dated 1/22/10 for the patient, admitted 1/19/10, only found the following notations for Social Work Interventions: "liaison with family/significant other." Liaison with family was a generic social work function, not an individualized treatment intervention.

Based on record review and interview, the facility failed to provide psychiatric evaluations that included estimates of memory, orientation and intelligence for 11 of 16 active sample patients (A2, B16, B22, C12, D5, E2, F10, G18, H14, I14 and K24). Additionally, the facility failed to describe the methods utilized in the assessment of memory, orientation and intelligence for 6 of 16 sample patients (C12, E2, F10, G18, H14, and K24). Lack of memory assessments can lead to failure to identify conditions that impact treatment. Failure to describe the methods used for testing results in inability to make comparisons when re-evaluating memory functioning.

Findings:

A. Record Review

1. Patient A2. The psychiatric evaluation, dated 12/3/09, only listed "O x 1" [sic].

2. Patient B16. The psychiatric evaluation, dated 8/17/09, did not address memory; it only addressed orientation as person and place.

3. Patient B22. The psychiatric evaluation, dated 3/10/09, listed memory and intellectual functioning as "WNL." Under "Orientation," the evaluation stated "see above." However, there was no actual assessment of orientation.

4. Patient C12. The psychiatric evaluation, dated 9/21/09, listed intellectual function as "normal" and memory functioning as "not tested." The measures used to assess intellectual functioning were not noted.

5. Patient D5. The psychiatric evaluation, dated 8/26/09, listed "oriented as to 3 spheres."

6. Patient E2. The psychiatric evaluation, dated 11/24/09, listed intellectual functioning as "no overt impairment" and memory as "immediate, recent, remote memory intact." The methods used to assess intellect and memory functioning were not listed.

7. Patient F10. The psychiatric evaluation, dated 7/17/09, listed orientation as "partially intact" and memory as "poor in relating past history." The other areas of memory were not addressed. The assessment of intellectual functioning did not indicate how "below average" was determined.

8. Patient G18. The psychiatric evaluation, dated 1/27/09, listed "orientation as to 3 spheres" and intellectual functioning as "average or low average" without specifying the methods used for the assessment.

9. Patient H14. The psychiatric evaluation, dated 11/2/09, listed memory as "intact," orientation as "AAOx3" [sic] and intellectual function as "appears to be of avgas [sic]" without noting methods used for the assessment.

10. Patient I14. The psychiatric evaluation, dated 1/7/10, listed "alert oriented."

11. Patient K24. The psychiatric evaluation, dated 10/14/09, listed memory as "appears intact" and intellectual functioning as "average" without noting the methods used for the assessment.

B. Interview

In an interview on 1/27/10 at 2:00 pm, the Medical Director agreed that psychiatric assessments did not adequately address memory, orientation or intellectual functioning.

Based on document review, observation and interview, the facility failed to ensure that active treatment was provided for 4 of 16 active sample patients (E1, E20, G18, and J11) and 3 non-sample patients (E13, F9, and F18) who were on a Privilege Level Zero" These patients were not allowed to go off of the unit and did not receive active treatment for days at a time. Five additional non-sample patients (E10, E11, F12, F 15 and F19) who had refused to attend their assigned groups were confined in the Treatment Mall gym without participating in activities rather than receiving alternative treatment. The hospital's failure to identify and correct the unjustified withholding of treatment results in patients being hospitalized without benefit of all necessary treatment interventions for recovery, potentially prolonging hospitalization.

Findings are:

A. Document Review

1) Facility policy entitled "Provision of Care Policy for Patient Levels System" (dated May 1989, Revised 10/08) states that "Level Zero" is for "the patient who presents a danger to him/herself or others, and remains on his/her unit at all times" and "The patient must be escorted by two staff members whenever he/she leaves the unit. Patients placed on precautions involving the use of 1:1 will automatically be assigned Level Zero." The other levels are: "Level One- Patient must be accompanied by a staff member whenever they [sic] leave the unit." "Level Two- Patient may go from one part of the building to another part of the building without accompaniment." "Level Three - may go out of the building without escort/supervision to: a walk or predetermined therapeutic activity." The policy also states under "Review and Revision of Levels"..."Levels are reviewed not less than weekly."

2) On 1/26/10 at 8:35 a.m., the PI Director gave the surveyor a report (dated 1/25/10) concerning the active treatment provided for patients on Level Zero. The one page report stated that McKeldin Building had ten patients on a Level Zero on 1/25/10. Those ten patients included active ample patients E1, E20, and G18 and non-sample Patients E13, F9, and F18. According to the 1/25/10 report, none of these patients received any active Treatment except for Patient E20 who reportedly had attended the "Goals and Exercise" group, scheduled for 9:00 a.m. and 9:30 a.m. for a total of one hour.
3) A review of the unit schedule revealed that there were only two available therapeutic groups after the closing time of the Treatment Mall. One group was an open recreation group offered at 6:30 p.m. for which Level Zero patients were ineligible because it is off the unit. The other group was a "Unit Activity" offered only on weekdays at 3:00 p.m. The Level Zero patients could attend this group.

B. Observation and Interview

1) On 1/25/10, the Treatment Mall/Clinical Nurse Specialist (CNS1) announced that at 11:00 a.m., the LPN1 would offer the "Fitness Group." LPN1 stood up and walked over to stand near the wall next to four stationary bicycles. No staff was observed encouraging any of the approximately 18 patients to participate. Sample patient E1 continued to sit on a bench while in restraints, with his eyes closed. Sample patient E20 sat on a chair near the door, observing the activity around the "command desk" where CNS1 and other staff gathered to review the patient assignments for the day. Of the other 16 patients in the room, no one expressed any interest including the following five non-sample Patients: Patient E11 (slept in a wheelchair), Patient E13 (continued to pace), Patient F9 (slept with head down on a table), Patient F15 (sat on floor, occasionally talking to himself), and Patient F18 (sat on a bench against the opposite wall). The overall atmosphere was disorganized and very congested. For so many severely ill patients, the chaos and stimulation level in the gym was counter- therapeutic and overly stimulating. When no patients went to join LPN1 in the corner of the room, she sat down.

2) On 1/25/10 at 1:20 p.m. in the McKeldin gym, 18 patients were counted in the gym group. RN1 identified eight patients in the gym who were assigned to Level Zero. These included sample patients E1, E20, and G18 and non-sample patients E13, F9, and F18. RN1 stated that these patients would not be permitted to attend group until they had received privilege Level One. RN1 also stated that non-sample patients, E10, E11, F12, F15 and F19 were in the gym at the time because they had refused to attend their assigned groups. Patient E10, described as mute, did not verbalize and was pacing without interacting with others. Patient E11 was observed sitting in a wheelchair asleep. Patient E13 aimlessly paced throughout the room from 12:20 p.m. until 2:00 p.m. Patient F12 was dressed in a bandanna, crookedly tied around his head while wearing a dirty, poorly groomed beard. The patient's hair was below his shoulders as he aimlessly walked around the room, staring upwards. Patient F15 sat slumped over asleep on the floor. Patient F19 had asked the surveyor about attending Music Group and attempted several times to talk to the staff at the assignment desk as well as other patients. She was not taken to music group and no alternative intervention was provided during observation.

3) On 1/26/10 at 9:40 a.m. in the McKeldin A hallway, approximately six patients were either sitting or pacing idly, including sample patient E20 and non- sample patient E11. The ADON [Assistant Director of Nursing] clarified that music group was in session. She agreed that the setting was too disorganized to constitute music group. Around the corner in the day room, the group leader, Activity Therapist Aide (ATA1) was sitting at a table, playing some type of music player. Approximately ten patients were sitting in various parts of the day room. Non-sample patient E11 was sitting in a wheelchair asleep with her head down. The setting and level of demonstrated skill was insufficient to establish or sustain adequate intensity and focus to facilitate a therapeutic experience.

4) On 1/27/10 at 10:30 a.m. in the McKeldin Gym, the video "Sea Life" was being shown to patients who were Level Zero and thus unable to leave the gymnasium. LPN3 stated that the purpose of the "Sea Life" video being shown to Level Zero patients and unable to leave the gymnasium was "entertainment and education." When asked who, among those watching the video, had "entertainment and education" as part of his/her treatment plan, LPN3 stated that no one had that as part of their plan.

C. Additional Staff Interviews

1) In interview on 1/25/10 at 11:10 a.m. in the McKeldin Mall, LPN1 stated that she did Fitness and Etiquette groups. When asked what training she had about leading groups, she said that she had some training during orientation when she was hired. She also stated that she did not know the treatment goals for the patients in the gym for whom she had just offered the Fitness group. She also could not identify their specific treatment needs.

2) In an interview on 1/27/10 at 10:30 a.m. in the McKeldin Gym, LPN3 stated that the purpose of the "Sea Life" video being shown to patients on 00 and thus unable to leave the gymnasium was "entertainment and education." She stated that she did not know if either entertainment or education were part of any of the patients' treatment goals.

3) On 1/25/10 in interview at 1:20 p.m. in the McKeldin gym, RN1 who was the assigned Mall Manager for the day explained that the gym is used daily, Monday through Fridays for all patients who have privilege Level Zero and are not permitted to attend groups because they are not permitted to leave their units; patients who refuse to attend their assigned groups; patients who have no assigned group at that time; and patients who are in between assigned groups and waiting for direction and escort to their next scheduled groups.

4) In interview on 1/26/10 at 10:50 a.m., OTR1(Registered Occupational Therapist) stated that she could not identify the individual treatment needs of the patients in the Gym that day for which she was assigned to serve as Mall Manager. At the time, approximately 20 patients were present in the Gym, including sample patients E20 and G18 and four non-sample patients (E13, F9, F15, and F18).

5) In an interview on Tuesday, 01/26/10 at 11:00 a.m., nursing supervisor RN8 stated that patients who are on Level Zero status must stay in the gymnasium during the structured treatment mall time. She stated that while Level Zero status patients are not permitted to go to their assigned groups, they nevertheless are designated in the database as having "refused group" and thus are given an "unexcused absence." RN8 further stated that when patients return to the unit from the Treatment Mall at 2:00 p.m., they are allowed to go to their rooms to be alone or to sleep until dinner at 5:30 p.m. This includes Level Zero status patients who have been sitting in the gymnasium throughout the day and have not attended any treatment. She stated that activities that would be offered in the evening included "ADLs, laundry time, medications, and an evening group on some nights." She explained that, when a patient's level is changed from Zero to One, the change does not go into effect until 2:00 p.m. on the day of the change, i.e. after the Treatment Mall has ended for the day. Thus she made it clear that, in practice, being placed on a Zero meant that the patient could not attend Treatment Mall therapeutic programming for a minimum of two days.

D. Review of Patient Specific Findings

1. Sample Patient E1

a. Record Review

1) According to the Annual Psychiatric Evaluation dated 12/16/09, Patient E1 was admitted with schizoaffective disorder bipolar type on 12/16/08 and continued to be hospitalized because of "assaultive behavior, multiple assaults and command hallucinations."

2) The Master/Individual Plan of Care for Patient E1, dated 12/22/09, listed interventions to address patient's command hallucinations and assaultive behavior as "18 hours of tx [treatment] mall programming 5 days a week" and "quiet time in bedroom offered by staff."

3) The "Treatment Mall" daily schedule on 1/25/10 noted that Patient E1 was assigned to five groups per day. The group times were 9:00-9:30 a.m., 9:30-10:00 a.m., 10:30-11:20a.m., 12:10-1:00 p.m. and 1:05-1:50 p.m.

4) A progress note by OTR2 (Registered Occupational Therapist dated 1/22/10 at 3:05 p.m. stated that patient E1 "will continue to be encouraged to attend OT groups as scheduled when level permits."

5) The Treatment Mall Patient Activity Report for Patient E1 for the period 1/20/10-1/26/10 stated that patient E1 was a "no show" at 5 of 5 groups on 1/25/10. It also stated that on 1/26/10, the patient was a "no show" for 4 of 5 groups, having attended walking group at 10:30 a.m.

b. Observations

1) During an observation on 1/25/10 from 10:45 a.m.-11: 30 a.m. in the McKeldin gym, Patient E1 was found sitting on a bench in wrist/waist/ankle restraints. He sat with his eyes closed. No interaction was observed between patient E1 and staff members during this time. There was no demonstration of the treatment plan intervention to offer use of his bedroom for quiet time, away from the stimulation of other patients using the gym.

2) During an observation on 1/25/10 between 12:20 p.m. and 2:00 p.m. in the McKeldin gym, Patient E1 continued to sit on a bench in wrist/waist/ankle restraints. He sat with his eyes closed. No interaction was observed between Patient E1 and staff members during this time. At one point Patient E1 stood up and briefly paced around the room before resuming his seat on the bench. There was no demonstration of the treatment plan intervention regarding use of the patient's bedroom for quiet time to reduce his exposure to the stimulation of other patients in the gym.

c. Interviews

In an interview on 1/25/10 at 1:30 p.m. in the McKeldin gym, RN1, who was the assigned Mall Manager for the day, explained that Patient E1 was on a Level Zero and was not permitted to attend his groups.

2. Sample Patient E20

a. Record Review

1) According to the multidisciplinary assessment dated 3/23/09, patient E20 was admitted on 3/30/01 for "schizoaffective disorder bipolar." The assessment also stated "he exhibits periodic psychotic symptoms....has shown 20 assaultive behavior [sic] in one year. He has been on day hall restriction." The listed psychiatric interventions were "current medications, day hall restriction, addiction treatment, and forensic evaluation."

2) The Review/individual plan of care, dated 12/31/09, stated "patient will attend treatment mall 5 days/wk [sic]" and, "quiet room offered by nursing staff.".

3) Review of the "Treatment Mall Daily Schedule" for patient E20 showed that the patient was scheduled for five groups per day. Times of the groups were 9:00 a.m.-9:30 a.m.; 9:30 a.m.-10:00 a.m.; 10:30 a.m.-11:20 a.m.; 12:10 p.m.-1:00 p.m. and 1:05 p.m.-1:50 p.m.

4). Review of the Treatment Mall patient activity report for the period 1/20/10-1/26/10 showed that the patient was scheduled for five on 1/25/10 and three groups on 1/26/10. The patient was a "no show" for five of five groups on 1/25/10 and was a "no show" at 1 of three groups on 1/26/10. On 1/26/10, he reportedly attended two groups, "Goals" and "Music Therapy."

b. Observation

1) Patient E20 was observed idly sitting without any staff interaction in the gym on 1/25/10 between 12:20 p.m. and 2:00 p.m.

2) On 1/26/10 at 9:40 a.m., patient E20 was observed pacing idly in the McKeldin A hallway. Approximately five other patients were either sitting or pacing idly. The ADON [Assistant Director of Nursing] stated that the music group was in session. She agreed that the setting was too disorganized to constitute a music group. Around the corner in the day room, ATA1 was sitting at a table playing some type of music player. Approximately ten patients were sitting in various parts of the day room. The setting and level of demonstrated skill was insufficient to establish or sustain adequate intensity and focus to facilitate a therapeutic experience. This was one of two groups that patient E20 was noted to have attended on 1/26/10 per the "patient activity report."

3) Patient E20 was observed idly sitting in the McKeldin Treatment Mall Gym on 1/26/10 without any staff interaction between 12:10 p.m. and 2:00 p.m.

c. Interview

1) In an interview on 1/26/10 at 12:30 p.m., patient E20 stated that he was bored, wanted to work and make money and be discharged from the hospital. He stated that he is bothered by some of the other patients and finds it difficult to refrain from poking or bumping into them.

2). In interview on 1/25/10 at 1:30 p.m. in the McKeldin gym, RN1 stated that patient E20 was on a Level Zero and was not permitted to attend groups.

3. Sample Patient G18

a. Record and Document Review

1) A review of Patient G18's medical record on 01/28/10 at 9:30 a.m. revealed no documentation of unit groups or activities that the patient attended on 01/25/10 and 01/26/10. As the result of an incident on 01/24/10, the patient was on privilege Level Zero and was not allowed to attend any groups or activities off the unit.

2) A document provided by the PI Director, dated 1/25/10 and entitled "Level Zero," noted that Patient G18 did not participate in any therapeutic activities that day.

3) A review of the unit schedule showed that there were two available therapeutic groups after the closing time of the Treatment Mall. One group was an open recreation group offered at 6:30 p.m. for which Level Zeropatients were ineligible because it was off the unit. The other group was a "Unit Activity" offered on weekdays at 3:00 p.m. Patient G18 did not attend any of these groups for which his level status made him eligible.

b. Observations and Interviews

1) On Monday, 01/25/10 at 10:30 a.m. in the Treatment Mall gymnasium in the McKeldin Building, Patient G18 was asked what daily activities he would be attending that day. He stated "I'm a Level Zero. I can't go to any activities. I'll be in the gym until 2:00 p.m. today. Then I will go back to my room and sleep until dinner."

2) On 1/26/10 at 10:30 in McKeldin Treatment Mall Gym, Patient G18 was present for the Leisure Education group with RT2. He appeared to be enthusiastically singing to the radio with a peer while walking around the room. At one point he sat in a chair. He was smiling and responsive to conversation with his peers. He was escorted out of the room at 10:40 a.m. On 1/26/10 at 11:00 a.m., Patient G18 was observed in the McKeldin Treatment Mall Gym., pacing idly. The ADON clarified that he had been brought to the Leisure Education group in error. He was not eligible to attend the group because he had a privilege Level Zero.

3) On Monday, 01/25/10 at 10:30 a.m., the Treatment Mall daily manager OTR2 (Registered Occupational Therapist) and staff person DCA4 stated that there would be no scheduled groups or activities occurring in the gymnasium that day during the Treatment Mall time (10:30 a.m. until 2:00 p.m.). OTR2 stated that on that day (01/25/10), there were nine patients in the McKeldin Building who were Level Zero 00 status and that "their privileges to attend groups have been suspended unless the group is held on the unit." Patient G18 remained in the gymnasium until 2:00 p.m. on 01/25/10, except for going to lunch from 11:30 a.m. until noon. He was observed at 1:15 p.m., sleeping in his chair in the corner of the gymnasium.

4) In an interview on Tuesday, 01/26/10 at 11:00 a.m., nursing supervisor RN8 stated that the treatment team had reviewed Patient G18's level that morning (01/26/10) at 8:30 a.m. and that he would be remaining at Level Zero00 status until the following morning (01/27/10) when his status would be reviewed again. She explained that, when a patient's level is changed from Zero to One, the change does not go into effect until 2:00 p.m. on the day of the change, i.e. after the treatment mall activities ended for the day. Thus she made it clear that, in practice, being placed on a Level Zero meant that the patient could not attend treatment mall therapeutic programming for a minimum of two days.

5) In an interview on 01/26/10 at 11:30 a.m. MD7 stated that Patient G18 "does not handle boredom and free time very well. When he is bored, he gets into trouble and that is almost every weekend." The physician acknowledged that the patient's Level Zero status contributed to his being bored and becoming a behavioral problem.

6) In an interview on 01/26/10 at 2:30 p.m. in the administrative conference room, OTR3 stated that Patient G18 did not attend the unit activity that she led on 01/25/10. She acknowledged that the group that she led at 3:00 p.m. on 01/25/10 was the only therapeutic activity throughout the entire day that Patient G18 was permitted to attend due to his Level Zero status. She stated that she had not individually approached Patient G18 to ask him to participate in that group and furthermore that she did not see him at any time throughout the day during her 12-hour shift. She stated that she "assumed" that he was in his room.

7) In a second interview on Wednesday, 01/27/10 at 10:20 a.m., RN8 stated that she had gone to a meeting with the Mall Director on the previous afternoon (01/26/10) at 2:30 p.m. and that staff received "clarification" about permitted activities of patients on Level Zero. She said that, as of that meeting on Tuesday 01/26/10, any change in the patient's level would go into effect immediately and that the patient would not have to wait until 2 p.m. for the level change to take effect. She reiterated that this was a change for McKeldin D, and that prior to the 01/26/10 meeting, changes in status did not take effect until 2:00 p.m. on the day of the change.

4. Sample Patient J1

a. Record Review

1) Patient J11 was a 21-year old Hispanic female admitted with Psychosis, NOS [not otherwise specified] on 1/19/10. She was 27 weeks pregnant and was viewed as hostile and threatening to herself and her unborn child. She was admitted from the County Detention Center and was on a "criminal detainer." At the Detention Center, she reportedly had scratched a correctional officer, was delusional and loud, and she was "maced."

2) The Master/Individual Plan of Care for the patient, dated 1/26/10, stated that, "Haldol concentrate will be used for psychosis" and "patient is to participate in discharge planning group, community living skills group, unit activities, volleyball group, creative arts, evening recreation, leisure education, socialization and exercise groups and music listening."

3) The Salomon C [unit]Program schedule, confirmed to be current by RN2, consisted of the two schedules posted on the Nursing Office window entitled "2009 Salomon C Multi-Disciplinary Treatment Group Schedule" and "Rehabilitation Department Special Activity Schedule" The Salomon C schedule identified both on-unit groups (Level Zero patients can attend) and off-unit groups (Level Zero patients cannot attend). On 1/25/10, the six on-unit groups were listed for the day: "9:30 a.m.-10:30 a.m. Nails Group"; "9:30 a.m.-11:00 a.m. Book Club"; "11:15 a.m.-11:45 a.m. Exercise Group"; "2:30 p.m-3:30 p.m." "Music Listening"; "3:30 p.m-4:30 p.m." "Psychotherapy group"; "6:30 p.m.-7:30 p.m. Arts and Games." Three of these groups were not held as scheduled. The Special Activity Schedule listed only out-of-building activities that patients with Privilege Level Zero could not participate in.

b. Interviews

1) In an interview on 1/25/10 at 10:15 a.m., RN2 stated that patients on "criminal detainer" on unit Salomon C must stay on Privilege Level Zero, and that they are not to leave the unit. These patients may attend on-unit unit groups.

2) In interview on 1/26/10 at 1:20 p.m., Patient J11 stated that since her 1/9/10 admission, she had not participated in any groups, had not received any group or individual therapy, and was bored.

3) In an interview on 1/27/10 at 10:55 a.m., LPN2 clarified that "the board" listed a total of seven patients who had privilege Level Zero that day, including Patient J11.

c. Observations

1) On 1/25/10 at 10:00 a.m., Patient J11 was pacing idly on Salomon C.

2) On 1/25/10 at 10:15 a.m., the surveyor asked to be directed to the Nails Group scheduled to occur on Mondays between 9:30 a.m. and 10:30 a.m. and was told by RN2 that the group was already over.

3) On 1/26/10 at 1:30 p.m., the surveyor went to observe the scheduled Salomon C Recreation Skills group. The group did not convene. RN10 stated that she didn't know why the group did not occur and that she had not been informed that it was cancelled. At the time RN10 confirmed that 18 of 20 patients, including Patient J11, were on the unit. The surveyor waited until 1:50 p.m.; the group never started.

4) On 1/27/10 at 10:45 a.m., the surveyor went to Salomon C to observe the scheduled 10:30 a.m.-11:00 a.m. Relaxation Group on the unit. No group of any kind was found on Salomon C. RN11 could offer no explanation and was not informed of any change in schedule.

5. Non-Sample Patient E11

a. Record Review

1) According to the facility census report provided by the PI Director on 1/25/10 at 10:00a.m., Patient E11 was a 45 year old woman admitted on 7/21/1997.

2) According to the "Review/Individual Plan of Care" dated 1/12/10, patient E11 was to attend the Treatment Mall "5x/week[sic] and attend at least 2 groups/day for 50 minutes each," to address her mood instability and discuss her discharge plans.

b. Interview

In interview on 1/26/10 at 1:20 p.m. RN1 identified Patient E11 who at the time was sleeping in a wheelchair against the wall in the Treatment Mall gym. RN1 stated that Patient E11 frequently refuses to attend her groups.

c. Observation

Between 1/25/10 and 1/26/10 Patient E11 was observed sleeping in a wheelchair in the Treatment Mall gym during both morning and afternoon treatment mall sessions and at no time were any staff attempts to interact with her observed.

6. Non-Sample Patient E13

a. Record Review

1) According to the facility census report provided by the PI Director on 1/25/10 at 10:00 a.m., Patient E13 was a 58 year old woman admitted on 2/28/07.

2) According to the Treatment Mall schedule, effective 1/4/10 for Patient E13, and provided by the CEO on 1/26/10 at 1:00 p.m., the patient was scheduled to attend five groups per day Monday-Thursday between the hours of 9:00 a.m. and 1:50 p.m., with the exception of the 11:30-12:10 lunch period, and three groups on Friday mornings between 9:00 a.m. and 11:20 a.m.

b. Interview

On 1/25/10 at 1:20 p.m. in the McKeldin gym, 18 patients were counted in the gym group. RN1 identified eight patients in the gym who were assigned to Level Zero. These were sample patients E1, E2, E20, and G18 and at least four non-sample patients E13, F9, F15 and F18 previously observed in the gym. RN1 stated that these patients would not be permitted to attend group until they had received privilege Level One.

c. Observation:

Patient E13 was observed to be idly pacing in the McKeldin Treatment Mall gym on every occasion the surveyor was present, including 1/25/10 between 12:20 p.m. and 2:00 p.m., 1/26/10 between 12:40 p.m. and 2:00 p.m., and on 10/27/10 between 10:00 a.m. and 10:45 a.m. At no time was any staff member observed attempting to directly engage the patient in some type of therapeutic interaction.

7. Non-Sample Patient F9

a. Record Review

1) According to the "Multidisciplinary Admission Assessment" dated 8/10/09, Patient F9 is a 30 year old Asian American female who was admitted on 8/10/09.

2) According to the "Review/Individual Plan of Care." dated 12/14/09 Patient was to attend 18 hours of therapeutic groups at the treatment mall per week.

3) According to the Treatment Mall schedule effective 1/4/10 Patient F9 was scheduled for four groups per day, Monday through Thursday between the hours of 9AM and 1:50PM except for the 11:30-12:10 PM lunch period and two groups on Fridays between 9AM and 11:20AM.

b. Observation:

Patient F9 was observed to be sleeping with her head on a table or idly pacing in the McKeldin Treatment Mall gym on every occasion the surveyor was present, including 1/25/10 between 12:20 p.m. and 2:00 p.m., 1/26/10 between 12:40 p.m. and 2:00 p.m., and on 10/27/10 between 10:00 a.m. and 10:45 a.m. At no time was any staff member observed attempting to directly engage the patient in some type of therapeutic interaction.

c. Interview

On 1/25/10 at 1:20 p.m. in the McKeldin gym, 18 patients were counted in the gym group. RN1 identified eight patients in the gym who were assigned to 000. These were sample patients E1, E2, E20, and G18 and non-sample patients E13, F9, F15 and F18. RN1 stated that these patients would not be permitted to attend group until they had received privilege level 1. RN1 stated that patient F9 was on a 00 because of being caught with contraband on two occasions, once with a cigarette lighter and the second time with cigarettes. The patient was not permitted to attend any groups on 00.

8. Non Sample Patient F15

a. Record Review

1) According to the facility census report provided by the PI Director on 1/25/10 at 10:00a.m., Patient F15 was a 37 year old male who was admitted on 7/02/04.

2) According to the "Treatment Mall Schedule" effective 1/4/10 for Patient F18 provided by the CEO on 1/26/10 at 1:00p.m., the patient was scheduled to attend four groups per day Monday-Thrusday, between the hours of 9:00a.m. and 1:50 p.m. with the exception of the 11:30a.m.-12:10 p.m. lunch period, and two groups on Friday morning between 9:300a.m. and 11:20 a.m.

3) According to the "Review/Individual Plan of Care," dated 12/7/09, Patient F15 was to attend "18hrs [sic]" of multidisciplinary groups at the TX Mall with emphasis on "appropriate skill development and community living skills." Additionally it stated that, Patient F15 "attended 0 Treatment Mall groups between 11/9/09 and 12/7/09, he continues to pace, chant, and speak to unseen others."

b. Observation

1) Patient F15 was observed to be sitting on a bench or a chair or pacing in the McKeldin Treatment Mall gym on every occasion the surveyor was present including 1/25/10 between 12:20p.m. and 2:00 p.m., 1/26/0 between 12:40 p.m. and 2:00 p.m., and on 1/27/10 between 10:00 a.m. and 10:45 a.m. At no time was any staff member observed attempting to directly engage the patient in some type of therapeutic interaction.

c. Interview

2) On 1/25/10at 1:20p.m. in the McKeldin gym, 18 patients were counted as present. RN1 identified at least eight patients in the gym who were assigned to privilege Level Zero or refused to attend groups. RN1 stated that Patient F15 who was present refused to attend groups.

9. Non-Sample Patient F18

a. Record Review

1) According to the facility census report provided by the PI Director on 1/25/10 at 10:00 a.m., Patient F18 was a 39-year-old African American male who was admitted on 1/30/2007.

2) According to the Treatment Mall schedule effective 1/4/10 for Patient F18 provided by the CEO on 1/26/10 at 1:00 p.m., the patient was scheduled to attend four groups per day Monday-Thursday, between the hours of 9:00 a.m. and 1:50 p.m. with the exception of the 11:30-12:10 lunch period, and two groups on Friday mornings between 9:00 a.m. and 11:20 a.m.

b. Observation

Patient F18 was observed to be sitting on a bench or a chair in the McKeldin Treatment Mall gym on every occasion the surveyor was present including 1/25/10 between 12:20 p.m. and 2:00 p.m., 1/26/10 between 12:40 p.m. and 2:00 p.m., and on 10/27/10 between 10:00 a.m. and 10:45 a.m. At no time was any staff member observed attempting to directly engage the patient in some type of therapeutic interaction.

c. Interview

In an interview on 1/25/10 at 11:00 a.m., patient F18 stated that he was not permitted to attend groups because he was on 00. He stated that he sat in the Mall gym every day. He stated he could not remember when he had privileges.

10. Non-sample patients E10, F12 and F19

1) On 1/25/10 at 1:20 p.m. in the McKeldin gym, 18 patients were counted in the gym group, including non-sample patients, E10, F12, and F19 who were in the gym at the time because they had refused to attend their assigned groups. Patient E10, described as mute, did not verbalize and was pacing without interacting with others. Patient F12 was dressed in a bandanna, crookedly tied around his head while wearing a dirty, poorly groomed beard. The patient's hair was below his shoulders as he aimlessly walked around the room, staring upwards. Patient F19 had asked the surveyor about attending Music Group and attempted several times to talk to the staff at the assignment desk as well as other patients. She was not taken to music group and no alternative intervention was provided during observation.

Based on record review, interview, observation and document review, the facility failed to provide adequate clinical leadership by the Clinical Director (Medical Director), Nursing Director, and the Director of Social Work. Specifically:

I. The Clinical Director (Medical Director) failed to ensure that all patients received: comprehensive psychosocial evaluations, psychiatric evaluations, and active treatment. These failures can result in a compromise of patient care and prolongation of hospitalization. (Refer to B144)

II. The Director of Nursing (DON) failed to assure that patients on Level Zero privilege status and patients who refused to participate in regularly scheduled programming were offered alternative nursing interventions. Failure to ensure active treatment, including alternative interventions when needed, results in patients being hospitalized without benefit of all necessary treatment interventions for recovery, potentially prolonging hospitalization. (Refer to B148)

III. The Director of Social Work did not ensure that all patients received comprehensive psychosocial assessments. A psychosocial assessment was not completed for one active sample patient (J24). The psychosocial assessments for 8 of 16 active sample patients (B16,D5, F10, G18, H15, H22, J11, and J15) did not include conclusions and recommendations for the social worker's role in treatment. These failures result in a lack of professional social work input into the treatment planning process. (Refer to B152).

IV. An appropriate Therapeutic Activity program was not provided for 4 of 16 sample patients (E1, E20, G18, and J11) and 3 non-sample patients (E13, F9, and F18) who were on Level Zero privilege status and were unable to leave their units in order to participate in the majority of regularly scheduled activities. Failure to provide an activities program, based on assessed patient needs, results in patients being hospitalized without benefit of all necessary treatment interventions for recovery, potentially prolonging hospitalization. (Refer to B156).

Based on medical record review and interview, the Medical Director failed to adequately monitor and ensure the quality of Medical Care. Specifically, the Medical Director failed to:

I. Assure completion of a psychosocial assessment for 1 of 16 sample patients (K24) and that the psychosocial assessments for 8 of 16 sample patients (B16, D5, F10, G18, H15, H22, I14, and J11) included conclusions and recommendations for social work roles in treatment. This results in a lack of professional social work input into treatment team planning. (Refer to B108).

II. Assure that memory function was assessed during the psychiatric evaluations for 11 of 16 active sample patients (A2, B16, B22, C12, D5, E2, F10, G18, H14, I14, and K24), and that the methods used for assessing memory, orientation and intelligence were described for 6 of 16 sample patients (C12, E2, F10, G18, H14, and K24). Lack of memory assessments can lead to failure to identify conditions that impact treatment. Failure to describe the methods used for testing results in inability to make comparisons when re-evaluating memory functioning. (Refer to B116).

III. Ensure that active treatment was provided for 4 of 16 active sample patients (E1, E20, G18, and J11) and 3 non-sample patients (E13, F9, and F18) who were on a Privilege Level "Zero" and five non-sample patients (E10, E11, F12, F15 and F19) who had refused to attend their assigned groups, and were confined in the Treatment Mall gym without participation in program activities and without provision of alternative treatment. The unjustified withholding of treatment results in patients being hospitalized without benefit of all necessary treatment interventions for recovery (Refer to B125).

Based on record review, interview, and document review, the Director of Nursing (DON) failed to ensure that nurses provided alternative treatment modalities for 4 of 16 active sample patients (E1, E20, G18, and J11) and 3 non-sample patients (E13, F9, and F18) who were on a Level Zero privilege status and could not participate in regularly scheduled programming, and five non-sample patients (E10, E11, F12, F15 and F19) who were confined in the Treatment Mall gym because they had refused to attend their assigned groups. Failure to ensure active treatment, including alternative nursing interventions when needed, results in patients being hospitalized without benefit of all necessary treatment interventions for recovery, potentially prolonging hospitalization.


Findings are:

1. Sample Patient E1.

a. According to the Annual Psychiatric Evaluation dated 12/16/09, Patient E1 was admitted on 12/16/08 for schizoaffective disorder, bipolar type and continued to be hospitalized because of "assaultive behavior, multiple assaults and command hallucinations."

b. The Master/Individual Plan of Care for Patient E1, dated 12/22/09, listed interventions "18 hours of tx [treatment] mall programming 5 days a week" and "quiet time in bedroom offered by staff."

c. On 1/25/10 between 12:20 and 2:00 p.m., the surveyors observed the Patient E1 in the McKeldin Mall gym. He was sitting on a bench in wrist/waist/ankle restraints. He sat on the bench for the entire time period, sleeping or otherwise looking very drowsy, without any attempted engagement by a nursing staff member. At approximately 1:00 p.m., the Mall/clinical nurse specialist (CNS1) announced on a microphone that a staff member would be offering a fitness group. Patient E1 was physically unable to participate in Fitness Group because he was in wrist/waist/ankle restraints (and at privilege Level Zero). The nursing staff provided no alternative treatment for the patient.

2. Sample Patient E20.

a. The Master/individual plan of care for the patient, dated 12/31/09, stated "patient will attend treatment mall 5 days/wk [sic]" and "quiet room offered by nursing staff." According to the medical record, the patient became agitated in the gymnasium on 1/25/10 (10:38 pm) and attacked another patient. He was put in mechanical restraints, which is an automatic Level Zero privilege status. Neither of the interventions on the treatment plan was observed to occur during observations on 1/25/10 or 1/26/10. He was not permitted to attend an "Anger Management" group led by MD5, and no alternative treatment was offered.

b. In an interview at 12:30 p.m. in the gym, MD5 stated that Patient E20 needed the Anger Management group, but that he would not be permitted to attend because, after such an incident as the fight, the policy is that patients involved are bumped to a Level Zero and consequently cannot leave the gym to attend therapeutic treatment.

3. Sample Patient G18.

a. A review of Patient G18's medical record on 01/28/10 at 9:30 a.m. revealed no documentation of unit groups or activities that the patient attended on 01/25/10 and 01/26/10. The record noted that because of an incident on 01/24/10, the patient was on privilege Level Zero and was not allowed to attend any groups or activities off the unit.

b. During an observation in the Treatment Mall gym on Monday, 01/25/10 at 10:30 a.m., Patient G18 was asked what daily activities he would be attending that day. He stated, "I'm a Level Zero. I can't go to any activities. I'll be in the gym until 2:00 p.m. today. Then I will go back to my room and sleep until dinner."

c. Other observations on 01/25/10 revealed that the patient remained in the gymnasium from early morning until 2:00 p.m., except for a half-hour lunch break. Nursing staff offered no alternative treatment during the observations.

d. On 1/26/10 at 10:30 in McKeldin Treatment Mall Gym, Patient G18 was present for the Leisure Education group with RT2. He appeared to be enthusiastically singing to the radio with a peer while walking around the room, and was smiling and responsive to conversation with his peers. He was escorted out of the room at 10:40 a.m. Later that day at 11:00 a.m., Patient G18 was observed in the McKeldin Treatment Mall Gym, pacing idly. The ADON stated that he had been brought to the earlier Leisure Education group in error; he was removed because he was not eligible to attend while on privilege Level Zero.

4. Sample Patient J11.

a. Patient J11 was a 21-year old Hispanic female admitted from the County Detention Center on 1/9/10 on a "criminal detainer." With the "detainer," she was on privilege Level Zero.

b. The "Master/Individual Plan of Care, dated 1/26/10, stated that the patient was to participate in "discharge planning group, community living skills group, unit activities, volleyball group, creative arts, evening recreation, leisure education, socialization and exercise groups and music listening."

c. On 1/25/10 at 10:00 a.m., Patient J11 was seen, pacing idly on the Salomon C Unit. Other observations on the unit on 1/26/10 and 1/27/10 revealed that several of the scheduled groups did not occur.

d. In an interview on 1/26/10 at 1:20 p.m., Patient J11 stated that since her 1/9/10 admission, she had not participated in any groups and there was nothing occurring on the unit to keep her occupied during the day, on any evening or on weekends.

5. Non-sample patient E11

a. The facility census report provided by the PI Director on 1/25/10 at 10:00 a.m. showed that Patient E11 was a 45 year old woman admitted on 7/21/1997.

b. According to the "Review/Individual Plan of Care" dated 1/12/10, patient E11 was to attend the Treatment Mall "5x/week[sic] and attend at least 2 groups/day for 50 minutes each," to address her mood instability and discuss her discharge plans.

c. In interview on 1/26/10 at 1:20 p.m. RN1 identified Patient E11 who at the time was sleeping in a wheelchair against the wall in the Treatment Mall gym. RN1 stated that Patient E11 frequently refuses to attend her groups.

d. Observations in the Treatment Mall gym during the mornings and afternoons on 1/25/10 and 1/26/10 showed Patient E11 sleeping in a wheelchair during both morning and sessions. During the observations, there were no staff attempts to interact with her.

5. Non-Sample Patient E13.

a. This patient was a 58 year old woman admitted on 2/28/07. According to the Treatment Mall schedule, she was supposed to attend five groups per day Monday- Thursday, between the hours of 9:00 a.m. and 1:50 p.m. and three groups on Friday mornings between 9:00 a.m. and 11:20 a.m.

b. Observations on 1/25/10 (12:20 p.m.-2:00 p.m.), 1/26/10 (12:40 p.m.-12:00 p.m.), and on 10/27/10 (10:00 a.m.-10:45 a.m.) found Patient E13 pacing the halls. At no time was any nursing staff member observed encouraging her go to group activities or attempting to engage her in some type of therapeutic interaction.

6. Non-Sample Patient F9.

a. According to the "Multidisciplinary Admission Assessment dated 8/10/09, this patient was a 30 year old Asian American female who was admitted on 8/10/09."

b. According to the "Review/Individual Plan of Care," dated 12/14/09, the patient was to attend 18 hours of therapeutic groups at the treatment mall per week. On the Treatment Mall schedule, she was scheduled for four groups per day, Monday through Thursday between the hours of 9:00 a.m. to 1:50 p.m. (excluding lunch), and two groups on Fridays between 9:00 a.m. and 11:20 a.m.

c. Observations in the McKeldin Treatment Mall gym found the patient sleeping with her head on a table or idly pacing on 1/25/10 (12:20 p.m.-2:00 p.m.), 1/26/10 (12:40 p.m.-2:00 p.m.), and 10/27/10 (10:00 a.m.-10:45 a.m.). At no time was any nursing staff member observed attempting to engage the patient in some therapeutic interaction.

d. In an interview on 1/25/10 at 1:30 p.m., RN1 stated that patient F9 was on a Level Zero because of being caught with contraband on two occasions, once with a cigarette lighter and the second time with cigarettes. The patient was not permitted to attend any groups because of her Level Zero status.

7. Non-Sample Patient F18.
a. According to the facility census report provided by the PI Director on 1/25/10 at 10:00 a.m., Patient was a 39-year-old African American male who was admitted on 1/30/2007.
b. The Treatment Mall schedule showed that the patient was to attend four groups per day Monday-Thursday, between the hours of 9:00 a.m. and 1:50 p.m. (excluding lunch time) and two groups on Friday mornings between 9:00 a.m. and 11:20 a.m.
c. Patient F18 was observed to be sitting on a bench or a chair in the McKeldin Treatment Mall gym on 1/25/10 (12:20 p.m.-2:00 p.m.), 1/26/10 (12:40 p.m.-2:00 p.m.), and 10/27/10 (10:00 a.m.-10:45 a.m.). No staff attempted to engage the patient in therapeutic interactions at these times.

d. In an interview on 1/25/10 at 11:00 a.m., patient F18 stated that he was not permitted to attend groups because he was on Level Zero. He stated that he sat in the Mall gym every day. He stated he could not remember when he had privileges.

8. Non-sample patients E10, F12 and F19

On 1/25/10 at 1:20 p.m., non-sample patients, E10, F12, and F19 who had previously refused to attend their assigned groups were observed in the McKeldin Treatment Mall gym. Patient E10 was pacing around the gym without interacting with others. Patient F12 was dressed in a bandanna, crookedly tied around his head while wearing a dirty, poorly groomed beard. The patient's hair was below his shoulders as he aimlessly walked around the room, staring upwards. Patient F19 had asked the surveyor about attending Music Group and attempted several times to talk to the staff at the assignment desk as well as with other patients. She was not taken to music group; no alternative intervention was provided during observation.

Based on record review and interview, the Director of Social Work failed to monitor and evaluate the quality and appropriateness of social services provided. A psychosocial assessment was not completed and documented for one sample patient (K24). The psychosocial assessments for 8 out of 16 sample patients, (B16, D5, F10, G18, H15, H22, I14, and J11) failed to include conclusions and recommendations for the social worker's role in treatment. These failures result in a lack of professional social work input into the treatment planning process.

Findings are:

A. Record Review:

1. Patient Specific Findings

a. No Psychosocial Assessment Completed

Review of the Social Work Multidisciplinary Admission Assessment for patient K24, admitted 10/14/09, showed that the assessment was blank and had not been completed. The section entitled "Social Work Interventions" was blank and identified no recommendations for social work interventions.

b. Psychosocial assessments that did not include conclusions and recommendations that described anticipated social work roles in treatment.

1. Patient B16

Review of the Social Work Multidisciplinary Admissions Assessment dated 8/21/09 for the patient, admitted on 8/17/09, found under the Social Work Interventions section the following: "Additional Background Material and, Liaison with Family/Significant Other(s)." Both activities were routine social work functions and not therapeutic interventions specific to the patient's assessed needs.

2. Patient D5

Review of the Social Work Multidisciplinary Annual Assessment dated 8/13/09 for the patient, admitted on 8/9/04, listed the following "Social Work Recommendations/planned interventions:" "medication, group therapies, individual meetings, and social worker as needed." These activities are either areas of other disciplines or are generic social work functions that as stated would be provided as needed only instead of individualized treatment services consistent with the assessed treatment needs of the patient.

3. Patient F10

The Social Work Multidisciplinary Admission Assessment dated 7/31/07 for the patient, admitted 7/25/07, listed "Additional Background Material and continue offering supportive services in an effort to locate relatives as needed." This activity is a generic social work function and not a therapeutic intervention specific to the patient's assessed needs.

4. Patient G18

The Social Work Multidisciplinary Annual Assessment (undated) for the patient, admitted 1/10/07, listed "medication, TX (sic) mall groups, supportive counseling per tx (sic) team and social work as needed." These activities are either tasks for other disciplines or are generic social work functions and are not therapeutic social work interventions specific to the patient's assessed needs.

5. Patient H15

The Social Work Multidisciplinary Annual Assessment dated 7/31/09 for the patient, admitted 7/25/07, listed "Additional Background Material and continue offering supportive services in an effort to locate relatives as needed." This activity is a generic social work function and not a therapeutic intervention specific to the patient's assessed needs.

6. Patient H22

Review of the Social Work Multidisciplinary Admission Assessment (undated or signed) for the patient, admitted 10/15/10, revealed the following notations under the section entitled Social Work Interventions: "liaison with family/significant other" Liaison with the family is a generic social work function, not an individualized treatment intervention.

7. Patient I14

Review of the Social Work Multidisciplinary Admission Assessment dated 1/14/10 for the patient, admitted 1/7/10, showed that the section entitled Social Work Interventions identified no recommendations for social work interventions.

8. Patient J11

Review of the Social Work Multidisciplinary Admission Assessment dated 1/22/10 for the patient, admitted 1/19/10, determined that the section entitled Social Work Interventions only consisted of "liaison with family/significant other." Liaison with the family is a generic social work function, not an individualized treatment intervention.

B. Interviews

In an interview on 1/26/10 at 2:35 p.m., the Social Work Director (SWD) corroborated the surveyors' findings concerning the psychosocial assessments. The SWD also stated that he did not conduct any quality assurance monitoring of the psychosocial assessments.

Based on record review, observation and interview, the facility failed to provide a Therapeutic Activity program for 4 of 16 sample patients (E1, E20, G18, and J11) and 3 non-sample patients, (E13, F9, and F18) who were on a Privilege Level Zero and were unable to leave their units to participate in the majority of recreational opportunities. The primary leisure, spiritual and recreational offerings during the evenings and weekends were located in buildings that were not accessible to these patients. The hospital's failure to provide appropriate and sufficient therapeutic, leisure and recreation activities results in patients being hospitalized without benefit of all necessary treatment interventions for recovery, potentially prolonging hospitalization.

Findings are:

A. Observations

1. On 1/25/10 at 10:00 a.m., Patient J11 was observed, pacing idly on Salomon C Unit.

2. On 1/26/10 at 9:35 a.m., during the "Music Therapy" group time in the McKeldin Building, five patients were pacing idly, including patient E20. Approximately ten other patients were sitting in various parts of the Day Room. Activity Therapist Aide ATA1, the group leader, was sitting at a table, working with a music recorder. The Assistant Director of Nursing (ADON), who was present, noted that the setting was too disorganized to provide a meaningful Music Group. The setting and level of demonstrated skill was insufficient to establish or sustain adequate intensity and focus to facilitate a therapeutic experience.

3. Observations on the Solomon C Unit (1/26/10; 1:30 p.m.) revealed that the scheduled Recreation Skills group, (start time 1:30 p.m.) did not occur. This was a group that patients on Level Zero could have attended.

4. An observation on Solomon C on the morning of 1/27/10, revealed that the on-unit 10:30 a.m.-11:00 a.m., Relaxation (OT) Group did not occur. This was a group that patients with privilege Level Zero could have attended. RN10 stated that she was not notified of the reason for the group cancellation without notice to the nursing staff or patients.

C. Interview

1. In an interview on 1/25/10 at 10:15 a.m. concerning Patient J11, RN2 stated that patients on "criminal detainer" residing on the Salomon C Unit must stay on privilege Level Zero, and they are not to leave the unit. She added that groups for these patients only occur on the unit.

2. In an interview on 1/26/10 at 1:20 p.m., Patient J11 stated that since her 1/9/10 admission, she had not participated in any groups. She noted that there was nothing for her to do on the unit. She said she did not know of any activity groups occurring on the unit at any time during the day, evenings or on weekends.

3. In interview on 1/26/10 at 10:50 a.m., OTR1(Registered Occupational Therapist) stated that she could not identify the individual treatment needs of the patients in the Gym that day for which she was assigned to serve as Mall Manager. At the time, approximately 20 patients were present in the Gym.

4. In an interview on 1/26/10 at 2:00 p.m. concerning her hospital wide staffing, the Director of Rehabilitation agreed that the "Rehabilitation Services Department's Special Activity Schedule for 2010" is "predominantly oriented towards patients with privilege Levels Three and Four." The Director also acknowledged that patients with privilege Level Zero do not receive benefit of the regularly scheduled leisure, spiritual and recreational services provided by the rehabilitation services department because these activities do not occur on their units. The Director added that the Sunday schedule is limited to support for church services which occur in the "Big G" Building. These services are only available to patients who can attend out of building activities.

5. In the same interview as above, the Director of Rehabilitation stated that she does no formal Quality Assurance monitoring of the needs of the patients in order to design and develop a program schedule based upon the patients' individual needs. The Director also had no explanation for why the Solomon C Recreation Skills group, scheduled for 1/26/10 at 1:30 p.m. did not occur, or why the Salomon C nursing staff had not been informed of a change in program schedule.