HospitalInspections.org

Based on observation, interview, medical record review, and document review, there was a systemic failure by the facility to document the provision of comprehensive assessments and active treatment for each patient by facility staff who provided clinical services. Specifically, the facility failed to:

I. Ensure that: (1) social work assessments for two (2) of eight (8) sample patients (A6 and A7) were completed before treatment planning occurred so that critical information could be provided for the development of the comprehensive treatment plan; (2) social work assessments for three (3) of eight (8) sample patients (A1, A5, and A8) included sufficient factual and historical information on which to base treatment recommendations; and (3) social work assessments for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) included recommendations regarding the role of the social worker in treatment and discharge planning. The absence of essential findings from social work assessments at the time Master Treatment Plans were developed and specific recommendations on the role of the social worker in treatment provision and discharge planning does not allow the treatment team to integrate the social worker into the delivery of care and prevents the treatment team from clarifying treatment interventions and goals related to the patient's psychosocial needs. (Refer to B108).

II. Ensure that the psychiatric assessments for seven (7) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, and A7) included all necessary information to justify the patient's diagnosis (es) and planned treatment. Various content areas in the psychiatric assessments were not completed, including information on substance use and details of the patient's family/educational/vocational/occupational/social histories. The absence of this information compromises the treatment team's ability to formulate an accurate diagnostic view of the patient and limits the team's ability to formulate a meaningful plan of care to meet the patient's individual needs. (Refer to B110)

III. Ensure that the psychiatric assessments for two (2) of eight (8) sample patients (A3 and A6) included a complete mental status evaluation of the patient. The absence of this information compromises the treatment team's ability to formulate an accurate diagnostic view of the patient and limits the team's ability to formulate a meaningful plan of care to meet the patient's individual needs. (Refer to B113)

IV. Ensure that the psychiatric assessments for two (2) of eight (8) sample patients (A3 and A6) included an estimate of intellectual functioning, memory functioning, and orientation. Lack of this basic clinical information can negatively affect decision-making on the need for further evaluation. Without more detailed information about a patient's orientation, level of intellectual functioning, and/or memory functioning, it is not possible to know the specific extent of the patient's capacity or impairment so that appropriate treatment modalities can be chosen, and/or so that changes in response to treatment can be measured. (Refer to B116)

V. Ensure that the psychiatric assessments for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) included an inventory of the patient's assets in descriptive and interpretive fashion. This deficient practice results in insufficient information to guide the treatment team in developing appropriately individualized plans of care for their patients and limits the team's ability to engage patients in therapy. (Refer to B117)

VI. Ensure that the Master Treatment Plans (MTPs) were revised when the patients two (2) of eight (8) patients (A6 and A7) failed to participate in the active treatment program. Master treatment plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of all patients. (Refer to B118-I)

VII. Develop and document comprehensive interdisciplinary treatments for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Instead, treatment plans were completed separately by clinical disciplines. Each discipline formulated a problem statement, short-term goals, and interventions for MTPs. However, these MTPs were not developed using a consensus agreement among clinical staff during treatment team meetings. This practice fails to reflect input by all team members resulting in the potential to compromise patients' opportunity to receive appropriate treatment measures. (Refer to B118-II)

VIII. Ensure that MTPs contained interventions for all disciplines involved in providing active treatment and that interventions included a specific focus of treatment. Specifically, there were no interventions listed for recreational therapy staff to provide active treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This deficiency results in failure to guide treatment staff to achieve measurable, behavioral outcomes for therapeutic activities provided to patients. (Refer to B118 - III & B122)

IX. Provide comprehensive Master Treatment Plans (MTPs) that were individualized and included all required components for eight (8) of eight (8) active sample patients (A2, A3, A4, A5, A6, A8¸ A9 and A10). Failure to develop Master Treatment Plans with all the required components hampers the staff's ability to provide coordinated multidisciplinary care; potentially resulting in patient's treatment needs not being met. Specifically, the facility failed to:

A. Ensure clearly defined and descriptive psychiatric problem statements were developed to improve or resolve problems prior to discharge for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). In addition, MTPs did not include medical problems identified in physical examinations of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). These failures result in treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems and medical needs. (Refer to B119).

B. Ensure that the written treatment plans for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) and for added active non-sample patient B1 included substantiation of the psychiatric and medical diagnoses that would form the basis for treatment. Lack of confirmation of diagnoses compromises the treatment team's ability to generate a comprehensive problem list for which specific treatment modalities would be delineated and implemented. Meaningful and complete patient care cannot be provided without diagnostic clarity for both psychiatric and medical conditions. (Refer to B120)

C. Ensure that the written treatment plans for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) and for active non-sample patient B1 included short term and long-term goals described in observable and measurable terms and based on the problems identified for treatment. This results in a treatment plans that fail to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients and creates the potential that the treatment plan will fail to address patient needs during the course of hospitalization and at discharge. (Refer to B121)

D. Develop individualized treatment plans that clearly delineated active treatment interventions to address specific patient problems and assist patients to accomplishment treatment goals for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). These deficiencies potentially result in staff being unable to provide consistent and focus active treatment. (Refer to B122)

X. Ensure that treatment notes were written to reflect patients' response to treatment efforts for five (5) of eight (8) active sample patients (A1, A3, A4, A5 and A6). Specifically, active treatment interventions listed on Master Treatment Plans (MTPs) and/or attended by patients were not documented in the medical record to include the patients' attendance or non-attendance. When patients attended active treatment sessions, there was no documentation regarding specific topics discussed, patients' behavior during interventions, their response to interventions (level of participation and understanding), and specific comments by patients. This failure results in information regarding active interventions and the response to these interventions not being available for the treatment team to assist in evaluating each patient's progress. (Refer to B124)

XI. Ensure that active treatment measures, such as group treatment, individual treatment, and therapeutic activities, were provided to two (2) of eight (8) active sample patients (A6 and A7) who were unwilling to participate in and/or attend groups. Specifically, these patients spent many hours without any appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125-I)


XII. Ensure proper documentation of a restraint procedure for added active non-sample patient B3. Specifically, staff used a chemical restraint to manage the patient's behavior and because unit staff did not consider this as a restrictive procedure, the required face-to-face assessment documentation was not completed. In addition, the facility failed to track the use of physical holds when patients become agitated, were given forced medications, or redirected against their will. There were also no policy guidelines and procedures to direct staff when physical hold procedures were used. These failures result in a restriction of the patient's rights without adequate documented justification and demonstrated unsafe practices that can potentially result in serious outcomes for patients. (Refer to B125-II)

XIII. Ensure that activity staff documented progress notes for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, there were no progress notes written by the recreational therapy staff that showed each patient's progress or lack of progress related to problems and treatment goals identified on Master Treatment Plans (MTPs). This deficiency results in an absence of information regarding patients' progress and level of functioning being available to treatment team members thereby resulting in the potential for delayed discharge. (Refer to B129)

Based on record review and interview, the facility (1) failed to ensure that the social work assessments for two (2) of eight (8) sample patients (A6 and A7) were completed before treatment planning occurred so that critical information could be provided for the development of the comprehensive treatment plan; (2) failed to ensure that the social work assessments for three (3) of eight (8) sample patients (A1, A5 and A8) included sufficient factual and historical information on which to base treatment recommendations; and (3) failed to ensure that the social work assessments for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) included recommendations regarding the role of the social worker in treatment and discharge planning. Completion of social work assessments after the treatment planning meeting has taken place does not allow for essential psychosocial information to be integrated into the care planning process. For those assessments completed on time, the absence of critical information from the social work assessment prevents the treatment team from addressing essential patient needs during the course of hospitalization, from formulating the patient's discharge plan, and from ensuring the patient's safe re-entry into the community. The absence of specific recommendations on the role of the social worker in treatment provision and discharge planning does not allow the treatment team to integrate the social worker into the delivery of care and prevents the treatment team from clarifying treatment interventions and goals related to the patient's psychosocial needs.

Findings include:

A. Record Review

The social service assessments of the following patients were reviewed (dates of evaluations, as documented by the social worker's signature and date at the end of the report, are in parentheses): A1 (4/26/16); A2 (5/9/16); A3 (3/29/16); A4 (4/27/16); A5 (5/6/16); A6 (4/20/16); A7 (5/9/16); and A8 (5/6/16). This review revealed:

1. Patient A1: The Interim Social Assessment provided no information on the patient's past biopsychosocial functioning, family/marital history, pertinent religious and cultural factors, significant aspects of psychiatric/medical/substance abuse history and treatment, or educational/vocational/employment history. The Social Service Assessment from a previous admission within the calendar year, which would have included the missing information, was not brought forward and included in the medical record for the current admission. In addition, no specific recommendations on the social worker's role in treatment and discharge planning were provided.

2. Patient A2: The Social Service Assessment provided no specific recommendations on the social worker's role in the patient's treatment and discharge planning.

3. Patient A3: The Social Service Assessment provided no specific recommendations on the social worker's role in the patient's treatment and discharge planning.

4. Patient A4: The Social Service Assessment provided no information on the patient's past psychiatric history (patient carries the diagnosis of Schizophrenia in addition to Dementia) and provided no specific recommendations on the social worker's role in the patient's treatment and discharge planning.

5. Patient A5: The Interim Social Assessment provided no information on the patient's past biopsychosocial functioning, family/marital history, pertinent religious and cultural factors, significant aspects of psychiatric/medical/substance abuse history and treatment, or educational/vocational/employment history. The Social Service Assessment from a previous admission within the calendar year, which would have included the missing information, was not brought forward and included in the medical record for the current admission. In addition, no specific recommendations on the social worker's role in treatment and discharge planning were provided.

6. Patient A6: The Social Service Assessment was not completed until 4/20/16, but the Individualized Comprehensive Treatment Plan was developed on 4/18/16. In addition, the Social Service Assessment provided no specific recommendations on the social worker's role in the patient's treatment and discharge planning.

7. Patient A7: The Social Service Assessment was not completed until 5/09/16, but the Individualized Comprehensive Treatment Plan was developed on 5/05/16. In addition, the Social Service Assessment provided no specific recommendations on the social worker's role in the patient's treatment and discharge planning.

8. Patient A8: The Interim Social Assessment provided no information on the patient's past biopsychosocial functioning, family/marital history, pertinent religious and cultural factors, significant aspects of psychiatric/medical/substance abuse history and treatment, or educational/vocational/employment history. The Social Service Assessment from a previous admission within the calendar year, which would have included the missing information, was not brought forward and included in the medical record for the current admission. In addition, no specific recommendations on the social worker's role in treatment and discharge planning were provided.

B. Staff Interview

An interview was conducted with the Director of Social Work on 5/10/16 at 4:00 p.m. When the two social work assessments completed after the treatment planning meeting for the identified patients (A6 and A7) were discussed, the Director of Social Work acknowledged that the assessments were not completed before the treatment planning meeting was held. In discussing the Social Service Assessments and Interim Social Assessments of the sample patients, the Social Work Director stated "I don't disagree" when it was pointed out that the assessments need to be completed prior to the team convening to develop the Comprehensive Treatment Plan. He stated "I see your point" when only the limited content of the Interim Social Assessments was discussed and concurred ("I agree.") that critical information was missing for treatment planning without the inclusion of the Social Service Assessments developed during a previous admission within the year. When the lack of specific recommendations for the role of the social worker in treatment and discharge planning within the Social Work Assessments and Interim Social Assessments was pointed out, he indicated, "I see." He concluded, "We have some work to do."

Based on record review and interview, the facility failed to ensure that the psychiatric assessments for seven (7) of eight (8) sample patients (A1, A2, A3, A4, A5, A6 and A7) included all necessary information to justify the patient's diagnosis (es) and planned treatment. Various content areas in the psychiatric assessments were not completed, including information on substance use and details of the patient's family/educational/vocational/occupational/social histories. The absence of this information compromises the treatment team's ability to formulate an accurate diagnostic view of the patient and limits the team's ability to formulate a meaningful plan of care to meet the patient's individual needs.

Findings include:

A. Record Review

The Initial Psychiatric Assessments of the following patients were reviewed (dates of evaluations are in parentheses): A1 (4/26/16); A2 (5/7/16); A3 (not dated); A4 (4/27/16); A5 (5/6/16); A6 (4/16/16); A7 (5/5/16); and A8 (5/5/16). This review revealed:

1. Patient A1: Section on "Sexual Orientation" not completed. Section on "Developmental/Childhood Hx" not completed.

2. Patient A2: Sections on "Vocational/Finances/Military" not completed.

3. Patient A3: Section on "Drugs/Etoh/Tobacco" not completed. Section on "Allergies" not completed. Sections on "Language" "Interpretive services" not completed. Section on "Social History" not completed.

4. Patient A4: Section on "Interpretive Services" not completed. Information on the patient's family history not completed. Sections on "Education" and "Religion" not completed. Sections on "Vocational/Finances/Military" not completed. Section on "Developmental/Childhood Hx" reported as "unknown."

5. Patient A5: Section on "Religion" not completed. Sections on "Finances" and "Military" not completed. Information on "Developmental/Childhood Hx" noted as "none."

6. Patient A6: Section on "Allergies" not completed. Section on "Interpretive Services" not completed. The only information provided on the patient's "Developmental/Childhood Hx" was "raised by both parents in Brooklyn."

7. Patient A7: Section on "Interpretive Services" not completed. Section on "Religion" not completed. Sections on "Vocational" and "Finances" not completed. Section on "Military" not completed. Information provided under "Developmental/Childhood Hx" was "none available."

B. Staff Interview

An interview was conducted with the Psychiatric Medical Director and MD1 on 5/10/16 at 12:00 noon. Missing components of the Psychiatric Assessments were reviewed. Both physicians agreed that certain sections were not completed in full.

Based on record review and interview, the facility failed to ensure that the psychiatric assessments for two (2) of eight (8) sample patients (A3 and A6) included a complete mental status evaluation of the patient. The absence of this information compromises the treatment team's ability to formulate an accurate diagnostic view of the patient and limits the team's ability to formulate a meaningful plan of care to meet the patient's individual needs.

Findings include:

A. Record Review

The Initial Psychiatric Assessments of the following patients were reviewed (dates of evaluations are in parentheses): A1 (4/26/16); A2 (5/7/16); A3 (not dated); A4 (4/27/16); A5 (5/6/16); A6 (4/16/16); A7 (5/5/16); and A8 (5/5/16). This review revealed:

1. Patient A3: The mental status exam sections on "Attention/Conc.," "Orientation," "Memory," "Insight," "Judgment," "Intellectual Functioning," and "Abstraction" were blank.

2. Patient A6: The mental status exam sections on "Attention/Conc.," "Orientation," "Judgment," "Intellectual Functioning," and "Abstraction," were blank.

B. Staff Interview

An interview was conducted with the Psychiatric Medical Director and MD1 on 5/10/16 at 12:00 noon. Missing components of the Psychiatric Assessments were reviewed. Both physicians agreed that certain sections were not completed in full.

Based on record review and interview, the facility failed to ensure that the psychiatric assessments for two (2) of eight (8) sample patients (A3 and A6) included an estimate of intellectual functioning, memory functioning, and orientation. Lack of this basic clinical information can negatively affect decision-making on the need for further evaluation. Without more detailed information about a patient's orientation, level of intellectual functioning, and/or memory functioning, it is not possible to know the specific extent of the patient's capacity or impairment so that appropriate treatment modalities can be chosen, and/or so that changes in response to treatment can be measured.

Findings include:

A. Record Review

The Initial Psychiatric Assessments of the following patients were reviewed (dates of evaluations are in parentheses): A1 (4/26/16); A2 (5/7/16); A3 (not dated); A4 (4/27/16); A5 (5/6/16); A6 (4/16/16); A7 (5/5/16); and A8 (5/5/16). This review revealed:

1. Patient A3: The mental status exam sections on "Orientation," "Memory," and "Intellectual Functioning" were blank.

2. Patient A6: The mental status exam sections on "Orientation," and "Intellectual Functioning" were blank.

B. Interview

An interview was conducted with the Psychiatric Medical Director and MD1 on 5/10/16 at 12:00 noon. Missing components of the Psychiatric Assessments were reviewed. Both physicians agreed that certain sections were not completed in full and stated, "There are incomplete sections."

Based on record review and interview, the facility failed to ensure that the psychiatric assessments for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) included an inventory of the patient's assets in descriptive and interpretive fashion. This deficient practice results in insufficient information to guide the treatment team in developing appropriately individualized plans of care for their patients and limits the team's ability to engage patients in therapy.

Findings include:

A. Record Review

The Initial Psychiatric Assessments of the following patients were reviewed (dates of evaluations are in parentheses): A1 (4/26/16); A2 (5/7/16); A3 (not dated); A4 (4/27/16); A5 (5/6/16); A6 (4/16/16); A7 (5/5/16); and A8 (5/5/16). This review revealed that none of the Initial Psychiatric Assessments contained information on patient assets.

B. Interview

An interview was conducted with the Psychiatric Medical Director and MD1 on 5/10/16 at 12:00 noon. Missing components of the Psychiatric Assessments were reviewed. Both physicians agreed that certain sections were not completed in full, including that information on patient assets was not collected -- "Not on our assessment form."

Based on record review, policy review, and interview, the facility failed to:

I. Ensure that the Master Treatment Plans (MTPs) were revised when the patients two (2) of eight (8) patients (A6 and A7) failed to participate in the active treatment program. Master treatment plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Record Review

1. Patient A6 was admitted on 4/15/16. The "Initial Psychiatric Assessment" dated 4/16/16 included the diagnosis of "Major Depressive Disorder." The form titled, "Updates - Master Treatment Plan" on the following dates - 4/25/16, 5/2/16, and 5/9/16 were reviewed. These updates, except for changes in medications, failed to address the patient's non-participation in active treatment or specify revisions to be made in the treatment plan.

2. Patient A7 was admitted on 5/4/16. The "Initial Psychiatric Assessment" dated 5/5/16 included the diagnosis of "Schizophrenia." Despite the Patient A7's low level of functioning and non-participation in active treatment, the MTP was not revised to reflect alternative active treatment approaches based on his/her current level of functioning

B. Policy Review

The facility's policy titled, "Multidisciplinary Comprehensive Treatment Plan Development and Review/Update Process" revised 2/4/16, stipulated, "Treatment plan reviews focus on insuring adequate representation, relevancy, and specificity of current identified problems, goals, and interventions...LTG/STG and respective time frames are reviewed to determine whether the goals: have been achieved...require revision as well as further treatment toward achievement...should be stopped due to current irrelevancy...when it has become apparent that the goal criteria...exceeds patient's current capacity for achievement..."

II. Develop and document comprehensive interdisciplinary treatments for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Instead, treatment plans were completed separately by clinical disciplines. Each discipline formulated a problem statement, short-term goals, and interventions for MTPs. However, these MTPs were not developed using a consensus agreement among clinical staff during treatment team meetings. This practice fails to reflect input by all team members resulting in the potential to compromise patients' opportunity to receive appropriate treatment measures.

Findings include:

A. Observation

During observation of the treatment team meeting on 5/9/16 at 11:00 a.m., the treatment-planning meeting of added active non-sample patient B1 was observed. Although clinical information on patient B1 was shared, there was no collaboration on the development of the problems to be addressed, the treatment modalities to be implemented, the goals for the treatment to be provided, or the role of specific disciplines in carrying out the plan of care. Representation from therapeutic activities was not present in the meeting; and specifics on the problems that therapeutic activities staff could address, the delineation of recommended treatment modalities to be carried out by therapeutic activity staff that would be relevant to the patient, and specific goals for therapeutic activity treatment modalities were not discussed.

B. Policy review

The facility's policy titled, "Multidisciplinary Comprehensive Treatment Plan Development and Review/Update Process" revised 2/4/16, stipulated, "Within 3 days of admission the Multidisciplinary Comprehensive Treatment Team (MCTT) will convene with the patient to formulate an individualized comprehensive treatment plan specific to his/her unique constellation of problems, strengths, and needs. This comprehensive treatment plan development meeting will include a review of available clinical assessments (e.g. Nursing, Psychiatric, Medical, Social Services,...Recreational Therapy, etc.)..."

C. Interviews

1. The staff members present during the treatment planning meeting of active non-sample patient B1 were interviewed on 5/9/16 at 11:30 a.m. When asked why there was no discussion of problems to be addressed and specific treatment modalities to be offered, MD1 responded, "Each discipline writes in their own problems and interventions later." When MD1 was asked if MD1 reviewed the completed treatment plan to ensure that all necessary problems were being addressed and that and necessary modalities were being offered, MD1 responded, "No, I do not do that." The Psychologist responded "I list my interventions in my note and regularly talk with staff." The APN and SW1 agreed with MD1. All confirmed that therapeutic activities personnel were not present in the meeting.

2. An interview was conducted with the Psychiatric Medical Director and MD1 on 5/10/16 at 12:00 noon. The treatment planning process was reviewed. When asked if the attending psychiatrist or APN facilitated a discussion to reach consensus on problems to be addressed and all treatment modalities to be offered, both indicated "No." When asked if the treatment planning discussion specifically addressed which groups led by therapeutic activity staff would be offered to a particular patient, MD1 answered "No."

III. Ensure that MTPs contained interventions for all disciplines involved in providing active treatment were included with a specific focus of treatment. Specifically, there were no interventions listed for recreational therapy staff to provide active treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This deficiency results in failure to guide treatment staff to achieve measurable, behavioral outcomes for therapeutic activities provided to patients. (Refer to B122)

Based on record review, policy review, and interview, the facility failed to ensure that Master Treatment Plans (MTPs) included clearly defined problem statements written in behavioral and descriptive terms for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A6, A7 and A8). Specifically, the stated problems on the treatment plans included diagnostic and/or generalized psychiatric terms rather than behaviorally descriptive psychiatric problems based on clinical assessment data and how presenting symptoms were specifically manifested by each patient. In addition, MTPs did not address medical problems identified in physical examinations of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) despite these patients having multiple medical problems. These failures can adversely affect clinical decision-making in formulating goal and intervention statements and results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric and medical problems.

Findings include:

I. Psychiatric Problem Statements

A. Record and Document Review

1. Patient's A1's MTP dated 4/26/16 listed the following problems: "Presenting Psychiatric Problems:

Psychiatrist/APN
"Aggression - R/O [rule out] paranoia, Mood lability, isolative, care refusal."

Nursing
"Pt [Patient] will refrain from behavioral displays which jeopardize the immediate safety of self/other."

Psychology
Same as Psychiatrist/APN but added, "Non compliance - meds [medication] care."

Social Worker
"Pt [Patient] reports dissatisfaction with LTC [Long Term Care], requests exploring alternatives at D/C [discharge]."

Recreation
There was no problem statement identified by recreational therapy staff.

These problem statement failed to include descriptions related to how precisely this patient manifested aggressive behaviors, mood lability, care resistance, and non-compliance. The nursing problem statement was actually a patient outcome not a problem statement based on the patient's presenting psychiatric problems and/or needs.

2. Patient's A2's MTP dated 5/10/16 listed the following problems:

Psychiatrist/APN
"1. Irritability/dysphoric mood, 2. Suicidal per [sic], 3. Inability to care for [himself/herself]."

Nursing
"Altered Thought Process RT [Related to] Dementia, Major Depression."

Psychology
"Mood lability/depression, Suicidal threat/ideation, R/O [Rule out] dementia."

Social Worker
"Absence of mental health & home care in the community."

Recreation
There was no problem statement identified by recreational therapy staff.

These problem statement failed to include descriptions related to how precisely this patient manifested the problem identified including depression, suicidal threat, and absence of mental health care.

3. Patient's A3's MTP dated 3/31/16 listed the following problems:

Psychiatrist/APN
"Aggressive Behavior, Mood lability, sexually inappropriate and intrusive, and Restlessness, pacing, anxiety."

Nursing
"Aggression, Sexual Inappropriate, Anxiety."

Psychology
"Agitation/Aggression, Sexually inappropriate bx [behavior]."

Social Worker
"Return to [Facility's name] or alt. [alternative] LTC [Long Term Care].

Recreation
There was no problem statement identified by recreational therapy staff.

These problem statement failed to include descriptions related to how precisely this patient manifested aggressive behaviors, sexual inappropriate behavior, and anxiety. The social worker's problem statement was not a problem statement but a potential plan for the patient's discharge.

4. Patient's A4's MTP dated 4/28/16 listed the following problems:

Psychiatrist/APN
"Agitation/impulsivity, Refusal for self care, Paranoia."

Nursing
"Pt [Patient] will refrain from behavioral displays, which jeopardize immediate safely of self/others."

Psychology
There was no problem statement identified by the psychologist.

Social Worker
"Determine placement [with] family & pt [patient] to include return to [Facility's name] if appropriate."

Recreation
There was no problem statement identified by recreational therapy staff.

These problem statement failed to include descriptions related to how precisely this patient manifested aggression, sexually inappropriate behavior, agitation, and refusal of care. In addition, there was no information regarding the content of the patient's paranoia and his/her response to paranoid symptoms. The nursing problem statement was actually a patient outcome not a problem statement based on the patient's presenting psychiatric problems and/or needs.

5. Patient's A5's MTP dated 5/9/16 listed the following problems:

Psychiatrist/APN
"Aggression, resistance to care, Anxiety, impulsive, intrusive, Mood lability, [sic] dysthymia, wt [weight] loss [sic], poor po [by mouth] intake."

Nursing
There was no problem statement identified by nursing.

Psychology
"Agitation/Anxiety, Depression, Psychosis."

Social Work
"Process discharge [with] [Facility's name] for aftercare placement."

Recreation:
There was no problem statement identified by recreational therapy.

These problem statement failed to include descriptions related to how precisely this patient manifested aggression, mood lability, resistance to care, depression, agitation, anxiety, and psychosis. In addition, there was no information regarding the extent of the patient's weight lost and poor food intake.

6. Patient's A6's MTP dated 4/18/16 listed the following problems:

Psychiatrist/APN
"Mood labile, anxiety, [decreased] mood, Agitation -yelling, [sic] varied appetite, dehydration risk."

Nursing
There was no problem statement identified by nursing.

Psychology
"Depression/Anxiety, R/O [Rule out] Dementia, Adjustment to LTC [Long Term Care]."

Social Work
"Return to LTC - [Facility's name]."

Recreation
There was no problem statement identified by recreational therapy staff.

These problem statement failed to include descriptions related to how precisely this patient manifested mood lability, depression, and agitation. In addition, there was no information regarding the extent of the patient's varied appetite and dehydration risk.

7. Patient's A7's MTP dated 5/5/16 listed the following problems:

Psychiatrist/APN Intervention
"1. Disorganized thought process. 2. Paranoia / delusions, 3. Aggression."

Nursing
"Fall Risk, Delusional / Paranoia behaviors, Skin Integrity Intact"

Psychology
There was no problem statement identified by psychology.

Social Work
There was no problem statement identified by social work.

Recreation:
There was no problem statement identified by recreational therapy.

The problem statements for the psychiatrist/APN and nursing failed to include descriptions related to how precisely this patient manifested delusional, paranoia, and disorganized thoughts. In addition, there was no information regarding the content of the patient's paranoia and delusions or how the patient responded to these symptoms.

8. Patient's A8's MTP dated 5/6/16 listed the following problems:

Psychiatrist/APN
"Aggression, Difficult to redirect, impulsivity, [decreased] sleep, pacing."

Nursing
"Risk for injurious behavior toward others R/T [related to] poor impulse control & Dementia."

Psychology
There was no problem statement identified by psychology staff.

Social Work
"Coordinate transfer to [Facility's name] safely when Tx [treatment] is completed."

Recreation:
There was no problem statement identified by recreational therapy staff.

These problem statement failed to include descriptions related to how precisely this patient manifested aggression, impulsivity, and dementia. In addition, there was no information regarding the extent of the patient's sleeping problem.

B. Interviews

1. In an interview on 5/10/16 at 11:45 a.m. with the Director of Nursing, MTPs were reviewed. She did not dispute the findings that the problem statements were not individualized and did not contain behavioral descriptions based on each patient's specific presenting problems or symptoms.

2. An interview was conducted with the Psychiatric Medical Director and MD1 on 5/10/16 at 12:00 noon. Neither physician disputed that the problem statements were not individualized and did not contain behavioral descriptions based on the patient's specific presenting problems or symptoms.

II. Medical Problem Statements

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (4/26/16), A2 (5/10/16), A3 (3/31/16), A4 (4/28/16), A5 (5/9/16), A6 (4/18/16), A7 (5/5/16) and A8 (5/6/16). This review revealed that there were no goals and intervention to address medical problems identified in physical examinations.

1. Patient A1's "Medical History" dated 4/26/16, included the following medical problems on the "Medical Problem List": "COPD [Chronic Obstructive Pulmonary Disease], NIDDM [Noninsulin-dependent diabetes mellitus], and GERD [Gastroesophageal Reflux Disease]." There were no goals and interventions to address these medical problems.

2. Patient A2s "Medical History" dated 5/7/16, included the following medical problems on the "Medical Problem List": "HTN [Hypertension], GERD [Gastroesophageal Reflux Disease] and Hypothyroid [sic]." There were no goals and interventions to address these medical problems.

3. Patient A3s "Medical History" dated 5/7/16, included the following medical problems on the "Medical Problem List": "GERD [Gastroesophageal Reflux Disease] and Vit. [Vitamin] D Defic [Deficiency]." There were no goals and interventions to address these medical problems.

4. Patient A4's "Medical History" dated 4/27/16, included the following medical problem on the "Medical Problem List": "HTN [Hypertension]." There were no goals and interventions to address this medical problem.

5. Patient A5's "Medical History" dated 5/6/16, included the following medical problems on the " Medical Problem List ": "HTN [Hypertension] and Hyperlipidemia." There were no goals and interventions to address these medical problems.

6. Patient A6's "Medical History" dated 4/16/16, included the following medical problems on the "Medical Problem List": "Insulin req [required] DM [Diabetes Mellitus], Seizure disorder, GERD [Gastro], HTN and [Hypertension], CVA [with] residual weakness..." There were no goals and interventions to address these medical problems.

7. Patient A7's "Medical History" dated 5/5/16, included the following medical problem on the "Medical Problem List": "HTN [Hypertension]." There were no goals and interventions to address this medical problem.

8. Patient A8's "Medical History" dated 5/5/16, included the following medical problems on the " Medical Problem List": "COPD [Chronic Obstructive Pulmonary Disease] and DM [Diabetes Mellitus] type 2." There were no goals and interventions to address these medical problems.

B. Policy Review

The facility's policy titled, "Multidisciplinary Comprehensive Treatment Plan Development and Review/Update Process" revised 2/4/16, stipulated, "Within 3 days of admission the Multidisciplinary Comprehensive Treatment Team (MCTT) will convene with the patient to formulate an individualized comprehensive treatment plan specific to his/her unique constellation of problems, strengths, and needs. This comprehensive treatment plan development meeting will include a review of available clinical assessments (e.g. Nursing, Psychiatric, Medical, Social Services,... etc.)...In addition to corresponding diagnoses for each active treatment problem identified, relevant medical/surgical...treatment history may also be listed at the discretion of the treatment team..."

C. Interview

1. An interview was conducted with the Psychiatric Medical Director and MD1 on 5/10/16 at 12:00 noon. Treatment plans were discussed. Both physicians agreed that the medical problems were not included. The Psychiatric Medical Director stated, "Yes, they should be included."

2. An interview with the Medical Director for Medical Services was conducted on 5/11/16 at 9:00 am. He acknowledged that the medical problems were not included in the Individualized Comprehensive Treatment Plans of the patients. He stated "We list them on the 'Problem List' in our medical assessment."

Based on record review and interview, the facility failed to ensure that the written treatment plans for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) and for added active non-sample patient B1 included substantiation of the psychiatric and medical diagnoses that would form the basis for treatment. Lack of confirmation of diagnoses compromises the treatment team's ability to generate a comprehensive problem list for which specific treatment modalities would be delineated and implemented. Meaningful and complete patient care cannot be provided without diagnostic clarity for both psychiatric and medical conditions.

Findings include:

A. Record Review:

The Individualized Comprehensive Treatment Plans of the following patients were reviewed (dates of evaluations are in parentheses): A1 (4/26/16); A2 (5/7/16); A3 (not dated); A4 (4/27/16); A5 (5/6/16); A6 (4/16/16); A7 (5/5/16); A8 (5/5/16); and B1 (5/9/16). This review revealed that none of the Individualized Comprehensive Treatment Plans contained substantiated psychiatric. Medical diagnoses were missing or incomplete. "Rule Out" diagnoses were listed on some of the plans.

1. Patient A1: "Provisional Diagnosis: Schizoaffective D/O - Bipolar Type" "Medical Problems: COPD with oxygen" - however the "Medical Problem List" from the Initial Medical Assessment (dated 4/26/16) included the additional diagnoses of "CAD," "NIDDM," "GERD," "abdominal hernia repair," and one other condition for which the writing was illegible.

2. Patient A2: "Provisional Diagnosis: Major depressive D/O, R/O Dementia"
"Medical Problems: blank - however the "Medical Problem List" from the Initial Medical Assessment (dated 5/7/16) included the medical diagnoses of "HTN," "GERD," "fibromyalgia/chronic pain," "hyperlipid [sic]", and "hypothyroid [sic]."

3. Patient A3: "Provisional Diagnosis: Dementia with Behavioral Disturbance"
"Medical Problems: blank - however the "Medical Problem List" from the Initial Medical Assessment (dated 3/29/16) included the medical diagnoses of "CAD s/p CABG '02 " "GERD," "pacemaker '02," "hx DM," "OA/DJD - severe," "Vitamin D deficiency," and two other illegible conditions.

4. Patient A4: "Provisional Diagnosis: "Dementia most likely Alzheimer's type with behavioral disturbance"
"Medical Problems: "UA (remainder illegible," "CAD," "HTN" - however the "Medical Problem List" from the Initial Medical Assessment (dated 4/27/16) included the diagnoses "HTN" and "Vitamin B12 deficiency"

5. Patient A5: "Provisional Diagnosis: Dementia with behavioral disturbance, No Etoh, No Hoarding, No Depression"
"Medical Problems: poor po intake, hs [sic] Falls" - however the "Medical Problem List" from the Initial Medical Assessment (dated 5/6/16) included the diagnoses "H/O hip fx (L s/p surgery)," "LUE fx," "HTN," and "hyperlipidemia"

6. Patient A6: "Provisional Diagnosis: Major Depressive Disorder, Dementia with behavioral disturbance"
"Medical Problems: No CVA, at risk for dehydration" - however the "Medical Problem List" from the Initial Medical Assessment (dated 4/16/126) included the diagnoses "Dysphasia," "Seizure Disorder," "GERD," "HTN," "hx CVA with R residual weakness," "Insulin req DM" and one other illegible condition

7. Patient A7: "Provisional Diagnosis: Schizophrenia"
"Medical Problems: blank - however the "Medical Problem List" from the Initial Medical Assessment (dated 5/5/16) included the diagnoses "HTN," "Hyperlipid [sic]," and one other illegible condition

8. Patient A8: "Provisional Diagnosis: Dementia with behavioral disturbance, Hs [sic] ETOH
"Medical Problems: blank - however the "Medical Problem List" from the Initial Medical Assessment (dated 5/5/16) included the diagnoses of "BPH," "Pacemaker -?" "Umbilical Hernia," "Lung nodule - benign on CT 4/21/16," "COPD changes on CT," DM type 2," and "?GERD"

9. Added active non-sample Patient B1: "Provisional Diagnosis: Dementia, Alzheimer's Type with Behavioral Disturbance"
"Medical Problems: blank - however the "Medical Problem List" from the Initial Medical Assessment (dated 5/6/16) included the diagnoses of "CAD -? details." "hypothyroid [sic]," "HTN," "hyperlipid [sic]," and "carotid stenosis s/p carotid endarterectomy."

B. Interview

An interview was conducted with the Psychiatric Medical Director and MD1 on 5/10/16 at 12:00 noon. The treatment planning process was reviewed. When the lack of inclusion of medical diagnoses on the treatment plans was reviewed, MD1 stated "They are not discussed." The Psychiatric Medical Director stated "I am aware of this and they need to be included." When asked if the psychiatric and medical diagnoses were reviewed and substantiated during the treatment planning meeting, both the Psychiatric Medical Director and MD1 stated "They are not."

Based on record review and interview, the facility failed to ensure that the written treatment plans for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) and for added active non-sample patient B1 included short term and long term goals described in observable and measurable terms and based on the problems identified for treatment. This results in a treatment plans that fail to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients and creates the potential that the treatment plan will fail to address patient needs during the course of hospitalization and at discharge.

Findings include:

A. Record Review

The Individualized Comprehensive Treatment Plans of the following patients were reviewed (dates of evaluations are in parentheses): A1 (4/26/16); A2 (5/7/16); A3 (not dated); A4 (4/27/16); A5 (5/6/16); A6 (4/16/16); A7 (5/5/16); A8 (5/5/16); and B1 (5/9/16).

1. Patient A1: The goals listed for Psychiatrist/APN interventions stated "reduce aggression/agitation in 7 days; mood stabilization in 7-10 days; medication & care compliance in 7-10 days." Goals for Nursing interventions stated, "Pt. will refrain from behavioral displays which jeopardize the immediate safety." The goals for Psychology interventions stated "decrease agitation to wnl (within normal limits)." No goals for recreation were stated (given the absence of stated problems or treatment modalities for this discipline). No goals for medical care were stated (given the absence of stated problems or treatment modalities for this discipline).

2. Patient A2: The goals listed for Psychiatrist/APN interventions stated "decrease irritability/improve mood; decrease suicidal ideation; ensure proper safety; improve ability to focus on self-care." The goals for Nursing interventions stated, "Pt. will display improved mood/thought processes." The goals for Psychology interventions stated, "to stabilize mood and eliminate suicidal ideation/threat; R/O dementia." No goals for recreation were stated (given the absence of stated problems or treatment modalities for this discipline). No goals for medical care were stated (given the absence of stated problems or treatment modalities for this discipline).

3. Patient A3: The goals listed for Psychiatrist/APN interventions stated, "reduce aggression, mood stabilization in 7 days; reduce intrusiveness and improve sexual behaviors in 7 days; improve anxiety & restlessness in 7 days." The goals for Nursing interventions stated, "Pt. will have a reduction in anxiety by day 14 of admission." The goals for Psychology interventions stated "to reduce agitation to wnl (within normal limits); to stabilize mood & eliminate sexually inappropriate bx (behaviors) to wnl and make bx recommendations." No goals for recreation were stated (given the absence of stated problems or treatment modalities for this discipline). No goals for medical care were stated (given the absence of stated problems or treatment modalities for this discipline).

4. Patient A4: The goals listed for Psychiatrist/APN interventions stated "control agitation; ensure proper hygiene; decrease severity of paranoia." The goals for Nursing interventions stated, "Pt. will refrain from behavioral displays which jeopardize immediate safety of self/others." No goals for recreation were stated (given the absence of stated problems or treatment modalities for this discipline). No goals for medical care were stated (given the absence of stated problems or treatment modalities for this discipline).

5. Patient A5: The goals listed for Psychiatrist/APN interventions stated "reduce aggression in 7 days; reduce anxiety in 7 days; mood stabilization in 7-10 days; maintain hydration." No goals for Nursing were stated (given the absence of stated problems or treatment modalities for this discipline). The goals for Psychology interventions stated, "to stabilize mood & challenge distorted thinking; reduce depression to wnl (within normal limits)." No goals for recreation were stated (given the absence of stated problems or treatment modalities for this discipline). No goals for medical care were stated (given the absence of stated problems or treatment modalities for this discipline).

6. Patient A6: The goals listed for Psychiatrist/APN interventions stated, "improve mood stabilization; reduce anxiety in 7-10 days; reduce agitation, yelling in 7-10 days; maintain hydration, needs assist [sic] secondary to hemiplegia." No goals for Nursing were stated (given the absence of stated problems or treatment modalities). The goals for Psychology interventions stated, "to stabilize mood & reduce depressive sx (symptoms); facilitate adjustment to LTC (long term care)." No goals for recreation were stated (given the absence of stated problems or treatment modalities for this discipline). No goals for medical care were stated (given the absence of stated problems or treatment modalities for this discipline).

7. Patient A7: The goals listed for Psychiatrist/APN interventions stated, "improve goal directed thinking, decrease paranoia, decrease aggression." No goals for social work were stated (given the absence of stated problems or treatment modalities for this discipline). No goals for recreation were stated (given the absence of stated problems or treatment modalities for this discipline). No goals for medical care were stated (given the absence of stated problems or treatment modalities for this discipline).

8. Patient A8: The goals listed for Psychiatrist/APN interventions stated, "improve aggressive behaviors in 7-10 days; improve sleep, decrease pacing in 7-10 days." The goals for Nursing stated, "Pt. will refrain from behavioral displays which jeopardize the immediate safety of self/others." No goals for recreation were stated (given the absence of stated problems or treatment modalities for this discipline). No goals for medical care were stated (given the absence of stated problems or treatment modalities for this discipline).

9. Added patient B1: The goals listed for Psychiatrist/APN interventions stated, "control agitation; decrease level of paranoia; ensure med compliance; mood stability." The goals for Nursing stated, "Pt. will have reduced behavioral displays which jeopardize immediate safety or self others [sic]." The goals for Psychology interventions stated, "to stabilize mood & reduce irritability & depression sx (symptoms) to WNL (within normal limits); to encourage med compliance; to challenge distorted thinking." No goals for recreation were stated (given the absence of stated problems or treatment modalities for this discipline). No goals for medical care were stated (given the absence of stated problems or treatment modalities for this discipline).

B. Interview

An interview was conducted with the Psychiatric Medical Director and MD1 on 5/10/16 at 12:00 noon. The treatment planning process was reviewed. When the lack of inclusion on the treatment plans of goals as measurable behavioral outcomes for the patient was reviewed, MD1 stated "They are not discussed...they are not always measurable behaviors." The Psychiatric Medical Director agreed.

Based on record review and interview, the facility failed to develop individualized treatment plans that clearly delineated active treatment interventions to address specific patient problems and assist patients to accomplishment treatment goals for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, Master Treatment Plans (MTPs) had the following deficiencies: (1) included routine and generic functions, such as monitoring, redirecting, encouraging, and medicating as prescribed, written as active treatment interventions; (2) failed to include a specific focus of treatment based on each patient's presenting psychiatric symptoms and/or behaviors for individual therapy, psychotherapy groups, and behavior management listed on MTPs; (3) failed to include groups attended by five (5) of eight (8) active sample patients (A2, A3, A4, A5, and A8), and (4) failed to include active treatment interventions to be provided by recreational therapy staff for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). These deficiencies result in a failure to provide guidance to treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in staff being unable to provide consistent and focus active treatment.

Findings include:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (4/26/16), A2 (5/10/16), A3 (3/31/16), A4 (4/28/16), A5 (5/9/16), A6 (4/18/16), A7 (5/5/16) and A8 (5/6/16). This review revealed the following deficiencies related to active treatment interventions on MTPs.

I. Failure to include individualized active treatment interventions

A. Record Review

A review of the "Individualized Comprehensive Treatment Plan" Form revealed that intervention statements failed include individualized specific active treatment interventions to assist patients to replace problem behaviors, and/or to improve (reduce and/or eliminate) presenting symptoms. Several statements failed to include a method of delivery (individual or group session) or were identical or similarly worded despite different presenting symptoms and needs of each patient.

1. Patient A1's MTP contained the following deficient intervention statements: "Aggression, R/O [Rule out] paranoia, Mood lability, isolative, Med [medication] refusal/care resistance." The following deficient interventions were listed on this patient's MTP.

Psychiatrist/APN Interventions

"Medication, ID [identify] triggers, firm limits, anticipate needs" for problem of "Aggression." "Medication, socialization, psychotherapy, reassurance" for the problem of "Mood lability, isolative." "Daily routine, medication, psychotherapy" for the problem of "Care refusal." These intervention statements were not individualized or specific to the reasons for the patient's admission and failed to specify the primary medication(s) to be used for the identified targeted symptoms and/or behaviors. The Psychotherapy Intervention identified failed to include the method of delivery (individual or group sessions) and a focus of treatment based on the precise symptom and/or behaviors identified in clinical assessments.

Nursing Interventions

"Maintain safe distance between peers and pt [patient]. Minimize environmental stressors" for the problem of, "Pt [Patient] will refrain from behavioral displays which jeopardize the immediate safety of self/other." These were not active treatment interventions but were routine and generic nursing tasks that would be performed regardless of patients' presenting symptoms. There were no individual or group active treatment interventions formulated by registered nurses that would assist this patient to improve or resolve problems identified in clinical assessments.

Psychology Interventions

"Individual psychotherapy, & Bx [Behavioral] Mgmt [Management]" for the problems of "Aggression" and "Mood Lability." "Group Therapy" for problem of "Non compliance - meds [medications] care." These intervention statements failed to identify a focus of treatment based on precisely how the patient manifested symptoms and/or behaviors identified in clinical assessments.

Social Worker Intervention

"Disc [Discuss] objectives [with] pt. [patient] & [Name of facility] to possibly resolve dissatisfaction" for the problem of "Pt [Patient] reports dissatisfaction with LTC [Long Term Care], requests exploring alternatives at D/C [discharge]." Since the extent and content related to the patient's dissatisfaction was not identified, this intervention statement was not individualized or specific to the patient's needs. The statement failed to specify whether the intervention would be provided in individual or group sessions.

Recreation Interventions

There was active treatment intervention(s) identified by recreational therapy staff.

2. Patient A2's MTP contained the following deficient intervention statements:

Psychiatrist/APN Interventions

"Med [Medication] Adjustment, Individual/ group psychotherapy" for problem "1. Irritability / dysphoric mood." "Monitor safety/ psychotherapy for problem," "2. Suicidal per [sic]." "Encourage proper self care / improve ADL" for problem, "3. Inability to care for [himself/herself]." Most of these were not active treatment interventions but were routine and generic physician/APN tasks that would be performed regardless of patients' presenting symptoms. The individual and group psychotherapy were intervention statements did not include a focus of treatment based on the precise symptom and/or behaviors identified at the time of admission.

Nursing Interventions

"Encourage daily participation in medication admin [administration]." "Keep stimulation to minimum." "Encourage pt [patient] to participate in all group activities" for the problem of "Altered Thought Process RT [Related to] Dementia, Major Depression." These were not active treatment interventions but were routine and generic nursing tasks that would be performed regardless of patients' presenting symptoms. Encouraging patient to participate in medication administration and to attend groups reflected nursing tasks and were not related to the patient's reasons for admission. There were no intervention statements at all that reflect active treatment provided by registered nurses and nursing staff such as, individual or group sessions with patients to provide information regarding medications, health issues, etc.

Psychology Interventions

"Individual psychotherapy" for "Mood lability/depression." "Group Therapy" for a problem of, "Suicidal threat/ideation." "[sic] /cognitive testing for R/O [Rule out] dementia." These intervention statements failed to identify a focus of treatment based on precisely how the patient manifested symptoms and/or behaviors identified in clinical assessments. "Cognitive testing" was a routine psychologist function not an active treatment interventions.

Social Worker Intervention

"Explore community resources & coordinate with POA [Power of Attorney] and [illegible] in the community" for the problem of "Absence of mental health & home care in the community." This intervention statement was general, non-specific, and non-individualized. There was no active treatment intervention that identified specific community resources that would be explored based on findings in the psychosocial assessment related to discharge and aftercare needs of this patient.

Recreation Interventions
There was active treatment intervention(s) identified by recreational therapy staff.

3. Patient A3's MTP contained the following deficient intervention statements:

Psychiatrist/APN Interventions

"Psychopharmacy, psychotherapy for the problem of "Aggressive Behavior, Mood lability." "Medication, psychotherapy, redirections / monitor, behavior modification" for the problem of, "sexually inappropriate." "Medication, socialization, calm structured environment for the problem of, "Restlessness, pacing, anxiety." Most of these were not active treatment interventions. The routine and generic discipline functions identified such as, redirection, monitoring, and providing a calm structured environment were tasks that would be performed regardless of patients' presenting symptoms. Additionally, these intervention statements were not individualized or specific to the reasons for the patient's admission and failed to specify the psycho-pharmacy to be used for the identified targeted symptoms and/or behaviors. The psychotherapy and behavior modification mentioned failed to include a focus of treatment based on the precise symptom and/or behaviors identified in clinical assessments.

Nursing Interventions

"Identify early signs of agitation & ways to [decrease] their agitation in a positive manner" for the problem of "Aggression." "Redirect pt [patient] from behaviors" for the problem of, "Sexual Inappropriate." "Use prn's [as needed (medication)] to [decrease] anxiety." "Reorient pt [patient] & [sic] pt in safe place" for the problem of, "Anxiety." These were not active treatment interventions but were routine and generic nursing tasks that would be performed regardless of patients' presenting symptoms. There were no intervention statements at all that reflect active treatment provided by registered nurses and nursing staff such as, individual or group sessions with patients to assist patient to replace aggression and sexually inappropriate behaviors with non-harmful and/or healthy ways of functioning.

Psychology Intervention

"Individual psychotherapy" for the problem of, "Agitation/Aggression." " Group psychotherapy" for the problem of, "Sexually inappropriate bx [behavior]." These intervention statements failed to identify a focus of treatment based on precisely how the patient manifested symptoms and/or behaviors identified in clinical assessments.

Social Worker Interventions

"Coordinate [with] family for hx [history] to inform d/c [discharge] plan." "Explore all alt. [alternative] placement for family." "Referrals to [Facility's name]" for the problem of, "Return to [Facility's name] or alt. [alternative] LTC [Long Term Care]. These intervention statements were general, non-specific, and non-individualized.

Recreation

There were no active treatment intervention statements identified by recreational therapy staff.

4. Patient A4's MTP contained the following deficient intervention statements:

Psychiatrist/APN Interventions

"Redirect, medication adjustment for the problems of, "1. Agitation / impulsivity." "Supportive/encouragement, psychotherapy for the problem of, "Refusal for self care." "Medication adjustment" for the problem of, "Paranoia." Intervention statement such as medication adjust, encouragement were not stated as active treatment interventions but were routine and generic tasks that would be performed regardless of patients' presenting symptoms. The psychotherapy mentioned failed to include method of delivery (group or individual sessions) and a focus of treatment based on the precise symptom and/or behaviors identified in clinical assessments.

Nursing Interventions

"Minimize environmental stressors and provide consistent routines." "Monitor for non-verbal signs anxiety/anger/agitation" for the problem of, "Pt [Patient] will refrain from behavioral displays, which jeopardize immediate safely of self/others." These were not active treatment interventions. The routine and generic nursing tasks listed such as minimizing stressors and monitoring signs and symptoms would be actually performed regardless of patients' presenting symptoms. There were no intervention statements at all that reflected active treatment provided by registered nurses and nursing staff such as, individual or group sessions to assist the patient to improve and/or resolve presenting symptoms and/or problems identified in clinical assessments.

Psychology Interventions

There was problem statement identified by the psychologist.

Social Worker Intervention

"Contact & supple clinical info [information] [sic] Meadowview & [sic] placement [with] [illegible]" for the problem of, "Determine placement [with] family & pt [patient] to include return to Meadowview if appropriate." This intervention statement was vague, non-specific, and non-individualized.

Recreation Interventions

There were active treatment intervention statements identified by recreational therapy staff.

5. Patient A5's MTP contained the following deficient intervention statements:

Psychiatrist/APN Interventions

"Medication, psychotherapy, Consistency, calm approach" for the problem of, "Aggression, resistance to care." "Medication, socialization, anticipate needs" for the problems of, "Anxiety, impulsive, intrusive." "Medication, calm environment, routine, ID [identify] triggers" for the problem of, "Mood lability, [sic] dysthymia." "Dietician, assist [with] meals, hydration protocol " for the problem of, "wt [weight] loss [sic], poor po [by mouth] intake." These intervention statements were broad and not individualized or specific to the reasons for the patient's admission. The statements failed to include a focus of treatment for psychotherapy and specify the primary medication(s) to be used for the identified targeted symptoms and/or behaviors.

Nursing Interventions

There was no active treatment interventions identified by the registered nurse.

Psychology Interventions

"Individual psychotherapy & Bx [Behavioral] management" for the problems of, "Agitation/Anxiety." "Group therapy when appropriate" for the problems of, "Depression, Psychosis." These intervention statements failed to identify a focus of treatment based on precisely how the patient manifested symptoms and/or behaviors identified in clinical assessments.

Social Work Intervention

"Provide clinical info [information] to [sic]. Also coordinate aftercare placement [with] family" for the problem of, "Process discharge [with] [Facility's name] for aftercare placement." This intervention statement was general and broad. It was not individualized and failed to specify clinical information the social worker would provide based of findings in the social work assessment. The statement failed to specify whether the intervention would be provided in individual or group sessions. In addition, the intervention statement was not based on information regarding barriers to discharge and aftercare and/or previous successful strategies related to the resistance to treatment.

Recreation:

There was active treatment intervention(s) identified by recreational therapy staff.

6. Patient A6 ' s MTP contained the following deficient intervention statements:

Psychiatrist/APN Intervention

"Medication, psychotherapy, anticipate needs, behavior mod. [modification]" for the problems of "Mood labile, anxiety, [decreased] mood." "Medication, structured environment, routine, socialization, behavioral plan to go back [with] pt [patient] to LTC [Long Term Care]" for the problem of, "Agitation -yelling." "Dietician, hydration protocol, assist [with] meals." These intervention statements were broad and not individualized or specific to the reasons for the patient's admission. They failed to specify the primary medication(s) to be used for the identified targeted symptoms and/or behaviors. Many of the intervention statements were instructions for other staff, such as structured environment, routine, Dietician, hydration protocol, etc. rather than specific interventions the psychiatrist/APN would be performing to assist this patient to resolve and/or improve symptoms and problems identified in clinical assessments.

Nursing Interventions

There were no active treatment intervention statements identified by the registered nurse.

Psychology Interventions

"Individual psychotherapy + Bx [Behavior] Mgmt [Management]" for the problems of, "Depression/Anxiety." These intervention statements failed to identify a focus of treatment based on precisely how the patient manifested symptoms and/or behaviors identified in clinical assessments.

Social Work Intervention

"Make referral to [Facility's name]" for the problem of, "Return to LTC - [Facility's name]." This intervention statement was general and broad. It was not individualized and failed to a specify focus of referral information based on the social worker's clinical assessment regarding discharge and aftercare needs.

Recreation Interventions

There were no active treatment intervention statements identified by recreational therapy staff.

7. Patient A7's MTP contained the following deficient intervention statements:

Psychiatrist/APN Interventions

"Medication, calm, structured environment, socialization, ID [identify] triggers" for the problem of, "1. Disorganized thought process." "Medication / Antipsy [sic]" for the problems of, "2. paranoia / delusion." "Antipsy [sic] for the problem of, "3. Aggression." These intervention statements were broad and not individualized or specific to the reasons for the patient's admission and failed to specify the primary medication(s) to be used for the identified targeted symptoms and/or behaviors.

Nursing Interventions

"Q15 monitoring" for the problem of, "Fall Risk." "Medicate as prescribed" for the problem of, "Delusional / Paranoia behaviors." "Maintain good skin condition by assessment Q [illegible] day." These intervention statements were broad and not individualized or specific to the reasons for the patient's admission. The routine and generic intervention statements such as Q15 monitoring, medicate as prescribe and assessment of skin condition were not stated as active treatment interventions but were nursing tasks that would be performed regardless of patients' presenting symptoms. There were no active treatment interventions regarding individual or group sessions to assist the patient to improve and/or resolve problems identified in the nursing assessment.

Psychology Interventions

There were no active treatment intervention(s) identified by psychology.

Social Work Interventions

There were active treatment intervention(s) identified by social work staff.

Recreation Interventions

There was active treatment intervention(s) identified by recreational therapy staff.

8. Patient A8's MTP contained the following deficient intervention statements:

Psychiatrist/APN Intervention

"Medication, calm, structured environment, socialization, ID [identify] triggers" for the problem of, "Aggression, Difficult to redirect, impulsivity." "Monitor, medication " for the problem of, "[decreased] sleep, pacing." These intervention statements included routine tasks, were broad, and not individualized or specific to the reasons for the patient's admission. The statements also failed to specify the primary medication(s) to be used for the identified targeted symptoms and/or behaviors.

Nursing Interventions

"Minimize environmental stressors and provide consistent routines. Monitor for non-verbal signs of Anxiety/Anger/Agitation" for the problem of, "Risk for injurious behavior toward others R/T [related to] poor impulse control & Dementia." These intervention statements were broad and not individualized or specific to the reasons for the patient's admission. They were routine and generic nursing functions instead of specific active intervention statements based this patient's presenting symptoms. There were no active treatment interventions regarding individual or group sessions that the registered would provide, such as patient teaching to assist the patient to improve and/or resolve problems identified in the nursing assessment.

Psychology Interventions

There were no active treatment intervention statements identified by psychology.

Social Work Intervention

"Provide clinical info [information] to NF [Nursing Facility] and coordinate and liaison with [illegible]" for the problem of, "Coordinate transfer to [Facility name] safely when Tx [treatment] is completed." This intervention statement was general and broad. It was not individualized and failed to specify clinical information the social worker would provide based on findings in the psychosocial assessment. The statement failed to specify whether the intervention would be provided in individual or group sessions.


Recreation Interventions

There were no active treatment intervention(s) identified by recreational therapy staff.

B. Interviews

1. In an interview on 5/10/16 at 11:45 a.m. with the Director of Nursing, MTPs were reviewed. She did not dispute the findings that nursing interventions were routine nursing functions instead of specific interventions to assist patients to resolve and/or improve presenting problems and symptoms.

2. An interview was conducted with the Psychiatric Medical Director and MD1 on 5/10/16 at 12:00 noon. The treatment interventions on MTPs were reviewed. They did not dispute the findings that psychiatrist interventions were not individualized.

II. Failure to include group treatment attended by patients

A. Observations and Record Review

1. During observation on 5/9/16 from 11:00 a.m. to 1:35 a.m., Patients A2, A3, A5, and A8 attended a group titled, "Name 10" in the day room. RT1 had patient identify at least name of various categories such as things you do in the summer, TV shows, etc. There was no group intervention with a focus of treatment based on these patients' presenting symptoms found on MTPs.

2. During observation on 5/9/16 from 1:10 p.m. to 1:20 p.m., Patient A4 attended a group titled, "Psychotherapy" in the group room. Psychologist1 discussed a topic regarding controlling anger. A group psychotherapy intervention was not included on Patient A4's MTP.

3. During observation on 5/10/16 from 10:15 a.m. to 10:30 a.m., Patients A2, A4, A5, and A8 attended a group titled "Exercise and Snacks" in the day room. This group included chair exercises and snacks provided after exercise. There was no group intervention with a focus of treatment based on these patients' presenting symptoms found on MTPs.

4. Patient A1 and A2 were observed attending a group titled, "Medication Group" on 5/10/16 at 1:30 p.m. The Director of Social Worker and the Pharmacist conducted the group and reported that these patients had attended previous group sessions. This group was not included on these patients' MTPs.

3. During observation on 5/10/16 from 3:00 p.m. to 3:15 p.m. Patient B1 attended a group titled, "Lady Bug Craft" in the day room with 5 other patients. This group was not included on Patient B1's MTP.

B. Interview

In an interview on 5/10/16 at 12:45 p.m. with RT1, MTPs were discussed. She did not dispute the findings that recreational therapy groups were not included on treatment plans. She stated that she does not attend treatment team meetings.

Based on record review and interview, the facility failed to ensure that treatment notes were written to reflect patients' response to treatment efforts for five (5) of eight (8) sample patients (A1, A3, A4, A5 and A6). Specifically, active treatment interventions listed on the treatment plan and/or attended by patients were not documented in the medical record to include the patients' attendance or non-attendance. When patients attended active treatment sessions, there was no documentation regarding specific topics discussed, patients' behavior during interventions, their response to interventions (level of participation and understanding), and specific comments by patients. This failure results in information regarding active interventions and the response to these interventions not being available for the treatment team.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (4/26/16), A2 (5/10/16), A3 (3/31/16), A4 (4/28/16), A5 (5/9/16), A6 (4/18/16), A7 (5/5/16) and A8 (5/6/16). This review revealed the following deficiencies related to documenting treatment notes.

1. Patient A1 was admitted 4/25/16. The MTP had "Psychotherapy" daily was to be provided by the psychiatrist/APN. "Individual Psychotherapy + Bx [Behavior] Mgmt [Management], and Group Therapy" 1- 2 times per week were to be provided by the psychologist. There were no treatment notes regarding topics discussed, the patient's response or attendance or non-attendance for these interventions. The form titled, "Group/Activity Progress Notes" was primarily used by the recreational therapy staff. The documentation on this form for Patient A1 documented whether the patient participated but failed to document how the patient responded, such as level of participation, level of understanding, or specific comments the patient made when attending group sessions.

2. Patient A3 was admitted 5/3/16. The MTP had "Psychotherapy" to be provided daily by the psychiatrist/APN. "Individual Psychotherapy and Group Therapy" 1- 2 times per week were listed to be provided by the psychologist. There were no treatment notes regarding topics discussed, the patient's response or attendance or non-attendance for these interventions. The form titled, "Group/Activity Progress Notes" was primarily used by the recreational therapy staff. The documentation on this form for Patient A1 documented whether the patient participated but failed to document how the patient responded, such as level of participation, level of understanding, or specific comments the patient made when attending group sessions.

3. Patient A4 was admitted 4/26/16. The MTP had "Psychotherapy" to be provided daily by the psychiatrist/APN. There were no treatment notes showing that the patient participation or non-participation in psychotherapy. There were no notes to show the patient's response and level of understanding. Additionally, documentation by activity theory staff on the form titled, "Group/Activity Progress Notes" showed when the patient refused or participated but failed to document how the patient responded, such as level of participation, level of understanding, or specific comments the patient made when attending group sessions.

4. Patient A5 was admitted 5/5/16. The MTP had "Psychotherapy" to be provided daily by the psychiatrist/APN. "Individual Psychotherapy + Bx [Behavior] Mgmt [Management]" 1-2 times per week were listed to be provided by the psychologist. There were no treatment notes regarding topics discussed, the patient's response or attendance or non-attendance for these interventions. Documentation by activity theory staff on the form titled, "Group/Activity Progress Notes" showed when the patient refused or participated but failed to document how the patient responded, such as level of participation, level of understanding, or specific comments the patient made when attending group sessions.

5. Patient A6 was admitted 4/15/16. The MTP dated 4/18/16 contained the following active treatment interventions: "Psychotherapy" and Behavior mod. [Modification] to be provided by the psychiatrist/APN. "Individual Psychotherapy + Bx [Behavior] Mgmt [Management] to be provided by the psychologist." The MTP noted that the patient was "not a candidate for group therapy." A review of the medical record revealed that there were no treatment notes written by the psychiatrist, APN, or psychologist showing that the patient had received these active treatment interventions.

B. Interview

In an interview on 5/11/16 at 10:15 a.m. with Psychologist1, treatment notes for group psychotherapy was discussed. She stated, "I only document the treatment that will be billed. I make a note that the patient attended the group. Medicare is not charged for the group session." She also reported that she understood that the required documentation for treatment notes. She acknowledged that treatment notes should include the topic discussed during group, the patient's response, level of understanding and participation, and recommendations to continue or discontinue treatment based on the patient's progress.

Based on observations, record review, document review, and interview, the facility failed to:

I. Ensure that active treatment measures, such as group treatment, individual treatment, and therapeutic activities, were provided to two (2) of eight (8) active sample patients (A6 and A7) who were unwilling to participate in the active treatment program and/or attend treatment groups. Specifically, these patients spent many hours without any appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement.

II. Ensure proper documentation of a restraint procedure for added active non-sample patient B3. Specifically, staff used a chemical restraint to manage the patient's behavior and because unit staff did not consider this as a restrictive procedure, the required face-to-face assessment documentation was not completed. In addition, the facility failed to track the use of physical holds when patients become agitated, were given forced medications, or redirected against their will. There were also no policy guidelines and procedures to direct staff when physical hold procedures were used. These failures result in a restriction of the patient's rights without adequate documented justification and demonstrated unsafe practices that can potentially result in serious outcomes for patients.

Findings include:

I. Failure to provide individualized active treatment interventions

A. Patient A6

1. Observations

a. During observation on the unit from 11 a.m. to 11:35 a.m. on 5/9/16, there was a "Name 10" Group held in the day room. Patient A6 was located in his/her room in his/her bed.

b. During observations on the unit from 2:15 p.m. to 3:00 p.m., a "Lady Bug Craft" Group was on the schedule to be held from 2:00 p.m. to 3:00 p.m. Patient A6 was located in his/her room in bed.

c. During observation on the unit from 10:30 a.m. - 11:30 p.m., a group titled "Exercise and Snack was scheduled to held from 10:15 to 11:00 a.m. and a group in "Root Beer Day" was held from 11:00 to 11:35 a.m. Patient A6 attended the Exercise group but was not in attendance in the group session from 11:00 a.m. to 11:35 a.m.

2. Medical Record and Document Review

a. Patient A6 was admitted on 4/15/16. The Psychiatric Assessment dated 4/16/16 noted diagnosis of "Major Depressive Disorder." The MTP dated 4/18/16 contained the following active treatment interventions: "Psychotherapy" and Behavior mod. [Modification] to be provided by the psychiatrist/APN. "Individual Psychotherapy + Bx [Behavior] Mgmt [Management] to be provided by the psychologist. The MTP noted that the patient was "not a candidate for group therapy." A review of the medical record revealed that there were no treatment notes written by the psychiatrist, APN, or psychologist showing that the patient had received these active treatment interventions.

b. The form titled, "Updates - Master Treatment Plan" on the following dates - 4/25/16, 5/2/16, and 5/9/16 were reviewed. These updates, except for changes in medications, failed to address the patient's non-participation in active treatment or specify revisions to be made in the treatment plan.

c. Out of the possible active treatment groups offered from 5/4/16 through 5/9/16, the patient did not consistently participate in group sessions held. The patient was noted to be primarily in his room or walking in the hallway during group times.

d. Census/Q15 minute Checklist Sheets: The unit scheduled contained the following groups: "Exercise and Snacks" at 10:15 a.m. held 7 days per week; Groups with various to topics at 11:00 a.m.; "Psychotherapy Group" at 1:00 p.m. held 2 times per week. The "Patient Observation Rounds sheets" from 5/4/15 through 5/9/16 were reviewed and revealed that Patient A6 was in his/her room most of the time during group times. The patient was coded as either sleeping, awake or sitting in the hallway.

3. Interview

In an interview on 5/11/16 at 1:15 p.m. with the Director of Nursing, She did not dispute the findings that Patient A6 was consistently not involved in active treatment groups and that the treatment plans were not revised to reflect alternative active treatment measures.

B. Patient A7

1. Observation

Patient A7, a 52 year old was admitted 5/4/16 with Schizophrenia. The patient who was thought-disordered and paranoid, was observed between 10:55 am and 12:00 noon, again at 12:15 pm, and again at 3:15 pm. At all observation times A9 was lying on the couch in the Social Rm. No staff engaged A7 in any therapeutic activities during the periods of observation. This lack of active treatment was consistent with A7's Individualized Comprehensive Treatment Plan dated 5/5/16 in that the plan did not contain any specific treatment modalities aside from medication management by the psychiatrist, and nursing tasks of q.15-minute monitoring, medication administration, and assessment of skin integrity.

2. Interview

An interview was conducted with the Psychiatric Medical Director and MD1 on 5/10/16 at 12:00 noon. The treatment plan of A7 was discussed. MD1 agreed that A7 was "not able to attend groups" and stated there were "no individualized 1:1 treatment modalities being offered" to A7.

II. Failure to use proper documentation of restraint procedures

A. Interviews and Record Review

1. In an interview on 5/11/16 at 9:05 a.m., when asked about the use of physical holds, RN 2 admitted that physical holds do occur occasionally and reported that a newly admitted patient (B3) received emergency IM medication to manage [his/her] behavior. She believed this patient had to be physically held to administer the medication.

2. Patient B3 was admitted on the evening of 5/10/16 from a general hospital due to agitation, disorganization, combativeness, and visual hallucinations. Patient has a pre-existing psychiatric diagnosis of Bipolar Disorder and was receiving psychotropic medication consisting of risperidone 1 mg every morning and 4 mg at night, fluoxetine 30 mg daily, and carbamazepine 200 mg twice a day.

3. A review of the medical record revealed the following noted dated 5/11/16 at 5:45 a.m., "Pt. [Patient] was up all night, walking up and down the hallway...Pt. is difficult to redirect...gets aggressive when redirected. At 8:35 a.m. a noted documented, "Pt. observed very aggressive, combative, unable to direct...APN called and Ativan 1 mg IM ordered and given for agitation..."

3. In an interview with the Medical Director at 9:55 a.m., she admitted that the medication the patient received was a chemical restraint. She stated that she would find the documents to be used to record this procedure.

4. A review of the medical record at 12:30 p.m., reviewed that the MD had completed no documentation of a face-to-face assessment for the chemical restraint.

5. In an interview on 5/11/16 at 2:15 p.m. with the Director of Nursing (DON) regarding active non-sample Patient B3 who received IM lorazepam earlier in the day was discussed. MD1 and the DON indicated that the facility did not consider the IM lorazepam a "chemical restraint" because the patient "cooperated with the injection." The DON went on to say that "we routinely give IMs and if the patient does not resist, we do not consider this a chemical restraint."

5. In an interview on 5/11/16 at 2:15 p.m., with MD1 and Director of Nursing, the use of a chemical restraint with Patient B3 was discussed. When asked if an assessment by a physician or advanced nurse practitioner was required within an hour of the injection, the DON responded "No." MD1 stated "I have been working here only 3 weeks and when I asked the charge nurse for paperwork to complete my assessment, I was told that it was not required."

B. Policy Review

The facility policy titled, "Restraints and Seclusion Policy" dated 7/16/13, stipulated, "...A restraint is any manual method physical or mechanical device...or drug or medication when it is used as a restriction to manage the patient's behavior or restraint the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition." Additionally, the policy stipulated, "Data on restraint/seclusion usage are aggregated and analyzed, in an effort to decrease restraint/seclusion usage by better understanding the circumstances in which it is used..."

C. Other interviews

1. In an interview on 5/10/16 at 10:20 a.m. with the CEO, the facility data regarding the use of restraint and seclusion was discussed. He reported that they were not collecting data or information on persons who were physically held. He stated, "I know we do this (physical holds) but we are just not tracking it." Later at approximately 10:30 a.m., the CEO clarified that they were aware of the standards regarding restraints and they had not had any mechanical restraints. He again admitted that they were not documenting physical holds at all.

2. In an interview on 5/11/16 at 10:15 a.m. with MHT1, the use of physical holds was discussed. MHT1 stated, "We use physical holds for patient's safety when is agitated and can't be redirected. MHT1 noted that they try all other measures before a physical hold is used because it requires two staff.

3. In an interview on 5/10/16 at 1:30 p.m. with the Director of Nursing, the forms used to document use of seclusion and restraints were reviewed. She agreed the forms (one for each shift) did not include a way to identify the type of restraint used. Additionally, there was no form to document the one-hour face-to-face assessment after episodes of restraint.

Based on record review, policy review, and interview, the facility failed to ensure that activity staff document progress notes for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, there were no progress notes written by the recreational therapy staff that showed each patient's progress or lack of progress related to problems and treatment goals identified on Master Treatment Plans (MTPs). This deficiency resulted in an absence of information regarding patients' progress and level of functioning being available to treatment team members thereby resulting in the potential for delayed discharge.

Findings include:

A. Record Review

1. Review of all eight (8) active sample patient medical records revealed that they did not contain progress notes written by the recreational therapy staff that showed each patient's progress or lack of progress related to problems and treatment goals identified on MTPs.

B. Policy Review

The facility's policy titled, "Multidisciplinary Comprehensive Treatment Plan Development and Review/Update Process" revised 2/4/16 stipulated under "Progress Notes": "...All other staff will provide progress notes on the designated 'Multidisciplinary Progress Notes' sheets...Each multidisciplinary note must: Indicate the date and time of entry...reference the problem #...evidence of progress toward identified treatment goals..."

C. Interview

In an interview on 5/10/16 at 12:45 p.m. with AT1, the form titled, "Group/Activity Progress Notes" was discussed. AT1 stated that this form was used to document group participation and did not dispute the finding that there was no evidence that activity staff documented each patient's progress or lack of progress toward problems and goals identified on the treatment plan.

Based on record reviews, policy reviews, observations, and interviews, the Medical Director failed to monitor the quality and appropriateness of clinical care provided. Specifically, the Medical Director failed to:

I. Ensure that the social work assessments for two (2) of eight (8) sample patients (A6 and A7) were completed before treatment planning occurred so that critical information could be provided for the development of the comprehensive treatment plan; (2) failed to ensure that the social work assessments for three (3) of eight (8) sample patients (A1, A5, and A8) included sufficient factual and historical information on which to base treatment recommendations; and (3) failed to ensure that the social work assessments for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) included recommendations regarding the role of the social worker in treatment and discharge planning. Completion of social work assessments after the treatment- planning meeting has taken place does not allow for essential psychosocial information to be integrated into the care planning process. For those assessments completed on time, the absence of critical information from the social work assessment prevents the treatment team from addressing essential patient needs during the course of hospitalization, from formulating the patient's discharge plan, and from ensuring the patient's safe re-entry into the community. The absence of specific recommendations on the role of the social worker in treatment provision and discharge planning does not allow the treatment team to integrate the social worker into the delivery of care and prevents the treatment team from clarifying treatment interventions and goals related to the patient's psychosocial needs.(Refer to B108)

II. Ensure that the psychiatric assessments for seven (7) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, and A7) included all necessary information to justify the patient's diagnosis (es) and planned treatment. Various content areas in the psychiatric assessments were not completed, including information on substance use and details of the patient's family/educational/vocational/occupational/social histories. The absence of this information compromises the treatment team's ability to formulate an accurate diagnostic view of the patient and limits the team's ability to formulate a meaningful plan of care to meet the patient's individual needs. (Refer to B110)

III. Ensure that the psychiatric assessments for two (2) of eight (8) active sample patients (A3 and A6) included a complete mental status evaluation of the patient. The absence of this information compromises the treatment team's ability to formulate an accurate diagnostic view of the patient and limits the team's ability to formulate a meaningful plan of care to meet the patient's individual needs. (Refer to B113)

IV. Ensure that the psychiatric assessments for two (2) of eight (8) sample patients (A3 and A6) included an estimate of intellectual functioning, memory functioning, and orientation. Lack of this basic clinical information can negatively affect decision-making on the need for further evaluation. Without more detailed information about a patient's orientation, level of intellectual functioning, and/or memory functioning, it is not possible to know the specific extent of the patient's capacity or impairment so that appropriate treatment modalities can be chosen, and/or so that changes in response to treatment can be measured. (Refer to B116)

V. Ensure that the psychiatric assessments for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) included an inventory of the patient's assets in descriptive and interpretive fashion. This deficient practice results in insufficient information to guide the treatment team in developing appropriately individualized plans of care for their patients and limits the team's ability to engage patients in therapy. (Refer to B117)

VI. Ensure that the Master Treatment Plans (MTP) were revised when the patients two (2) of eight (8) patients (A6 and A7) failed to participate in the active treatment program. Master treatment plans were not revised to provide alternative treatment modalities. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118-I)

VII. Develop and document comprehensive interdisciplinary treatments for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Instead, treatment plans were completed separately by clinical disciplines. Each discipline formulated a problem statement, short-term goals, and interventions for MTPs. However, these MTPs were not developed using a consensus agreement among clinical staff during treatment team meetings. This practice fails to reflect input by all team members resulting in the potential to compromise patients' opportunity to receive appropriate treatment measures. (Refer to B118-II)

VIII. Provide comprehensive Master Treatment Plans (MTPs) that were individualized and included all required components for eight (8) of eight (8) active sample patients (A2, A3, A4, A5, A6, A8¸ A9 and A10). Failure to develop Master Treatment Plans with all the required components hampers the staff's ability to provide coordinated multidisciplinary care; potentially resulting in patient's treatment needs not being met. Specifically, the facility failed to:

A. Ensure clearly defined and descriptive psychiatric problem statement were developed to improve or resolve problems prior to discharge for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). In addition, MTPS did not address medical problems identified in physical examinations of MTPs for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). These failures result in treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems and medical needs. (Refer to B119).

B. Ensure that the written treatment plans for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) and for added active non-sample patient B1 included substantiation of the psychiatric and medical diagnoses that would form the basis for treatment. Lack of confirmation of diagnoses compromises the treatment team's ability to generate a comprehensive problem list for which specific treatment modalities would be delineated and implemented. Meaningful and complete patient care cannot be provided without diagnostic clarity for both psychiatric and medical conditions. (Refer to B120)

C. Ensure that the written treatment plans for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) and added active non-sample patient B1 included short term and long-term goals described in observable and measurable terms and based on the problems identified for treatment. This results in a treatment plans that fail to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients and creates the potential that the treatment plan will fail to address patient needs during the course of hospitalization and at discharge. (Refer to B121)

D. Develop individualized treatment plans that clearly delineated active treatment interventions to address specific patient problems and assist patients to accomplishment treatment goals for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). These deficiencies potentially result in staff being unable to provide consistent and focus active treatment. (Refer to B122)

IX. Ensure that treatment notes were written to reflect patients' response to treatment efforts for five (5) of eight (8) active sample patients (A1, A3, A4, A5 and A6). Specifically, active treatment interventions listed on Master Treatment Plans (MTPs) and/or attended by patients were not documented in the medical record to include the patients' attendance or non-attendance. When patients attended active treatment sessions, there was no documentation regarding specific topics discussed, patients' behavior during interventions, their response to interventions (level of participation and understanding), and specific comments by patients. This failure results in information regarding active interventions and the response to these interventions not being available for the treatment team. (Refer to B124)

X. Ensure that active treatment measures, such as group treatment, individual treatment, and therapeutic activities, were provided to two (2) of eight (8) active sample patients (A6 and A7) who were unwilling to participate in the active treatment program and/or attend treatment groups. Specifically, these patients spent many hours without any appropriate alternative structured therapy or activities. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement. (Refer to B125-I)

XI. Ensure proper documentation of a restraint procedure for added active non-sample patient B3. Specifically, staff used a chemical restraint to manage the patient's behavior and because unit staff did not consider this as a restrictive procedure, the required face-to-face assessment documentation was not completed. In addition, the facility failed to track the use of physical holds when patients became agitated, given forced medications, or redirected against their will. There were also no policy guidelines and procedures to direct staff when physical hold procedures were used. These failures result in a restriction of the patient ' s rights without adequate documented justification and demonstrated unsafe practices that can result in serious outcomes for patients. (Refer to B125-II)

XII. Ensure that activity staff document progress notes for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, there were no progress notes written by the recreational therapy staff that showed each patient's progress or lack of progress related to problems and treatment goals identified on Master Treatment Plans (MTPs). This deficiency resulted in an absence of information regarding patients' progress and level of functioning being available to treatment team members thereby resulting in the potential for delayed discharge. (Refer to B129)

XIII. Ensure that death reviews (root cause analyses) were convened in a timely manner and a written report prepared whenever a patient death occurred. There were two patient deaths, C1 and C2, in the 18-month period prior to the re-certification survey. No death reviews were convened to review the clinical course of these patients and to ascertain whether the standard of care was met. The lack of a process and a procedure for the review of patient deaths prevents the facility from ascertaining whether appropriate standards of care and treatment were provided, and from taking appropriate corrective action in terms of staff education and training and policy and procedure revision, where warranted, in order to avoid similar issues in patient assessment and care in the future.

Findings include:

A. Record Review:

1. Patient C1: no death review on file for this case.

2. Patient C2: no death review on file for this case.

B. Interviews:

1. In a brief morning meeting on 5/10/16 at 9:00 am the CEO stated, "We do not conduct death reviews and I have no files to give you."

2. In an interview with the Psychiatric Medical Director on 5/10/16 at 12:00 noon, the Psychiatric Medical Director stated, "No, we did not perform death reviews."

3. In an interview with the Medical Director for Medical Services on 5/11/16 at 9:00 am, the Medical Director for Medical Services stated: "No" when asked if the facility conducted death reviews and if he participated.

Based on observation, record review, and interview, the facility failed to have a Director of Nursing (DON) to provide adequate oversight to ensure quality nursing services. Specifically, the facility failed to monitor to:

I. Develop individualized treatment plans that clearly delineated active treatment interventions to address specific patient problems and assist patients to accomplishment treatment goals for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, Master Treatment Plans (MTPs) only included routine and generic nursing functions written as active treatment interventions. These statements included nursing functions such as monitoring patients, redirecting patients, and medicating patients as prescribed. This deficiency results in a failure to provide guidance to nursing staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in nursing staff being unable to provide consistent and focus active treatment. (Refer to B122)

II. Ensure proper documentation of a restraint procedure for added active non-sample patient B3. Specifically, staff used a chemical restraint to manage the patient's behavior and because unit staff did not consider this as a restrictive procedure, the required face-to-face assessment documentation was not completed. In addition, the facility failed to track the use of physical holds when patients become agitated, were given forced medications, or redirected against their will. There were also no policy guidelines and procedures to direct staff when physical hold procedures were used. These failures result in a restriction of the patient's rights without adequate documented justification and demonstrated unsafe practices that can result in serious outcomes for patients. (Refer to B125-II)

Based on record review, policy review, and interview, the Social Work Director failed to ensure that the social work assessments for two (2) of eight (8) sample patients (A6 and A7) were completed before treatment planning occurred so that critical information could be provided for the development of the comprehensive treatment plan; (2) failed to ensure that the social work assessments for three (3) of eight (8) sample patients (A1, A5, and A8) included sufficient factual and historical information on which to base treatment recommendations; and (3) failed to ensure that the social work assessments for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) included recommendations regarding the role of the social worker in treatment and discharge planning. Completion of social work assessments after the treatment planning meeting has taken place does not allow for essential psychosocial information to be integrated into the care planning process. For those assessments completed on time, the absence of critical information from the social work assessment prevents the treatment team from addressing essential patient needs during the course of hospitalization, from formulating the patient's discharge plan, and from ensuring the patient's safe re-entry into the community. The absence of specific recommendations on the role of the social worker in treatment provision and discharge planning does not allow the treatment team to integrate the social worker into the delivery of care and prevents the treatment team from clarifying treatment interventions and goals related to the patient's psychosocial needs. (Refer to B108)

Based on record review and interview, the Director of Social Work (1) failed to ensure that the treatment team addressed the social work role and recommended social work interventions for patient care as recommended in the social assessment in the individualized comprehensive treatment plan, and (2) failed to ensure that the problems identified, treatment provided, discharge planning activities conducted, and liaison/follow-up efforts provided by the social worker were based on the treatment goals delineated in the individualized comprehensive treatment plan. Lack of this information prevents the treatment team from integrating psychosocial clinical data into an appreciation of a patient's problems and treatment goals, and in clarifying the role of the social worker in the provision of care and in discharge planning. (Refer to B108, B118, B119 and B121)

Based on observation, interview, and record review, the facility failed to plan and implement structured programming of therapeutic activities for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, the therapeutic activities program did not reflect planned active treatment measures designed to serve a target population of geriatric patients with psychiatric diagnoses, cognitive impairment, or dementia related behavioral symptoms with a focus of maintaining each patient's highest level of functioning. This failure potentially hinders the restoration and/or maintenance of patients' level of functioning.

Findings include:

A. Observation

During observation on 5/10/16 from 3:00 p.m. to 3:15 p.m. active non-sample Patient B1 attended a group titled, "Lady Bug Craft" in the day room with five (5) other patients. In an interview on 5/10/16 after the group session, RT1 was asked about the purpose of the group. She hesitated and then stated, "I guess to keep them active." When questions about the number of patients in the group given a census of 19 patients, she reported she goes from room to room to solicit patients to attend. Group attendance was not driven by each patient's treatment needs and recommendations by the treatment team

B. Record and Document Review

1. The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (4/26/16), A2 (5/10/16), A3 (3/31/16), A4 (4/28/16), A5 (5/9/16), A6 (4/18/16), A7 (5/5/16) and A8 (5/6/16). Although recreational therapy staff provided most of the groups, this review revealed that none of the active sample patients had active treatment interventions identified on MTPs to be provided by recreational therapy staff.

2. A review of the unit group schedule for May 2016 revealed a list of groups and diversional activities designed to keep patients busy, such as "Coloring pages, Movie Matinee, fancy nails, root beer day, snow cone day, etc. There was no evidence that the facility planned and developed the therapeutic activities program based on the facility's targeted population. Except for the exercise, sensory, and yoga groups, there were no other groups included on the schedule provided that specifically reflected groups that would assist patient to maintain their highest level of functioning, such as social skills, reminiscent therapy, creative arts, music therapy, relaxation, etc.

B. Interview

1. In an interview on 5/10/16 at 12:45 p.m. with RT1, the group being offered by the facility was discussed. She admitted that groups were not under any major heading reflecting the overall rationale or purpose for the groups provided. She stated, I try to get everyone to attend and admitted that she needed help during the group sessions. She reported that yoga and sensory stimulation groups, which were usually offered two times per day, were not provided as scheduled. She stated, "I don't have anyone to assist."


2. In an interview on 5/10/16 at 3:15 pm. after the group session, RT1 was asked about the purpose of the group. She hesitated and then stated, "I guess to keep them active." When questions about the number of patients in the group given a census of 19 patients, she reported she goes from room to room to solicit patients to attend. Group attendance was not driven by each patient's treatment needs and recommendations by the treatment team.