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Based on document review and interview, the facility failed to ensure a thorough neglect investigation for 1 of 1 internal reviews of the investigation for patient #25, resulting in a failure to identify system wide problems related to implementation of post-fall monitoring and a risk for harm for all patients who fall while receiving treatment at the facility. Findings Include:

On 11/12/2014 at 1000 during entrance conference, the facility was asked to present documentation for any sentential events that had occurred at the facility over the past year. Staff E (Director of Quality) stated, "we did not have any sentential events the past year. No one has expired here at the facility."

On 11/12/2014, during review of the medical record for patient #25, revealed that during his hospitalization he fell 4-6 times and was subsequently transferred to an acute care hospital related to a change in condition and expired within 24 hours of the discharge.

During review of the RCA (root cause analysis), that was performed on 09/02/2014 it revealed that the only action taken related to the incident was a new "Fall Reduction Plan," which more clearly identified fall risk patients. The patient who fell multiple times, #25, was identified as high risk for fall starting on the day of admission. When the facility reviewed the case, they identified four falls, in patient # 25's medical record, however six falls were reported. No post-fall interventions were identified. No "Action Items" to reduce risk were identified; these sections of the tool were left blank. The "Plan of Action" column was also left blank. The facility's RCA did not show evidence of a thorough investigation, as evidenced by lack of details, and the incomplete and blank areas on the RCA tool and the lack of corrective action.

On 11/14/2014 at approximately 0930 an interview took place with the following staff regarding the RCA for patient #25, which included the Medical Director, the CEO (chief executive officer), both physicians that cared for the patient, the manager of the Generations unit, where patient #25 was hospitalized, the quality director, the CNO (chief nursing officer), the COO (chief operating officer), the social worker caring for the patient, this surveyor and the federal surveyor. This surveyor asked the group why sections of the RCA tool were left blank and what actions were taken to ensure patients who fell in the future, would be provided post-fall monitoring. An answer was not given related to the tool lacking details of action items. This surveyor then asked if any areas of concern were identified regarding monitoring after falls. Staff O (CNO) stated, "We looked at the process leading up to the falls and changed our Fall Reduction Policy, but we did not look at the "back end" of the process (for patient monitoring) after the falls.

Based on observation and interview the facility failed to provide a safe environment for all 96 patients at the facility potentially resulting in patient harm. Findings include:

On 11/12/14 from approximately 1100 until 1230 it was observed during a tour of the Crisis Unit that 8 plastic bags for Styrofoam cups were available on the crisis unit in the day room and activity room with suicidal patients housed on the unit.

On 11/12/14 from approximately 1100 until 1230 during interviews with staff K it was stated, "The plastic bags are not supposed to be out, patients could swallow them." Staff K picked up the bags and removed them.

Based on document review and interview, the Medical Staff leadership failed to play an active role in Quality Assurance Performance Improvement (QAPI) program planning and implementation. Findings include:

Review of the QAPI minutes and data provided from January 2015 through October 2015, on 11/13/14 at approximately 1400, revealed no sign in or input from the Medical Staff Leadership or Medical Staff representation. Interview with the Quality Director, on 11/14/14 at approximately 1100, verified that the Medical Staff did not provide input directly to the QAPI program. The Quality Director stated that she has gone to the Medical Staff Business Meeting and stated, "I know I sign in and (they) give an update". Review of the "Physician Meeting" documents for the past quarter, on 11/14/14 at approximately 1230, revealed only sign in sheets and no meeting minutes or agendas. Request for further documentation of Medical Staff Meeting Minutes for the past year, on 11/14/14 at approximately 1300, revealed only agendas with "Quality" but no medical staff documented input, action plans, or any meeting minutes, except for one month in the past eighteen months (March 8, 2013 to September 12, 2014). The CEO and COO verified that was all that was available to review, on 11/14/14 at approximately 1330.


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On 11/13/2014 at 1145 during interview with the Medical Director when queried if he attends the quality meetings, he stated, "Not all of them." When queried if he could identify what projects the facility was looking at for quality initiatives, he stated, "I know we were looking at hand hygiene, but I think we have gotten pretty good at that." He then went on to state, "I think they will be looking at the flu (influenza) vaccines since that time is here." When asked if he was aware that the facility was looking at urinary tract infections in the geriatric population, he stated, "No, but that would probably be a good one." When asked if it would be safe to say that he is not very involved in the quality program at the facility, he stated, "I can see that I need to be more involved with what is going on."

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

1. The facility failed to update the master plan of care for patients resulting in the failure to assess the daily needs of the patients receiving treatment at the facility. (See tag A 396)

2. The facility failed to ensure the competency of the nursing staff assigned care to patients resulting in the failure of competent care to be provided to patients. (See tag A 397)

3. The facility failed to maintain a safe environment to prepare and administer medications resulting in the potential to contaminate medications for all 37 patients on the unit. (See tag A 405)

Based on medical document review, interview, and policy review the facility failed to update the master plan of care in 9 of 11 patients (#16, #18, #21, #24, #25, #29, #30, #32 and #33) resulting in the failure to assess the daily needs of the patients receiving treatment at the facility and the potential for poor outcomes. Findings include:

On 11/12/2014 at approximately 1115 during the medical record review of patient #16 it was revealed that the Master Treatment Plan (MTP) did not have the signature of the psychiatrist as part of the Interdisciplinary Team. On 11/12/2014 at approximately 1120 staff X was asked if the psychiatrist was part of the Interdisciplinary Team and expected to sign the MTP. Staff X replied "Yes." Staff X was then queried if the MTP was considered complete without the involvement of the psychiatrist. Staff X replied, "No."

On 11/12/2014 at approximately 1130 during the medical record review of patient #18 it was revealed that the Master Treatment Plan did not have the signature of the psychiatrist as part of the Interdisciplinary Team. On 11/12/2014 at approximately 1135 staff X was asked if the psychiatrist was part of the interdisciplinary Team and expected to sign the MTP. Staff X replied, "Yes." Staff X was then queried if the MTP was considered complete without the involvement of the psychiatrist. Staff X replied, "No."

On 11/14/2014 at approximately 0800 during medical record review of patient #41 it was revealed that vital signs had not been recorded in the patient's medical record. The patient had been admitted on 10/23/2014 and discharged on 11/8/2014. The patient's medication administration record showed the patient was prescribed antihypertensive medication which required blood pressures taken daily, in order to determine if the medication was to be administered daily or held when the systolic blood pressure was below 110. According to the medical record, the patient only had recorded blood pressures documented on 10/26/2014, 10/27/2014, 10/28/2014, and 10/29/2014.

On 11/14/2014 at approximately 0915 an interview with staff B occurred. Staff O was asked how could the nurse dispensing medications make the determination on whether to dispense the antihypertensive medications without blood pressures. Staff O responded, "We keep a log of blood pressures on the unit but fail to transfer them over to the patient's chart at times." Staff O was then asked how the patient's plan of care could be updated without current information being part of the medical record. Staff O responded, "I understand and we need to work on that."

On 11/14/2014 at approximately 0830 a review of the undated policy titled, "Interdisciplinary Treatment Team Plan/Conference" occurred. According to the policy "Each patient will have a comprehensive, individualized master treatment plan that will identify patient problems, strengths, and severity of illness based upon a interdisciplinary patient assessment. The person centered planning process is collaborative and interdisciplinary. The patient is a participant in the treatment planning process and is informed of their clinical status and progress towards their goals at established intervals."

According to the policy the procedure states:

"1. The registered nurse will initiate the Master Treatment Plan immediately after completing the nursing/patient assessment in collaboration with the psychiatrist."

2. The registered nurse will complete the following areas on the Master Treatment Plan within eight (8) hours of admission to inpatient treatment.
Identify patient
Date of admission
Reason for hospitalization
Check the box for appropriate patient needs
Identify problem(s) through collaboration with physician upon obtaining admission orders. Rationale for problem will be identified by patient descriptive behavior using the words "as evidenced by" (AEB)
Identify problems noted by, which will not be treated and provide reason.
Identify problems noted but, which will not be treated and provide reason.
identify focus of treatment (point of concern for a suicidal patient the primary concern/focus is protecting the patient from self-harm)
Identify a goal/outcome related to the problem (measurable)
Identify an objective (patient focused)

3. The registered nurse will develop a nursing, intervention for the identified problems, indicate nursing as the responsible discipline, time and date implemented. The nursing intervention will be based upon the focus of treatment (point of concern, example: for a suicidal patient the primary concern is protecting the patient from self-harm). The treatment modality is the way the treatment is delivered (Example: psychotherapy, medication management, group therapy, individual therapy, activity therapy, nutritional education, psycho education, medication education, illness management). The RN will address Axis III (MEDICAL PROBLEMS) on the MTP with goals and interventions at the time of admission to Facility Z. The RN's signature, date and time is required on page 2 of the Master Treatment Plan.

4. The psychiatrist, registered nurse, social worker, and activity therapist will continue to identify problems, and develop interventions within the first 72-hours of inpatient treatment and within two (2) Partial Center Program days utilizing the above protocol. The registered pharmacist and registered dietician will participate in developing the Master Treatment Plan as needed.

5. The psychiatrist and clinical team will confer within 72-hours of inpatient treatment or two (2) Partial Center Program days time frame. At that time, the psychiatrist will provide a substantiated diagnosis (Axis I - IV) and further direction in the completion of the Master Treatment Plan:
Additional patient needs
Problems
Problems noted but not treated
Focus of Treatment
Strengths to be used in treatment
Barriers to treatment
Estimated time to complete goals
Estimated length of stay
Discharge Plan
Living Arrangement
Establish Individualized DC Criteria
GAF Score (Global Assessment of Functioning)
Physician signature & date
Clinical Team Signatures

6. The psychiatrist and the Clinical Team members will sign and date the Master Treatment Plan.

7. The patient will be provided the opportunity to participate in their treatment planning within 72-hours for inpatient treatment or the first two (2) Partial Center Program visits and at established intervals.

8. The registered nurse will review and provide a copy of the treatment plan to the patient/family/guardian and document the following with 72 hours for inpatient treatment or two (2) Partial Center program visits:
Patient participation, agreed and received a copy of the MTP
Patient refused participation in their MTP

9. The registered nurse obtains the signature of the patient/parent/guardian/family and date/time.

10. The registered nurse will document the degree to which the patient/parent/guardian/family understand the MTP.

11. The Clinical Team member's signature is required at the completion of the Master Treatment Plan to indicate follow-through of communication (72-hours for inpatients and tow (2) visits for Partial Center)

12. The Treatment Plan Review will be conducted on a weekly basis. During the review the team will address:
Change in diagnosis
Change in focus of treatment
Problems, Progress, and any changes in interventions from Master Treatment Plan
New Problems
Medical Problems
DC (discharge) Criteria
Reason for continued hospitalization
Change in medication
Reason for change in medication
DC (discharge) plan
Anticipated DC date
Psychiatric follow-up
Medical follow-up
Registered nurse will review and provide copy of Master Treatment Plan to the patient/parent/guardian/family
Registered nurse will obtain signature of the patient/parent/guardian and date/time
Registered nurse will document the degree to which the patient/parent/guardian/family understand the treatment plan"

On 11/14/2014 at approximately 0920 an interview with staff O occurred. Staff O was asked if all patient Master Treatment Plans were complete and updated as the policy required. Staff O stated, "No."


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On 11/12/14 at approximately 1135, review of patient #29's medical record revealed incomplete documentation on the document titled "Master Treatment Plan." Patient #29 was a 60 year old Spanish speaking male, who was admitted on 11/05/14 for Schizophrenia. He also had a history of unstable blood sugar and high blood pressure. The "Master Treatment Plan" dated 11/05/14 revealed no daily updating for the dates of 11/06/14 to 11/12/14, for monitoring unstable blood sugar, high blood pressure, and different means of communicating with the patient, who is of Spanish decent and "speaks little English" (according to the document titled "Clinical Progress Note" dated 11/05/14 at 0615).

On 11/12/14 at approximately 1200, review of patient #30's medical record revealed incomplete documentation on the document titled "Master Treatment Plan." Patient #30 was a 60 year old male, who was admitted on 10/30/14 for confusion and agitation. He also had a history of unstable blood sugar. The "Master treatment Plan" dated 10/30/14 revealed no daily updating for the dates of 11/05/14 to 11/12/14, for monitoring of the patient's unstable blood sugar.

On 11/12/14 at approximately 1345, review of patient #32's medical record revealed incomplete documentation on the document titled, "Master Treatment Plan." Patient #32 was a 75 year old female, who was admitted on 10/31/14 for anxiety and delusions. She also had a history of high blood pressure. The "Master Treatment Plan" dated 10/31/14 revealed no daily updating for the dates of 11/01/14 to 11/12/14, or alternate means of obtaining a blood pressure reading. It was documented for the patient's 13 days of hospitalization that she "refused (blood pressure monitoring)."

On 11/12/14 at approximately 1415, review of patient #33's medical record revealed incomplete documentation on the document titled, "Master Treatment Plan." Patient #33 was a 74 year old female, who was admitted on 11/06/14 for agitation, delusions, and paranoia. The "Master treatment Plan" dated 11/06/14 revealed no daily updating for other means of attempts made to try to get the patient to be involved in therapy groups. It was documented for the patient's 6 days of hospitalization that she "refused" or that the patient was "sleeping/ didn't want to bother patient."

On 11/12/14 at approximately 1430, during an interview, staff AA was queried regarding the incomplete updating documentation in the "Master Treatment Plan" for patients #29, #30, #32 and #33 to which she replied, "I agree, the documentation is incomplete, we should be updating on here (the care plan) daily."


29314

On 11/12/14 at approximately 1200 during open medical record review for patient #21 it was revealed that the patient was put in restraints three times prior to 11/12/14, the treatment plan was not updated related to the restraint use. The treatment plan had not been updated since it was initiated when the patient was admitted on 11/3/14.

On 11/12/14 at approximately 1200, during an interview with staff K it was confirmed that patient #21 did not have a care plan update related to the restraint use or any updates after admission on 11/3/14.

On 11/13/14 at approximately 1400 during review of the closed medical record for patient #24 it was revealed that the patients treatment plan was not individualized for increased fall risk and nutrition concerns for weight loss and dehydration.

On 11/13/14 at approximately 1430 staff E confirmed that the treatment plan for patient #24 was not individualized to the patient regarding falls and nutrition concerns.

On 11/13/14 at approximately 0900 during review of the closed medical record for patient #25 it was revealed that the patients treatment was not updated or individualized to the patient. The patient fell six times from 7/31/14 through 8/15/14 and the treatment plan was not updated to prevent further falls or to monitor for injury after falls. The treatment plan was reviewed on 8/6/14, however, changes were not made to the treatment plan. After 8/6/14 the treatment plan was not reviewed or updated.

On 11/13/14 at approximately 1330 during an interview with staff K it was confirmed that patient #25's treatment plan was not updated or adjusted for the frequent falls throughout the hospital stay.

Based upon observation, medical document review, facility competency review, and interview the facility failed to ensure the competency of the nursing staff assigned care to patients resulting in the inability to assure competent care to be provided to all patients. Findings include:

On 11/5/2014 at approximately 1135 during the initial tour of the facility registered nurse EE was asked if she could perform a quality check on the glucometer machine that was in use. Staff EE failed to be able to conduct a quality check on the glucometer machine. Staff EE was then asked, "Have you completed nursing competencies?" Staff EE responded, "Not at this facility, but at my other job I have."

On 11/7/2014 at approximately 0830 during the medical record review of patient #42 it was revealed the nurse did not administer medications scheduled for 2100 on 11/4/2014. Medications scheduled for 2100 administration on 11/4/2014 were Ativan 1 mg (milligram), Zocor 20 mg, Depakote DR 500 mg, Prolixin HCL (Hydrochloride) 25 mg, and Cogentin 0.5 mg. According to the medication administration record (MAR) the nurse documented the "patient as sleeping". Review of the mental health assistant charting for patient #42 on 11/4/2014 documented the patient as being awake from 1900 to 2315 in the patient room, dayroom, and hallway.

On 11/7/2014 at approximately 0915 an interview with staff O occurred. Staff O was asked what the expectation was for patients to receive medications at the scheduled time. Staff O stated, "they (patient #42)should have been given their medications." Staff O was then asked if there was a policy to support omitting medications. Staff O stated, "No. Medications should be given to patients as scheduled." Staff O was then asked about the discrepancy between the nurse's charting on the medication administration record and the mental health assistant's charting of the patient being asleep and awake. Staff O stated, "I can not explain why the charting is not the same." Staff O was then asked should the patient have received the medications and if the nurse should wake a patient to administer medications as scheduled. Staff O responded, "Yes. The nurse should have waked the patient and administered the medications."

On 11/7/2014 at approximately 0920 a review of nursing staff competencies occurred. Staff O was asked if competencies for standard nursing practice such as urinary catheterizations occurred on a annual basis. Staff O stated, "We realize a need for conducting competencies on an annual basis. We are currently in the process of interviewing for a nurse educator." Staff O further stated, "We are not a medical facility and provide psychiatric care. If a patient were to need something such as a (urinary) catheter (insertion) they would be transferred out." Staff O was then asked if the nursing staff needed to show competent nursing care and decision making skills for the safety of the patient. Staff O responded, "Yes."

Based on observation and interview the facility failed to maintain a safe environment to prepare and administer medications, resulting in the potential to contaminate medications for all 37 patients on the unit. Findings include:

On 11/12/14 at approximately 1130 during a tour of the Crisis Unit it was observed in the medication room that staff were eating popcorn and drinking coffee while passing medications. The medication room was very cluttered and the work area was soiled with residue of spilled liquids.

On 11/12/14 at approximately 1130 during an interview with staff U this surveyor asked, "I noticed that you are eating popcorn and drinking coffee in the medication room, is this practice ok in this facility?" Staff U stated, "No, we were told not to have it in here." The popcorn and coffee was not taken out of the medication room while the surveyor was there.

Based on medical record review, interview and policy review, the facility failed to ensure that staff provide complete information documented in the medical record related to patient vital signs (blood pressures, respirations, pulses and temperatures) weights, therapy attendance, blood sugar monitoring and patient falls for 7 of 9 patients (patients #21, #24, #25, #29, #30, #32 and #33) resulting in the potential for unmet patient needs during hospitalization and the potential for poor patient outcomes. Findings include:

On 11/12/14 at approximately 1135, review of patient #29's medical record revealed incomplete documentation on the "Flowsheet." Patients' weights, meal intakes, blood sugars, temperatures, pulses, respirations or blood pressure readings were absent. The document titled, "Attending Physician Progress Note" dated 11/08/14, 11/09/14, 11/10/14 and 11/11/14 lacked documented vital signs, whether the current medications were reviewed, and if the facility was going to "continue plan of care as previously documented." The document titled, "Nursing Group Note" dated 11/07/14 at 0830 lacked the response to group therapy and barriers to learning. The document titled, "Nursing Group Note" dated 11/07/14 at 1205 lacked the patient's attitude, level of participation, barriers to learning, and response to group therapy. The document titled, "Nursing Group Note" dated 11/07/14 at 1400 lacked the patient's attitude, readiness to learn, barriers to learning, and response to group therapy. The patient was Spanish speaking and there was no documentation that an interpreter was available for the patient, during therapy group time.

On 11/12/14 at approximately 1200, review of patient #30's medical record revealed incomplete documentation on the "Flowsheet." There were no weights, blood sugars, temperatures, pulses, respirations or blood pressure readings documented. The document titled, "Attending Physician Progress Note" dated 11/08/14, 11/09/14, 11/10/14 and 11/11/14 lacked documented vital signs, whether the current medications were reviewed, and if the facility was going to "continue plan of care as previously documented." The document titled, "Nursing Group Note" dated 11/07/14 at 0830 lacked the response to group therapy and barriers to learning. The document titled, "Nursing Group Note" dated 11/07/14 at 1205 lacked the patient's attitude, level of participation, barriers to learning, and response to group therapy. The document titled, "Nursing Group Note" dated 11/07/14 at 1400 lacked the patient's attitude, readiness to learn, barriers to learning, and response to group therapy.

On 11/12/14 at approximately 1345, review of patient #32's medical record revealed incomplete documentation on the "Flowsheet." There were no weights, temperatures, pulses, respirations or blood pressure readings documented. The document titled, "Nursing Group Note" dated 11/06/14 at 1330 lacked the response to group therapy and barriers to learning. The document titled, "Nursing Group Note" dated 11/07/14 at 1205 lacked the patient's attitude, barriers to learning, readiness to learn and response to group.

On 11/12/14 at approximately 1415, review of patient #33's medical record revealed incomplete documentation on the "Flowsheet." There were no weights, temperatures, pulses, respirations or blood pressure readings documented. The document titled, "Attending Physician Progress Note" dated 11/08/14, 11/09/14, 11/10/14 and 11/11/14 lacked vital signs, whether the current medications were reviewed, and if the facility was going to "continue plan of care as previously documented." The document titled, "Nursing Group Note" dated 11/07/14 at 0830 lacked the response to group therapy and barriers to learning. The document titled, "Nursing Group Note" dated 11/07/14 at 1205 lacked the patient's attitude, level of participation, barriers to learning, and response to group. The document titled, "Nursing Group Note" dated 11/07/14 at 1400 lacked the patient's attitude, readiness to learn, barriers to learning, and response to group.

On 11/13/14 at approximately 1335, staff AA was queried about the missing and incomplete documentation in the medical record for patients #29, #30, #32 and #33. Staff AA stated "I don't know why they aren't complete, a lot of things are just missing."

On 11/14/14 at approximately 0915, during review of the undated policy titled, "Nursing Process Documentation", it was noted that "6. It is the ultimate responsibility of the Clinical Nurse to ensure that all charts are intact and completed at the end of the shift."


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On 11/12/14 at approximately 1200 during medical record review for patient #21 it was revealed that the physicians orders were not legible. An order written for oral haldol appeared to be written for "IV" haldol. The order had to be clarified for staff to interpret.

On 11/12/14 at approximately 1200 during an interview with staff K this surveyor asked, "What route does this order say?" when looking at the order for haldol. Staff K stated "It looks like IV, but it is PO in the MARs [Medication Administration Record]. Let me check." Staff K came back after speaking with staff X and stated, "It is written for oral Haldol, they [staff] had to call to clarify the order."

On 11/13/14 during medical record review of patient #24 it was revealed that the patient was hospitalized from 10/2 through 10/9 then transferred to facility B for "dehydration and weight loss". Vital signs were not recorded on 10/3, 10/8 and 10/9. The patient did not have weights recorded after 10/4.

On 11/13/14 at approximately 1400 during an interview with staff GG it was confirmed that vital signs and weights were not recorded for patient #24 for the dates indicated above. This surveyor asked, "How did they know that he lost weight and needed to be transferred for dehydration and weight loss if weights and vitals are not recorded?" Staff GG stated, "I'm not sure, I do not see anything documented either."

On 11/13/14 at approximately 1000 during medical record review for patient #25 it was revealed that vital signs were not recorded on 8/1/14, 8/3/14, 8/7/14, 8/14/14 and 8/16/14. Also, the physician progress notes and orders written by staff HH were illegible.

On 11/13/14 at approximately 1330 during an interview with staff K it was confirmed that no evidence of vital signs for patient #25 on the above documented dates could be found in the medical record. It was also confirmed with staff K that staff HH did not write legibly in the medical record which could potentially cause medication and care errors.

Based on document review and interview, the facility failed to ensure that medical record documentation was completed within thirty (30) days of discharge for closure of the record. Findings include:

On 11/13/2014 at 0800 during review of documentation, revealed that the facility had 59 medical records for patients who had been discharged more than 30 days. A document titled, "Medical Record Delinquency" showed that there were 36 records that remained opened after 30 days, 20 records that remained opened after 60 days and 3 records that remained opened after 90 days.

On 11/13/2014 at 0900, review of the Medical Staff rules and regulations dated February 17, 2014 reads, "8.23 Medical Record completion must not exceed 30 calendar days post discharge, at which time medical records will be considered delinquent." The medical staff rules and regulations nor the medical staff bylaws address the issue of delinquent records any further for physicians who are currently on staff and have delinquent records.

On 11/13/2014 at 0930 during an interview with staff I (Director of Health Information), when queried as to what steps she takes when medical records are not completed after 30 days, she stated, "Each week I make a list of each doctor's delinquencies and they are provided a copy of the list along with the Medical Director." When asked what are the next steps taken, staff I replied, "I am not sure, that is my part." When queried if there were currently any physicians suspended related to delinquent records, staff I replied, "I don't believe that we suspend them for delinquent records." When queried if the facility has a policy addressing the steps taken for delinquent medical records, she stated, "Not that I am aware of."

On 11/13/2014 at 1000 during an interview with the Chief Operating Officer (Staff B), when queried about a policy regarding delinquent medical records over 30 days, he stated, "We don't have a policy, it is addressed in the medical staff rules and regulations."

On 11/13/2014 at 1130 during an interview with the Medical Director (staff C), When queried about the delinquent medical records, he stated, "That is always a struggle to get these completed." When asked what steps are taken to get the records completed, he stated, "I speak with the physicians about getting in and getting them completed." When asked what are the steps taken if a physician does not comply with completing their records, he stated, "That is addressed in the bylaws."

Based on document review and interview, the Pharmacy Director failed to keep current records of expired scheduled drugs, which provided for a potential for diversion of these drugs. Findings include:

Interview with the Pharmacy Director, on 11/13/14 at approximately 1000, revealed that she kept all expired scheduled/controlled drugs in the pharmacy room in a box until third party disposal. Inspection of of the box, on 11/13/13 at 1030, revealed many expired medications in the box including forty-one (41) tablets of Morphine Extend Release 30 mg with an expiration date of 10/14. A request for a listing of expired controlled drugs in the box with respective counts revealed that was not available. Further interview regarding the disposable company and disposal procedure revealed that the last Disposal sheet documented was dated 10/21/13. When queried about frequency of third party disposal, the Pharmacy Director stated that occurred, "Once or twice a year". There was no evidence that the Pharmacy Director kept current and accurate counts of expired scheduled drugs from the time the drugs went in the box to third party pick up.

Based on observation and interview, the facility failed to ensure that outdated medications (medications labeled with expiration dates that have past) are not available for use resulting in the potential for a delay in treatment and poor patient outcomes. Findings include:

On 11/12/2014 at 1115 during observations on the adolescent unit revealed two outdated prefilled syringes of normal saline. The syringes were outdated from September 1, 2012.

On 11/12/2014 at 1120 during an interview with staff B, when queried about the cart that the syringes were found in he stated, "It is an emergency medical cart." When queried about the two syringes, he stated, "I don't believe that the cart is supposed to have any medications in it."

Based on document review and interview, the Pharmacy and QAPI programs were not coordinated or integrated in the medication error and adverse drug event reporting. Findings include:

Interview with the Pharmacy Director, on 11/13/14 at approximately 1100, revealed that she did not track medication errors, but stated that the Quality program did. She stated that she went to the quarterly QAPI meetings. Review of the Pharmacy & Therapeutics quarterly meeting minutes (3/14, 6/14, 9/14) revealed Medication error section documenting "No errors reported", "inventions required" equal "5 serious, 1 serious, 1 serious", in the respective quarters.

Interview with the Quality Director, on 11/14/14 at approximately 1100, revealed that QAPI Committee met monthly. A request for documented sign in by Pharmacy, revealed no sign in by the Pharmacy representative. Review of QAPI "medication error/variance reporting" with the Quality Director revealed multiple monthly entires totaling 28 for the period of 1/14 - 10/14. The Quality Director verified that there was no documented evaluation or plan of action documented for those medication variances, on 11/14/14 at approximately 1200.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated November 13, 2014.
K-0011
K-0020
K-0022
K-0025
K-0029
K-0033
K-0072
K-0144
K-0147

Based upon observation and interview the facility failed to maintain the physical plant resulting in the risk for harm of all patients housed in the facility.

Findings include:
On 11/13/14 at approximately 1025 it was observed that the handwashing sink in the medication dispensing area on 4-South was detaching from the wall. A gap of approximately 1/2 inch was observed between the wall and the fixture. This was confirmed with Staff BB.
On 11/13/14 at approximately 1030 based on observation there was a hole in the drywall approximately 4 inches by 4 inches in the ante room serving the seclusion rooms on 4-South. The seclusion room on the left was observed to have several pieces of vinyl cove base removed from the floor-wall juncture leaving an exposed gap.
On 11/13/14 between the hours of 1020 and 1200 janitors closets throughout the facility were observed to have chemical dispensing systems attached to mop sink faucets with built-in atmospheric vacuum breakers without the use of a wasting tee or Side-Kick device, causing the built-in atmospheric vacuum breaker to be subject to constant pressure, which it is not approved for. This was confirmed with Staff BB on 11/13/14 at approximately 1130.


29314

On 11/12/14 from approximately 1100 until 1230 the following was observed during a tour of the Crisis Unit:
-- Molding was hanging off the wall with sharp edges exposed in the seclusion room and in room 427.
-- Room 427, in the bathroom, there was a broken soap holder and metal paper towel dispenser with sharp edges, and a hole approximately 12 inches in diameter in the wall at the base of the toilet with exposed plumbing pipes.

On 11/12/14 from approximately 1100 until 1230 during an interview with staff K it was stated, "This room (427) needs a lot of work".

Based on observation and interview the facility failed to maintain the environment to provide an acceptable level of safety for the well being of patients potentially resulting in patient illness. Findings include:

On 11/12/14 at approximately 1100 during a tour of the Crisis Unit it was observed that the nutrition room had food left out on the counter that was room temperature that should have been refrigerated and was undated without a patient name. It was also observed that the refrigerator was soiled with spilled food and beverages. Milk and juice were left out on the counter and available for patient use.

On 11/12/14 at approximately 1100 during an interview with staff K it was confirmed that the nutrition room needed to be cleaned up. Staff K disposed of the food and beverages left out on the counters.

On 11/12/14 at approximately 1110 during observations of the seclusion/restraint room and shower it was revealed that the floor was soiled with wrappers, soap, dirt, dust, pieces of molding torn from the wall, paint and toilet paper.

On 11/12/13 at approximately 1110 during an interview with staff K, the observations in the seclusion/restrain room were confirmed. Staff K asked staff V to clean up the seclusion/restraint room at approximately 1125.

Based upon observation, record review and interview the facility failed to identify and take action to prevent processes in the kitchen likely to cause foodborne infections to patients and staff and failed to identify and take action in patient care units likely to cause infections to patients and staff.

Findings include:
On 11/13/14 at approximately 1100, while touring the kitchen, it was observed that there were no chlorine test strips available for testing the sanitizer concentration at the dish machine. When this was brought to the attention of Staff CC, he went to look for test strips in his office. Staff CC returned to the dishwashing area and stated that there were no chlorine test strips and he would need to contact the chemical vendor to obtain some. There were no records of monitoring logs for testing the chlorine concentration at the dishmachine.
On 11/13/14 at approximately 1100 while touring the kitchen, it was observed that there were no quaternary ammonia testing strips available for use with the sanitizer solution at the 3-compartment sink that is used to sanitize pots and pans and for use in wiping cloth solutions. Staff CC stated that he would also need to order these from the chemical vendor.
On 11/13/14 at approximately 1115 while touring the kitchen dry storage area, a storage system consisting of wooden pallets and flattened cardboard boxes was observed being used for storage of containers of "Vitamin Water" and water cooler bottles. Staff CC stated that the Vitamin Water product was relatively new to the facility and this storage system was put in place because there were no other options available. Debris and dust was observed accumulated in the storage space.
On 11/13/14 at approximately 1120 while touring the walk in freezer of the kitchen, large bags of ice were observed stored directly on the walk in freezer floor. When asked what these bags of ice were used for, Staff CC responded that they were used for patient consumption while the ice machine was out of order.
On 11/13/14 at approximately 1130 while touring the cafeteria line service area, a kitchen worker was observed monitoring hot food temperatures using a probe thermometer and wiping the probe on a paper napkin between foods to clean it. When asked if this was the approved method to clean the temperature probe, Staff CC replied no, and that he needed to order some more alcohol prep pads as well.

On 11/13/14 between the hours of 1000 and 1200, while touring the patient units, it was observed that the facility is storing packages of paper towel, to be used at handwashing sinks on the counters in the soiled utility rooms throughout. Extra paper towel was also observed stacked behind sinks and on top of paper towel dispensers in the medication room of 4 South and the clean utility room of 3 South.

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

1. Provide social work assessments that included conclusions and recommendations of the anticipated necessary steps for discharge to occur and the anticipated social work role in treatment and discharge planning for six (6) of eight (8) active sample patients (R2, R3, G5, G6, G7, and G8). As a result, the social work role, conclusions, and specific recommendations regarding treatment of patients' psychosocial problems are not described for the treatment team. (Refer to B108)

2. Provide comprehensive Master Treatment Plans (MTPs) which were individualized, behavioral, and measurable with all necessary components for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8). Specifically, the MTPs did not include the following: 1) behaviorally descriptive psychiatric problem statements and medical problems noted in assessments for two (2) of two (2) active sample patients (G5 and G6) on the Geriatric Unit. (Refer to B119), 2) observable, patient focused, measurable, and behaviorally stated goals (Refer to B121), 3) individualized treatment interventions (Refer to B122), and 4) the name and specific discipline responsible for each intervention (Refer to B123). Failure to develop individualized MTPs with all the necessary components hampers the staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met.

3. Provide active treatment or alternative programming/activities for 1 of eight (8) active sample patients (R1) who was too acutely ill or refuse to attend scheduled programming activities and interpreter services according to facility policy for 1 of two (2) active sample patients (G5) on the Geriatric Unit who was not proficient in the English language. Despite, inconsistent or lack of regular attendance in groups, master treatment plans were not revised to reflect individual treatment sessions instead of group treatment. 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)

Based on record review and staff interviews, the facility failed to ensure that the social service assessments included individualized recommendations for social work services from the data gathered for six (6) of eight (8) active sample patients (R2, R3, G5, G6, G7, and G8). As a result, the treatment team did not have current baseline social functioning on these patients for establishing treatment goals and interventions and social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams.

Findings include:

A. Record Review

1. Patient R2 was admitted on 11/03/14. The psychosocial assessment, done on 11/04/14, did not include individualized social services specific recommendations. The recommendations documented were generic in nature describing routine unit activities and reason for the admission.

2. Patient R3 was admitted on 10/28/14. The psychosocial assessment, done on 10/31/14, did not include individualized social services specific recommendations. The recommendations documented were generic in nature describing routine unit activities, generic treatment goals and reason for the admission.

3. Patient G5 was admitted on 11/05/14. The psychosocial assessment, done on 11/06/14, did not include individualized social services specific recommendations. The recommendations documented were generic in nature describing routine unit activities, generic treatment goals and reason for the admission.

4. Patient G6 was admitted on 11/07/14. The psychosocial assessment, done on 11/08/14, did not include individualized social services specific recommendations. The recommendations documented were generic in nature describing routine unit activities, generic treatment goals and reason for the admission.

5. Patient G7 was admitted on 11/09/14. The psychosocial assessment, done on 11/11/14, did not include individualized social services specific recommendations. The recommendations documented were generic treatment goals and reason for the admission.

6. Patient G8 was admitted on 11/06/14. The psychosocial assessment, done on 11/07/14, did not include individualized social services specific recommendations. The recommendations documented were generic in nature describing routine unit activities, generic treatment goals and reason for the admission.


B. Staff Interviews


1. During an interview on 11/13/14 at 11:25 AM, the Director of Social Work stated, "I agree the social assessments do not include individualized recommendations. I am aware of the problem. I am working on a plan of correction."

2. During an interview on 11/13/14 at 12:00 PM, the Medical Director agreed that the social assessments do not include patient's individualized recommendations.

Based on record review and staff interview, it was determined that the facility failed to perform and document an estimate of memory functioning with supportive information in the psychiatric evaluation for seven (7) of eight (8) active sample patients (R1, R3, R4, G5, G6, G7, and G8) and failed to perform and document an examination of orientation with supportive information in the psychiatric evaluation for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8). These failures potentially result in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromise future comparative re-examinations to assess patient's response to treatment interventions.

Findings include:

Record Review:

1. Patient R1 was admitted on 11/07/14. The psychiatric evaluation, done on 11/08/14 stated, "Oriented X2, poor memory." There was no supportive information documented.

2. Patient R2 was admitted on 11/03/14. The psychiatric evaluation, done on 11/04/14 stated, "Oriented X3." There was no supportive information documented.

3. Patient R3 was admitted on 10/28/14. The psychiatric evaluation, done on 10/29/14 did not document memory and orientation findings.

4. Patient R4 was admitted on 11/08/14. The psychiatric evaluation, done on 11/08/14, stated, " Fair memory, " there was no supportive information documented, and there was no documentation for orientation findings.

5. Patient G5 was admitted on 11/05/14. The psychiatric evaluation, done on 11/05/14 stated, "Oriented at least times one," there was no supportive information documented, and there was no documentation for memory findings.

6. Patient G6 was admitted on 11/06/14. The psychiatric evaluation, done on 11/07/14, stated, "Poor memory, Oriented times one." There was no supportive information documented.

7. Patient G7 was admitted on 11/09/14. The psychiatric evaluation, done on 11/10/14, stated, "Oriented times two, Memory intact." There was no supportive information documented.

8. Patient G8 was admitted on 11/06/14. The psychiatric evaluation, done on 11/07/14, stated, "Fair memory, Oriented X3." There was no supportive information documented.

Interview:

During an interview on 11/13/14 at 12:00 PM, the Medical Director stated, "I have looked at some documentations for memory and orientation. I agree with you we can do a better job. I am not disagreeing with your observations."

Based on record review, the facility failed to provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary elements to provide treatment. Specifically, the MTPs were missing the following components:

1.Behaviorally descriptive psychiatric problem statements to be used as the basis for developing the plans for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8) and medical problems identified in clinical assessments for two (2) of two (2) active sample patients (G5 and G6) on the Geriatric Unit. (Refer to B119).

2. Observable and measurable goals for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8). (Refer to B121)

3. Individualized treatment interventions for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8). (Refer to B122)

4. Both the name and discipline of the person accountable for interventions identified on MTPs for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8). (Refer to B123)

Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met.

Based on record review and staff interviews, the facility failed to:

I. Ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on Master Treatment Plans (MTPs). Instead, the stated problems on the treatment plans included diagnoses and/or generalized lists of statements or symptoms, rather than behaviorally descriptive clinical information based on patients' presenting symptoms which had to be resolved or reduced prior to discharge for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8).

II. Ensure that medical problems that had been identified in assessments were addressed on the MTPs for two (2) of two (2) active sample patients on the Geriatric Unit (G5 and G6). This failure results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting medical problems.

Findings include:

I. Psychiatric Problems

A. Record review

1. The MTP for Patient R1 dated 11/7/14 had the following psychiatric problem statement: "Alteration in thought process as evidenced by: Pt [Patient] is having Auditory Hallucinations." The following statements were selected from a preprinted list: "Disintegration of thinking process, Presence of delusion/hallucinations R/T [related to] history of psychosis, Impaired judgment." The problem statement failed to include behaviorally descriptive clinical information to show how this patient precisely manifested auditory hallucinations such as the content of hallucinations and also failed to provide behavioral descriptions of items selected from the preprinted list of items.

2. The MTP for Patient R2 dated 11/3/14 included but not limited to the following psychiatric problems developed: "Violence risk directed at self as evidenced by Hx [History] of SA [Suicide Attempt]." "Alteration in thought process as evidenced by: Disintegration of thinking process, Presence of delusion/hallucination R/T [related to] history of psychosis. Impaired judgment." These statements regarding thought process were selected from a preprinted list of items. Patient R2's psychiatric evaluation dated 11/4/14 did not develop clinical information regarding history of suicide attempts. The problem statement failed to include behaviorally descriptive clinical information to document how this patient precisely manifested suicide behavior and failed to provide behavioral descriptions of items selected from the preprinted list of items.

3. The MTP for Patient R3 dated 10/28/14 included but not limited to the following psychiatric problems developed: "Alteration in thought process as evidenced by: Disintegration of thinking process." This statement was selected from a preprinted list of items. "Violence risk directed at other as evidenced by: Aggression." The problem statement failed to include behaviorally descriptive clinical information to show how this patient precisely manifested alteration in thought process and aggressive behavior.

4. The MTP for Patient R4 dated 11/8/14 had the following psychiatric problem developed: Patient R4: Problem - "Violence directed at self as evidenced by: Pt [Patient] [with] suicidal attempt (hx [history] of cutting]." The problem statement failed to include behaviorally descriptive clinical information to show how this patient currently manifested violence toward self.

5. The MTP for Patient G5 dated 11/5/14 had the following psychiatric problem developed: "Violence risk directed at others as evidenced by carrying a hand gun to his counseling appointment." The problem statement failed to include a complete descriptive clinical picture of the patient's presenting symptoms as outlined in Patient G5's psychiatric evaluation dated 11/5/14 noting that this Spanish-speaking patient, "...[S/he] believed people injured him... wandering street, responding to internal cues."

6. The MTP for Patient G6 dated 11/7/14 included but not limited to the following psychiatric problem developed: "Violence directed at self as evidenced by: Pt [Patient] stated [s/he] wanted to kill herself." [Note: The Psychiatric evaluation dated 11/8/14 did not document clinical evidence related to this patient having suicidal ideation]. The problem statement failed to include behaviorally descriptive clinical information to document how this patient precisely manifested suicide behavior.

7. The MTP for Patient G7 dated 11/10/14 included but not limited to the following psychiatric problem developed: Patient G7: Problem - "Altered Thought Process AEB: Pt [Patient] has a Hx [history] of Schizoaffective DO [Disorder] and bipolar." The problem statement failed to include behaviorally descriptive clinical information to show how this patient precisely manifested symptoms of Schizoaffective and Bipolar Disorders. Patient R7's psychiatric evaluation dated 11/10/14 noted, "Patient threatened to kill [his/her] mother...admits to having mood swing, feeling irritable, racing thoughts..."

8. The MTP for Patient G8 dated 11/3/14 had the following psychiatric problem developed: Patient G8: Problem - "Violence directed at self as evidenced by: Suicidal ideation." The problem statement failed to include behaviorally descriptive clinical information to show how this patient precisely manifested the suicide behavior such as specific information regarding content of suicide ideation(s), suicide plan, and stressors.

B. Policy Review

The facility failed to follow their policy regarding document problem statements. The facility's Policy "Interdisciplinary Treatment Team Plan/Conference, Section: 2.21, Number: 02" stipulated that, "The registered nurse will complete the following areas on the Master Treatment Plan within 8 hours of admission...Identify problem(s) through collaboration with physician upon obtaining admission orders. Rationale for problem will be identified by patient descriptive behavior..."

II. Medical Problems

A. Record Review

1. Patient G5 was admitted 11/5/14.The "History and Physical" dated 11/5/14 noted the following medical problems: "Diabetes Mellitus, and Hypertension." There were no problem statements, goals, and interventions formulated to address these medical conditions.

2. Patient G6 was admitted 11/7/14.The "History and Physical" dated 8/11/13 noted the following medical problems: "Hypothyroidism and Chronic Anemia." There were no problem statements, goals, and interventions formulated to address these medical conditions.

B. Policy Review

The facility failed to follow their policy regarding medical problems. The facility's Policy "Interdisciplinary Treatment Team Plan/Conference, Section: 2.21, Number: 02" stipulated that, "The registered nurse will address Axis III (MEDICAL PROBLEMS) on the MTP with goals and interventions at the time of admission to BCA."

C. Staff Interviews

1. In an interview on 11/13/14 at 2:35 p.m. with the Director of Nursing (DON) and Assistant DON, the MTPs for Patients G1 and G6 were reviewed. They acknowledged that medical problems were not included on the MTPs. The DON stated, "We have been working on these" and was surprised that they were not included on the MTP.

2. During an interview with RN4 on 11/14/14 at 11:10 a.m., the registered nurse's role in developing psychiatric and medical problems was discussed. RN4 stated that normally the RN initiates problem statements at the time of admission based on information from the doctor or they may be added later. RN4 acknowledged that medical problems should have been included on MTPs.

Based on record review and interview, the facility failed to include individualized long and short-term goals which stated what the patient would do to lessen the severity of problems identified for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8). The Master Treatment Plans (MTPs) contained long term and identical preprinted short-term goals (called objectives by the facility) that were not individualized and were global, non-measurable, and/or staff expectations. Objectives were identical for patients with different diagnoses and/or different presenting symptoms. Because patients' medical problems were not listed on the plans, there were no goals related to them for two (2) of two (2) active sample patients (G5 and G6) on the Geriatric Unit. Failure to identify individualized goals potentially hampers the treatment team's ability to determine whether the treatment plan is effective and if it needs to be revised.

Findings include:

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): R1 (11/7/14), R2 (11/3/14), R3 (10/28/14), R4 (11/8/14), G5 (11/5/14), G6 (11/7/14), G7 (11/9/14), and G8 (11/6/14). This review revealed that MTPs included but not limited to the following goals that were not individualized patient outcome based on each patient ' s presenting symptoms.

1. Patient R1: Problem - "Alteration in thought process as evidenced by: Pt [Patient] is having Auditory Hallucinations." Long Term Goal: "Pt [Patient] will return his highest level of functioning. Pt [Patient] will alleviate symptoms of psychosis...Pt [Patient] will reduce harmful thoughts/behaviors." Objectives: "1. Recognizes changes in thinking/behavior. 2. Identifies delusions and increases capacity to cope effectively with them... 6. Patient wil1 attend daily group activities. 7. Patient will take prescribed medications."

Long term goals were non-measurable and global statements that failed to include behavioral descriptions of behaviors staff expected to observe prior to discharge. Objectives 1 and 2 were not measurable or written in behavioral terms. These objectives failed to assist staff to determine the patient's progress or lack of progress when assessing to what degree the objectives have been achieved. Objective 6 and 7 were staff expectations instead of patient oriented objectives reflecting what the patient will do to eliminate, reduce, and/or improve his/her presenting problems.

2. Patient R2: "Violence risk directed at self as evidenced by Hx [History] of SA [Suicide Attempt]." Long term goals: "Decrease altered thoughts. Eliminate [prescriptive] drug abuse. Utilize coping skills. Comply [with] Rx [treatment]." Objectives: "1. Patient will not harm or injure self for 10 days prior to discharge. 4. Patient wil1 attend daily activities. 5. Patient will take prescribed medications."

Long term goals were non-measurable and global statements that failed to include behavioral descriptions of behaviors staff expected to observe prior to discharge. Objective 1 was not measurable or behaviorally specific. Objective 4 and 5 were staff expectations instead of patient oriented objectives reflecting what the patient will do to eliminate, reduce, or improve his/her presenting problems.

3. Patient R3: Problem - "Alteration in thought process as evidenced by: Disintegration of thinking process, Presence of delusional/hallucinations R/T [Related to] history of psychosis..." Long term goals: "Pt [Patient] will eliminate delusions. Pt [Patient] will [Patient] eliminate aggressive Bx [behavior]. Pt [Patient] will eliminate manic Bx [behavior]. Pt [Patient] will comply with Tx [treatment] plan." Objectives: "1. Recognizes changes in thinking/behavior. 2. Identifies delusions and increases capacity to cope effectively with them... 6. Patient wil1 attend daily group activities. 7. Patient will take prescribed medications."

Long term goals were non-measurable and global statements that failed to include behavioral descriptions of behaviors staff expected to observe prior to discharge. Objectives 1 and 2 were not measurable or behaviorally specific. Objective 6 and 7 were staff expectations instead of patient oriented objectives reflecting what the patient will do to eliminate, reduce, or improve his/her presenting problems.

4. Patient R4: Problem - "Violence directed at self as evidenced by: Pt [Patient] [with] suicidal attempt (hx [history] of cutting]." Long term goals: "[not] harm self. Dev. [Develop] coping strategies." Objectives: "1. Recognizes changes in thinking/behavior. 4. Patient will attend daily group activities. 5. Patient will take prescribed medications."

Long term goals were non-measurable and global statements that failed to include behavioral descriptions of behaviors staff expected to observe prior to discharge. Objective 1 was not measurable or behaviorally specific. Objective 4 and 5 were staff expectations instead of patient oriented objectives reflecting what the patient will do to eliminate, reduce, or improve his/her presenting problems.

5. Patient G5: Problem - "Violence risk directed at others as evidenced by carrying a hand gun to his counseling appointment." Long term goal: "To stabilize mood, eliminate psychosis, and have zero harm to self and others." Objectives: "1. Patient will not harm or injure self for 10 days prior to discharge. 4. Patient wil1 attend 3-4 groups per day. 5. Patient will attend individual and/or family therapy weekly."

The long term goal contained statements that were non-measurable and global and failed to include behavioral descriptions of behaviors staff expected to observe prior to discharge. Objective 1 was not behaviorally specific and failed to identify non-harmful behaviors that the patient should exhibit prior to discharge. Objective 4 and 5 were staff expectations instead of patient oriented objectives reflecting what the patient will do to eliminate, reduce, and/or improve his/her presenting problems.

6. Patient G6: Problem - "Violence directed at self as evidenced by: Pt [Patient] stated [s/he] wanted to kill herself." [Note: The Psychiatric evaluation dated 11/8/14 documented, related to this patient having suicidal ideation]. Long term goals: "Pt [Patient] will decrease depression, paranoia and delusions. Pt [Patient] will comply with medications. Pt [Patient] will decrease SA [sic]." Objectives: "1. Patient will not harm or injury self for 3 days prior to discharge. 4. Patient wil1 attend 3-4 groups per day. 5. Patient will take prescribed medications."

Long term goals were non-measurable and global statements that failed to include behavioral descriptions of behaviors staff expected to observe prior to discharge. Objective 1 was not behaviorally specific and failed to identify non-harmful behaviors that the patient should exhibit prior to discharge. Objectives 4 and 5 were staff expectations instead of patient oriented objectives reflecting what the patient will do to eliminate, reduce, and/or improve his/her presenting problems.

7. Patient G7: Problem - "Violence directed at others as evidenced by: Patient became upset at her mom, patient threw things at her mom...Patient was threatening to kill [his/her] mom if she went back to sleep." Long term goals: "1. Reduce harm to others. 2. Reduce aggression. 3. Med [Medication] compliance." Objectives: "1. Patient will not harm or injury self for 10 days prior to discharge. 4. Patient wil1 attend 3-4 groups per day. 5. Patient will take prescribed medications."

Long term goals were non-measurable and global statements that failed to include behavioral descriptions of behaviors staff expected to observe prior to discharge. Objective 1 and 2 were not measurable or behaviorally specific. Objectives 4 and 5 were staff expectations instead of patient oriented objectives reflecting what the patient will do to eliminate, reduce, and/or improve his/her presenting problems.

8. Patient G8: Problem - "Violence directed at self as evidenced by: Suicidal ideation." Long term goals: Long term goals: "Pt [Patient] will eliminate SI [suicide ideation]. Pt [Patient] will lessen depressed mood. Pt [Patient] will eliminate AH [Auditory Hallucination]." Objectives: "1. Patient will not harm or injury self for 3 days prior to discharge. 4. Patient wil1 attend 3-4 groups per day."

Long term goals were non-measurable and global statements that failed to include behavioral descriptions of behaviors staff expected to observe prior to discharge. Objective 1 was not measurable and did not identify specific safe behaviors the patient will exhibit instead of harming or injuring self. Objectives 4 was a staff expectation instead of patient oriented objectives reflecting what the patient will do to eliminate, reduce, and/or improve his/her presenting problems.

9. Medical problems identified on the "History and Physical" and those being treated during hospitalization were not included on the MTPs for two (2) of two (2) active sample patients on the Geriatric Unit (G5 and G6). Therefore, there were no objectives on MTPs to address medical problems for these patients.

B. Staff Interviews

1. During an interview with the Medical Director on 11/13/14 at 12:00 p.m., he acknowledged that the treatment goals were not individualized and not measurable.

2. In an interview on 11/13/14 at 2:35 p.m. with the Director of Nursing (DON) and Assistant DON, the MTPs for Patients G5 and G6 were reviewed. They acknowledged that treatment goals were not measurable and/or staff expectations instead of behaviorally specific patient outcomes.

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

I. Provide eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6,G7, and G8) with Master Treatment Plans (MTPs) that included individualized interventions that stated specific treatment modalities with a focus of treatment based on each patient's presenting problems and goals. Instead, the MTPs included preprinted routine discipline functions written as treatment interventions and/or generic vague global statements without an identified method of delivery. There were no interventions identified to be implemented by the attending psychiatrist and activity therapy staff for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6,G7, and G8) and no SW intervention identified for four (4) of eight (8) active sample patients (R4, G5, G6, and G8). In addition, because medical problems were not listed on MTPs, there were no interventions identified to address medical problems for two (2) of two (2) active sample patients (G5 and G6) on the Geriatric Unit.

II. Ensure that those active treatment sessions listed on the "Unit Treatment Schedule" and attended by patients were included and described on patients' Master Treatment Plans (MTPs) of eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8). These active treatment groups were not included MTPs despite the facility's expectation that each patient attend groups on these schedules.

The above deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

I. Failure to include individualized treatment intervention

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): R1 (11/7/14), R2 (11/3/14), R3 (10/28/14), R4 (11/8/14), G5 (11/5/14), G6 (11/7/14), G7 (11/9/14), and G8 (11/6/14). This review revealed that the MTPs included but not limited to the following routine and generic statements (such as assessing, documenting, and encouraging) and/or other generic discipline functions written as treatment interventions to be delivered by registered nurses (RN) and social workers (SW). Intervention statements were identical or similarly worded.

1. Patient R1 and R3 had the following identical generic and routine discipline and clinical tasks written as treatment interventions instead of individualized interventions based on their psychiatric symptoms or problems identified upon admission. Patient R1's psychiatric evaluation dated 11/8/14 noted, "He attacked his father...The patient is responding to internal cues...and seemed very paranoid" that the problem was "Alteration in thought process as evidenced by: Pt [Patient] is having Auditory Hallucinations" and Patient R3's problem was "Alteration in thought process as evidenced by: Disintegration of thinking process, Presence of delusional/hallucinations R/T [Related to] history of psychosis..."

RN Interventions: "1. Assess the presence/severity of patient ' s altered thought process including form, content, and [sic]." "2. Establish at therapeutic nurse-client relationship." "5. Monitor medication regimen. Observe for therapeutic effects." "7. Provide Meds [medications]."

SW Interventions: "3. Reinforce congruent thinking." "6. Provide daily supportive therapy (individual and/or group) to help alleviate the client's fears and reduce feelings of alienation."

There were no interventions identified for the psychiatrist and activity therapists to provide treatment to these patients. Most of the intervention statements were identical for these patients despite different presenting clinical history. Intervention statements 1, 2, 3, 5, and 7 were actually generic and routine discipline functions that would be provided these patients regardless of their presenting symptoms. Intervention 6 was a broad and generic statement that did not include the specific group or groups that were to be provided by SW. This statement also failed to include the focus of individual and/or group contact based on each patient's needs and presenting clinical history.

2. Patient R2 and R4 had the following identical generic and routine discipline and clinical tasks written as treatment interventions instead of individualized interventions based on their psychiatric symptoms or problems identified upon admission. Patient R2's problem was "Violence risk directed at self as evidenced by Hx [History] of SA [Suicide Attempt]" and Patient R4's problem was "Violence directed at self as evidenced by: Pt [Patient] [with] suicidal attempt (hx [history] of cutting]."

RN Interventions: "1. Assess and document the degree of risk/potential for harm to self." "2. Implement assaultive precautions/close observation per facility policy, documenting the need for and frequency of intervention needed." (Patient R4 only) "3. Daily provide a safe environment, removing all dangerous objects from the patient's environment." "4. Provide group therapy for expression of feelings." (Patient R4 only). This intervention was assigned to a Mental Health Associate (MHA). However, "Group Therapy" was listed as a social intervention on each unit's schedule. "8. Provide medications." This intervention was assigned to the LPN.

SW Interventions: "5. Provide group therapy for expression of feelings." "7. Teach problem solving techniques."

There were no interventions identified for the psychiatrist and activity therapists to provide treatment to these patients. The intervention statements were identical for these patients despite different presenting clinical history. Intervention statements 1, 3, and 8 were actually generic and routine clinical functions that would be provided these patients regardless of their presenting symptoms. Intervention 5 was a broad and generic statement that did not include the specific focus of group therapy based on each patient's need and level of functioning. Intervention 7 failed to include a method of delivery (group or individual sessions) and what aspects of problem solving were pertinent to each patient's need.

3. Patient G5: Problem - "Violence risk directed at others as evidenced by carrying a hand gun to his counseling appointment."

RN Interventions: "1. Assess and document the degree of risk/potential for harm to others." "2. Implement assaultive precaution/close observation per facility policy, documenting the need [sic] and frequency of intervention needed." "5. Provide group therapy for expression of feelings." "7. Teach problem solving technique."

There were no interventions identified for the psychiatrist, social workers, and activity therapists to provide treatment to these patients. Intervention statements 1 and 2 were actually generic and routine nursing functions that would be provided these patients regardless of their presenting symptoms. Intervention 5 was a broad and generic statement that did not include the specific group or groups that were to be provided by the RN and LPN. This statement also failed to include the focus of group therapy based on each patient's needs and presenting clinical history. Group Therapy was on the unit schedule to be provided by the social worker not the registered nurse or licensed practical nurse. Intervention 7 failed to include a method of delivery (group or individual sessions) and what aspects of problem solving were pertinent to each patient's need.

4. Patient G6: Problem - "Violence directed at self as evidenced by: Pt [Patient] stated [s/he] wanted to kill herself."

RN Interventions: "1. Assess and document the degree of risk/potential for harm to self." "5. Provide group therapy for expression of feelings." "7. Teach problem solving techniques" "8. Provide medications."

There were no interventions identified for the psychiatrist, social workers, and activity therapists to provide treatment to these patients. Intervention statements 1 and 8 were actually generic and routine nursing functions that would be provided these patients regardless of their presenting symptoms. Intervention 5 was a broad and generic statement that failed to include the focus of group therapy based on each patient ' s needs and presenting clinical history. This group was assigned to the RN and LPN [Licensed Practical Nurse]; however Group Therapy was on the unit schedule to be provided by the social worker. Intervention 7 failed to include a method of delivery (group or individual sessions) and what aspects of problem solving were pertinent to each patient's need.

5. Patient G7: Problem - "Violence directed at others as evidenced by: Patient became upset at [his/her] mom, patient threw things at [his/her] mom...Patient was threatening to kill [his/her] mom if [s/he] went back to sleep."

RN Interventions: "1. Assess and document the degree of risk/potential for harm to others." "3. Daily provide a safe environment, removing all dangerous objects from the patient's environment." "9. Provide medications."

SW Interventions: "5. Provide group therapy for expression of feelings." "7. Teach problem solving technique."

There were no interventions identified for the psychiatrist and activity therapists to provide treatment to these patients. Intervention statements 1, 3, and 9 were actually generic and routine nursing functions that would be provided these patients regardless of their presenting symptoms. Intervention 5 was a broad and generic statement that failed to include the focus of group therapy based on each patient's needs and presenting clinical history. Intervention 7 failed to include a method of delivery (group or individual sessions) and what aspects of problem solving were pertinent to each patient's need.

6. Patient G8: Problem - "Violence directed at self as evidenced by: Suicidal ideation."

RN Interventions: "1. Assess and document the degree of risk/potential for harm to self." "2. Implement assaultive precaution/close observation per facility policy, documenting the need for and frequency of intervention needed." "3. Daily provide a safe environment, removing all dangerous objects from the patient's environment." "5. Provide group therapy for expression of feelings." "7. Teach problem solving techniques."

There were no interventions identified for the psychiatrist, social workers, and activity therapists to provide treatment to these patients. Intervention statements 1, 2, and 3 were actually generic and routine nursing functions that would be provided these patients regardless of their presenting symptoms. Intervention 5 was a broad and generic statement that failed to include the focus of group therapy based on each patient's needs and presenting clinical history. Group Therapy was on the unit schedule to be provided by the social worker not the registered nurse or licensed practical nurse. Intervention 7 failed to include a method of delivery (group or individual sessions) and what aspects of problem solving were pertinent to each patient ' s need.


B. Staff Interviews

1. In an interview on 11/12/14 at 1:00 p.m. with Director of SW who was also the Director of Activity Therapy, he acknowledged that there were no SW interventions included on some of the MTPs. During another interview on 11/13/14 at 11:40 a.m. with the Director of SW, the MTPs for G5 and G6 were reviewed. He confirmed that there were no interventions assigned to social workers on the MTPs.

2. In an interview on 11/13/14 at 2:40 p.m., SW1 acknowledged that there were no social worker interventions on the MTPs for Patient G8 and stated, "Social work interventions should be on the treatment plan."

3. In an interview on 11/13/14 at 2:35 p.m. with the Director of Nursing (DON) and Assistant DON, the MTPs for Patients G5 and G6 were reviewed. They acknowledged that medical interventions were not included on the MTPs. They agreed that nursing interventions were clinical tasks rather than specific interventions to assist patients themselves to improve or reduce presenting symptoms and accomplish treatment outcomes.

II. Failure to include active treatment measures provided on MTPs

A. Observations and Interviews

1. During observation on 3 South on 11/12/14 at 12:50 p.m., the surveyor was told that Patient G6 was in the shower. The "3 South - Generations" Schedule showed "Med [Medication] Education" to be conducted by the registered nurse from 12:45 - 1:30 p.m. This group did not begin until 1:05 p.m. after the surveyor asked where the group was being held. The Patient G6 entered the group room near the end of the group and asked for the handout that the RN had distributed.

2. During interview on 11/12/14 at 1:40 p.m., RN2 stated that she was not aware that the group was scheduled at 12:45 p.m. and stated the Charge RN had gone to lunch and was not available to do the group. RN2 also stated the she had not received training to do the Medication Education group.

3. During interview with Patient G6 on 11/12/14 at 3:00 p.m. the unit group schedule was reviewed. Patient G6 stated that s/he had been attending groups and stated that s/he had several questions about his/her medications especially his/her Seroquel.

4. Patients G5 and G6 was observed in a group on 11/13/14 at 10:10 a.m. with 7 other patients. The "3 South - Generations" schedule showed "Group Therapy (SW) scheduled from 9:30 - 10:30 a.m." A review of these patients MTP revealed that the social worker was not listed as being responsible for group therapy. The MTP had the following information: Intervention - "Provide group therapy for expression of feelings"; Frequency - "per schedule"; and Responsible Person - "RN, LPN, MHA."

5. Patient G5 was observed in a group session on 11/13/14 from 10:40 a.m. to 11:10 a.m. with 6 other patients. The "3 South - Generations" schedule showed "Recreational Therapy(AT) scheduled from 10:30 - 11:30 a.m." A review of this patient's MTP revealed that there was no recreational therapy included on the MTP to be provided by AT.

B. Document Review

A review of the schedules for each unit showed that at least 3 different active treatment groups were scheduled each day for patients. On 11/14/14 the following treatment sessions were scheduled and a review of the MTPs showed none of these groups except group therapy were included on the treatment plan for active sample patients below who were assigned to these units.

1. Patient R1 and R2 - Adult One South: "Expressive Therapy (AT)" from 9:15 - 10:15 a.m. "Expressive Therapy (AT)" from 1:00 - 2:00 p.m. "Group Therapy" from 2:00 - 3:00 p.m.

2. Patient R4 - South Restorations: "Art Therapy (AT)" from 10:15 - 11:15a.m.; "Group Therapy A (SW 1)" and "Group Therapy B (SW 2)" from 1:30 - 2:30 p.m.; "Med [Medication] Education (RN)" from 6:00 - 7:00 p.m.

3. Patient R3 - Adult Four South: "Group Therapy A (SW)" from 1:00 - 2:00 p.m.; "Art Therapy (AT)" from 2:00 - 3:00 p.m. "Med [Medication] Education" from 6:00 - 7:00 p.m.

4. Patient G5 and G6 - South Generations (Geriatric Unit): "Group Therapy (SW)" from 9:30 - 10:30 a.m.; "Recreational Therapy (AT)" from 10:30 - 11:30 a.m.; "Med [Medication] Education (RN) from 12:45 - 1:30 p.m.

5. Patient G7 - Inspiration (Dual Diagnosis): "Music Therapy (AT)" from 9:30 - 10:30 a.m. "Group Therapy (SW)" from 1:30 - 2:30 p.m.

6. Patient G8 - Foundation (Adolescent Unit): "Expressive Therapy (AT)" from 12:30 - 1:30 p.m. "Group Therapy (SW)" from 1:30 - 2:30 p.m.; "Med [Medication] Education (RN) from 7:00 - 8:00 p.m."

C. Staff Interview

1. In an interview on 11/13/14 at approximately 11:40 a.m., with the Director of Activity Therapy (also Director of Social Work), the MTPs for Patients G5 and G6 were reviewed. The Director of Active therapy confirmed that there none of the active therapy groups listed on the unit schedules were included on the master treatment plans. He also agreed that the social work group listed on unit schedules were not consistently assigned on MTPs to be provided by the social worker.

2. During interview on 11/13/14 at 2:35 p.m. with the Director of Nursing (DON) and Associate Director of Nursing (ADON), they both acknowledged that the medication education group listed on unit schedules was not included on MTPs and stated that patients were expected to attend this group.

Based on record and interview, the facility failed to provide MTPs that specified the both name and discipline of staff responsible for implementing interventions for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8). Failure to assign specific staff members for intervention modalities results in an inability to determine what staff member is responsible for ensuring the interventions are implemented, potentially hampering the effective coordination of treatment modalities.

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): R1 (11/7/14), R2 (11/3/14), R3 (10/28/14), R4 (11/8/14), G5 (11/5/14), G6 (11/7/14), G7 (11/9/14), and G8 (11/6/14). This review revealed that MTPs failed to consistently include both the name and discipline of clinical staff responsible for the checked preprinted interventions.

B. Staff Interviews

1. During an interview with the Medical Director on 11/13/2014 at 12:00 p.m., he acknowledged that MTPs did not contain the names of staff responsible for implementing treatment interventions.

2. In an interview on 11/13/14 at 2:35 p.m. with the Director of Nursing (DON) and Assistant DON, the MTPs for Patients G5 and G6 were reviewed. They acknowledged that interventions did not include the name of staff responsible for implementing interventions identified on the treatment plan.

Based on observation, interview, and document review, the facility failed to ensure that active individualized psychiatric care was provided for two (2) of eight (8) active sample patients (R1 and G5). Specifically there was failure to:

1. Provide alternative programming/activities for 1 of eight (8) active sample patients (R1) who was too acutely ill or refuse to attend scheduled programming activities. This deficiency results in patients idly lying/sitting around the dayroom and sleeping in bedroom and not receiving active treatment.


II. Provide interpreter services according to facility policy for 1 of two (2) active sample patients (G5) on the Geriatric Unit who was not proficient in the English language. Specifically, there was no documented evidence that an interpreter was consistently available to assist the patient during active treatment groups while hospitalized. Patient G5 spent most of his/her day either lying on his/her bed or wandering around the hallways. This failure compromised this patient's ability to adequately participate in active treatment.

Findings include:

I. Failure to provide alternative programing

A. Observation

Patient R1 was observed to be not in the group/unit activities on 11/13/2014 at 9:45 a.m., on 11/13/2014 at 02:20 p.m. and was observed sleeping in his/her bedroom during these group activities.

B. Record Review:

Review of activity therapy group progress notes indicated that the patient (R1) did not attend activity group on 11/08/2014, 11/09/2014, 11/10/2014, and on 11/12/2014, and also did not attend social work groups on 11/08/2014, 11/09/2014, and on 11/10/2014. The treatment plan was not updated to reflect patient's behaviors and no alternative treatment modalities were implemented.

C. Interview:

1. During an interview on 11/13/2014 at 11:25 a.m., the director of social services stated, "I agree patient should not be sleeping in bedroom during activities, they should be actively participating in group activities."

2. During an interview on 11/13/2014 at 12:00 p.m., the medical director stated, "I understand what you are telling me, it is quite clear, patient should be receiving active treatment."

3. During an interview in the patient's (R1) bedroom on 11/13/2014 at 02:25 p.m., patient (R1) stated, "I do not feel like going to groups, I do not like groups."


I1. Failure to provide necessary interpreter services:

A. Observations

During an observation on 11/12/14 at 12:45 p.m. on the Geriatric Unit, Patient G5 was in his room in bed at 12:45. A Medication Group was scheduled, however it did not start until 1:05 p.m. after the surveyor asked where it was being held. Patient G5 remained in bed while this group was being held. No interpreter was made available for the patient to attend group. No alternative active measure such as 1:1 medication education was provided.

B. Document Review

1. A review of the medical record revealed that Patient G5 was admitted 11/5/14. The Psychiatric Evaluation dated 11/5/14 documented a diagnosis of "Mood Disorder, Not Otherwise Specified, Hypertension, Diabetes Mellitus Type I." The Psychiatric Evaluation documented, "...patient, "...was taken to [Hospital's name] because of severe paranoia and bizarre behavior...went to [his/her] appointment with a handgun. [S/he] believed people injured [him/her]...wandering street, responding to internal cues." An interpreter was not available for this interview, because the psychiatrist documented, "When I interviewed [him/her], [s/he] seemed confused, mumbling to [himself/herself] and very paranoid. [S/he] does not speak English. Most of the information I obtained from the chart."

3. A review of the Master Treatment Plan (MTP) for Patient G5 dated 11/5/14 revealed that there was no documentation regarding the patient's status as a non-English or limited English Speaking patient. There was no documented evidence that an interpreter was available for the Treatment plan Review meeting or when the patient signed the MTP.

4. A review of the "Patient Observation Record" from 11/7/14 through 11/12/14 revealed that the Patient G5 was not involved in active treatment groups.

a. On Friday, 11/7/14 - The patient was documented as being in his/her room from 9:15 to 10:00 a.m. in the hallway; from 10:15 to 11:30 a.m. in the dayroom and in his/her room, in the hallway or in the dayroom in Group from 10:30 - 11:00 a.m. The "Social Work Progress Note (Absentee) Form showed that the patient was absent because,"...patient not staying the entire group. However, there was no evidence that an interpreter was available during this session. The patient was in his/her room from 2:30 - 3:15 p.m.; watching TV from 5:00 p.m. to 6:00 p.m.; in his/her room from 6:00 p.m. and rest of night.

b. On Saturday, 11/8/14 - The patient was documented as being in his/her room from 9:15 - 10:30 a.m.; from 11:15 - 12:00 p.m.; from 1:00 - 4:45 pm; and from 6:00 p.m. through the rest of the night. During this period the unit schedule showed that the only structured therapeutic activities group to be conducted by AT staff was "Expressive Therapy (AT)" and the patient was noted as being in his/her room during most of this group period. "Group Therapy (AT)" was also on the schedule for 9:30 - 10:30 a.m. Patient G5 was documented as being in his/her room during this group period. There was no evidence that an interpreter was available during either of these groups.

c. On Sunday, 11/9/14 - The patient was documented as being in his/her room from 9:00 - 11:00 a.m.; from 12:30 - 1:30 p.m.; in the hallway at 2:45 p.m. and in his/her room from 3:00 - 4:15 pm; and from 7:30 - 9:00 p.m. During this period the unit schedule showed that the only structured therapeutic activities group to be conducted by AT staff was "Expressive Therapy (AT)" from 10:30 - 11:30 a.m. "Group Therapy (AT)" was also on the schedule for 9:30 - 10:30 a.m. "Patient G5 was documented as being in his/her room when both of these groups were held." There was no evidence that an interpreter was available during either of these groups.

d. On Monday, 11/10/14 - The patient was documented as being in the hallway from 9:00 - 9:30 a.m.; in his/her room from 9:30 - 10:15 a.m.; from 11:30 - 12:00 p.m.; from 12:00 - 12:45 p.m.; from 1:00 - 3:15 p.m. and in his/her room from 3:00 - 4:15 pm; and from 7:30 - 9:00 p.m. During this period the unit schedule showed that the only structured therapeutic activities group to be conducted by AT staff was "Expressive Therapy (AT)" from 10:30 - 11:30 a.m. "Group Therapy (AT)" was also on the schedule for 9:30 - 10:30 a.m. and "Med [Medication] Education" was scheduled from 12:30 - 1:30 p.m. Patient G5 was documented as being in his/her room when these groups were held. Additionally, there was no evidence provided showing that an interpreter was available during any of these groups.

e. On Tuesday, 11/11/14 - The patient was documented as being in his/her room from 8:30 - 10:15 a.m.; from 10:45 - 11:30 a.m.; from12:15 - 1:30 pm; in the hallway at 1:45 p.m.; in his/her room 2:00 - 5:00 p.m.; and from 5:45 p.m. through the rest of the night. During this period the unit scheduled showed that the only structured therapeutic activities group to be conducted by AT staff was "Expressive Therapy (AT)." "Group Therapy (AT)" was also on the schedule for 9:30 - 10:30 a.m. and "Med [Medication] Education (RN)" was scheduled from 12:45 - 1:30 p.m. Patient G5 was documented as being in his/her room when these groups were held. Additionally, there was no evidence provided showing that an interpreter was available during any of these groups.

f. On Wednesday, 11/12/14 - The patient was documented as being in his/her room from 8:30 - 10:15 a.m.; from 10:45 - 11:30 a.m.; from12:15 - 1:30 pm; in the hallway at 1:45 p.m.; in his/her room 2:00 - 5:00 p.m.; and from 5:45 p.m. through the rest of the night. During this period the unit schedule showed that the only structured therapeutic activities group to be conducted by AT staff was "Expressive Therapy (AT)." "Group Therapy (AT)" was also on the schedule for 9:30 - 10:30 a.m. and "Med [Medication] Education (RN)" was scheduled from 12:45 - 1:30 p.m. Patient G5 was documented as being in his/her room during both of these groups. Additionally, there was no evidence provided showing that an interpreter was available during any of these groups.

5. A review of the Nursing Group Notes revealed that the first "Nursing Group Note" was documented on 11/12/14 by the registered nurse stating that the patient did not attend the group. Previous to this documentation there was no other notation regarding participation or non-participation by Patient G5. There was no documented evidence that an interpreter was provided for the patient to attend group.

6. A review of the "Social Work Group Process Note" Forms revealed that there seven notes documenting that the patient did not attend groups from 11/5/14 through 11/12/14. There was no documented evidence that an interpreter was available to assist the patient in these groups. In addition, there was no documented evidence that alternative active treatment sessions such as 1:1 sessions were made available to ensure that the patient received active treatment.

7. A review of the "Activity Therapy Group Process Note" Forms revealed that there were only five forms completed for the period from 11/5/14 through 11/12/14. Forms for the "Expressive Therapy (AT)" Group scheduled from 10:30 - 11:30 a.m. were found for 11/5/14, 11/8/14, 11/10/14, 11/11/14, and 11/12/14. These forms revealed that the patient participated in one group on 11/5/14. There was no documented evidence that an interpreter was available to assist the patient in these groups. In addition, there was no documented evidence that alternative active treatment sessions such as 1:1 sessions were made available to ensure that the patient received active treatment.

8. Patient G5 was scheduled to be discharged Friday, 11/14/14. A progress note dated 11/13/14 at 9:00 a.m. documented, "This writer and translator spoke with patient this morning...explained the plan for discharge tomorrow to go to transitional group home..." A review of the medical record revealed documented evidence of use of an interpreter only on 11/12/14 using the translator series [telephone] and 11/13/14 using a social worker student intern as an interpreter. The facility failed to consistently follow its own policy to provide interpreter services.

9. The facility failed to follow their policy to provide interpreter services to patients. The facility's Policy "Interpreter Services, Section: 3:03, Number: 03" stated, "Interpreter Services is utilized to ensure that non-English speaking patient [sic] have available translators to assist in understanding the activities of department services and involvement in the treatment planning process...BCA Stonecrest Center will have access to interpreter services in person or telephonically to ensure all patients understand the treatment they are receiving."

C. Interviews

1. During an attempted interview with Patient G6 on 11/12/14 at 3:25 p.m. s/he did not respond verbally to the surveyor. The surveyor was informed that an interpreter would be available Thursday, 11/13/14. The patient was interviewed 11/13/14 with a Social Work Student Intern serving as interpreter.

2. During interview on 11/12/14 at 1:35 p.m., RN 2 was asked why Patient G5's did not attend the group. RN 2 stated that all patients were expected to attend groups. She added, the MHA will ask patients to come to group but, "We can't force them to come to group." She had no knowledge of an interpreter being available for group sessions.

3. During interview on 11/13/14 at 10:45 a.m., SW 2 stated that the patient had not been coming to group and that this was the first time she had the patient in the group and stated "I don't know if there is an interpreter available for each group."

4. In an interview on 11/13/14 at 1:50 p.m. with a Social Worker Student Intern, she stated that she was at the hospital on Thursdays and Fridays. She was only available to provide interpreter services on these days. She noted that she was not on the "floor" last Friday [11/7/14] and was not available to provide interpreter services for Patient G5.

5. During interview on 11/14/14 at 9:10 a.m., the Director of Social Work/Activity Therapy stated, "No, we have not hired any interpreters for [Patient G5]." He noted that it is expected that an interpreter is available for active treatment and this service would be available for registered nurse, activity therapy, and social work groups.

Based on record review and interview, the facility failed to ensure that discharge summaries were dictated, transcribed and filed within 30 days of discharge in 1 of 5 discharge records reviewed (D4). This deficiency resulted in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan with outpatient providers.
Findings include:
Record Review:
Patient D4 was admitted on 08/27/14 and discharged on 09/03/14. The discharge summary was not dictated until 10/16/2014.
Interview:
During an interview on 11/13/14 at 12:00 p.m., the Medical Director stated, "I agree with you, this discharge summary is not completed in a timely manner. Our policy to complete discharge summary is within 30 days of discharge."

Based on record review and interviews, it was determined that the Medical Director failed to adequately monitor and evaluate the care provided to patients at the facility. Specifically, the Medical Director failed to assure that:

I. Social service assessments included individual patient's strengths and individualized recommendations for social work services from the data gathered for six (6) of eight (8) active sample patients (R2, R3, G5, G6, G7, and G8). As a result, the treatment team did not have current baseline social functioning on these patients for establishing treatment goals and interventions and social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams. (Refer to B108)


II. Physicians performed and documented an estimate of memory functioning with supportive information in the psychiatric evaluation for seven (7) of eight (8) active sample patients (R1, R3, R4, G5, G6, G7 and G8) and failed to perform and document an examination of orientation with supportive information in the psychiatric evaluation for eight (8) of eight (8)active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8). These failures potentially result in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromise future comparative re-examinations to assess patient's response to treatment interventions. (Refer to B116)

III. Ensure that each patient included individualized psychiatric problem statements written in behavioral and descriptive terms on Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8) and medical problems that had been identified in assessments were addressed on the MTPs for two (2) of two (2) active sample patients on the Geriatric Unit (G5 and G6). These failures result in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric and medical problems. (Refer to B119).

IV. Include individualized long and short-term goals which stated what the patient would do to lessen the severity of problems identified for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8). Because patients' medical problems were not listed on the plans, there were no goals related to them for two (2) of two (2) active sample patients (G5 and G6) on the Geriatric Unit. Failure to identify individualized goals potentially hampers the treatment team's ability to determine whether the treatment plan is effective and if it needs to be revised. (Refer to B121)

V. Included individualized interventions that stated specific treatment modalities with a focus of treatment based on each patient's presenting problems and goals and ensure that those active treatment sessions listed on the "Unit Treatment Schedule" and attended by patients were included and described on patients' Master Treatment Plans for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8). These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective treatment. (Refer to B122)

VI. Identify by name and discipline the staff responsible for providing interventions for eight (8) of eight (8) (R1, R2, R3, R4, G5, G6, G7, and G8) active sample patients. This failure results in the patient and other staff being unaware of which staff member is assuming responsibility for treatment of the patient, the intervention being implemented and documenting progress toward treatment goals. (Refer to B123)

VII. Provide and document active treatment measures including alternative interventions for 1 of eight (8) active sample patients (R1) based on individual patient needs/presenting behaviors and provide necessary interpreter services for 1 of two (2) active sample patients (G5) on the Geriatric Unit. (Refer to B125)

VIII. Discharge summary for 1 of five (5) discharge summary (D4) was completed within 30 days of discharge. This deficiency resulted in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan with outpatient providers. (Refer to B133)

Based on document review and staff interview, the facility failed to have a Director of Nursing (DON) with a Master's Degree, ongoing training in psychiatric nursing, and/or documented evidence of consultation from a nurse with a Master's degree in Psychiatric/Mental Health Nursing.

Findings include:

A. Document Review

A review of the DON resume' revealed that he had a Master's of Science in Nurse Anesthesia. His resume' showed no psychiatric nursing experience or no psychiatric management experience. The DON was not able to produce evidence of on-going training in psychiatric nursing and had no consultation with a nurse with a Master's in Psychiatric/Mental Health Nursing.

B. Staff Interview

During interview on 11/13/14 at 2:35 p.m., the DON acknowledged that he did not have documentation of on-going training in psychiatric nursing but stated that he did have access to a registered nurse with a Master's Degree in Psychiatric/Mental Health Nursing to provide consultation. However, during a discussion on 11/13/14 at 3:45 p.m., the DON was unable to produce a contract agreement for consultation and did not have documented evidence that a Master's prepared nurse in Psychiatric/Mental Health Nursing had provided him consultation.

Based on observation, record review, and interview, the Director of Nursing (DON) failed to provide adequate oversight to ensure quality nursing services. Specifically, the DON failed to provide eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6,G7, and G8) with Master Treatment Plans (MTPs) that included individualized nursing interventions that stated specific treatment modalities with a focus of treatment based on each patient's presenting problems and goals. Instead, the MTPs included preprinted routine nursing functions written as treatment interventions and/or generic vague global statements without an identified method of delivery. In addition, because medical problems were not listed on MTPs, there were no nursing interventions identified to address medical problems for two (2) of two (2) active sample patients (G5 and G6) on the Geriatric Unit. This deficiency results in a failure to guide treatment nursing staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective treatment.

Findings include:


A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): R1 (11/7/14), R2 (11/3/14), R3 (10/28/14), R4 (11/8/14), G5 (11/5/14), G6 (11/7/14), G7 (11/9/14), and G8 (11/6/14). This review revealed that the MTPs included but not limited to the following routine and generic statements (such as assessing, documenting, and encouraging) and/or other generic nursing functions written as treatment interventions. Nursing intervention statements were identical or similarly worded.

1. Patient R1 and R3 had the following identical generic and routine nursing tasks written as treatment interventions instead of individualized interventions based on their psychiatric symptoms or problems identified upon admission. Patient R1's psychiatric evaluation dated 11/8/14 noted, "[S/he] attacked his father...The patient is responding to internal cues...and seemed very paranoid." That the problem was "Alteration in thought process as evidenced by: Pt [Patient] is having Auditory Hallucinations" and Patient R3's problem was "Alteration in thought process as evidenced by: Disintegration of thinking process, Presence of delusional/hallucinations R/T [Related to] history of psychosis..."

RN Interventions: "1. Assess the presence/severity of patient's altered thought process including form, content, and [sic]." "2. Establish at therapeutic nurse-client relationship." "5. Monitor medication regimen. Observe for therapeutic effects." "7. Provide Meds [medications]."

Most of the intervention statements were identical for these patients despite different presenting clinical history. Intervention statements 1, 2, and 7 were actually generic and routine nursing functions that would be provided these patients regardless of their presenting symptoms.

2. Patient R2 and R4 had the following identical generic and routine nursing tasks written as treatment interventions instead of individualized interventions based on their psychiatric symptoms or problems identified upon admission. Patient R2's problem was "Violence risk directed at self as evidenced by Hx [History] of SA [Suicide Attempt]" and Patient R4's problem was "Violence directed at self as evidenced by: Pt [Patient] [with] suicidal attempt (hx [history] of cutting]."

RN Interventions: "1. Assess and document the degree of risk/potential for harm to self." "2. Implement assaultive precautions/close observation per facility policy, documenting the need for and frequency of intervention needed." (Patient R4 only.) "3. Daily provide a safe environment, removing all dangerous objects from the patient ' s environment." "4. Provide group therapy for expression of feelings." (Patient R4 only). This intervention was assigned to a Mental Health Associate (MHA). However, "Group Therapy" was listed as a social intervention on each unit's schedule. "8. Provide medications." This intervention was assigned to the LPN.

The intervention statements were identical for these patients despite different presenting clinical history. Intervention statements 1, 3, and 8 were actually generic and routine nursing functions that would be provided these patients regardless of their presenting symptoms. Intervention 5 was a broad and generic statement that did not to include the specific focus of group therapy based on each patient's need and level of functioning.

3. Patient G5: Problem - "Violence risk directed at others as evidenced by carrying a hand gun to his counseling appointment."

RN Interventions: "1. Assess and document the degree of risk/potential for harm to others." "2. Implement assaultive precaution/close observation per facility policy, documenting the need [sic] and frequency of intervention needed." "5. Provide group therapy for expression of feelings." "7. Teach problem solving technique."

Intervention statements 1 and 2 were actually generic and routine nursing functions that would be provided these patients regardless of their presenting symptoms. Intervention 5 was a broad and generic statement that did not include the specific group or groups that were to be provided by the RN and LPN. This statement also failed to include the focus of group therapy based on each patient's needs and presenting clinical history. Group Therapy was on the unit schedule to be provided by the social worker not the registered nurse or licensed practical nurse. Intervention 7 failed to include a method of delivery (group or individual sessions) and what aspects of problem solving were pertinent to each patient's need.

4. Patient G6: Problem - "Violence directed at self as evidenced by: Pt [Patient] stated [s/he] wanted to kill herself."

RN Interventions: "1. Assess and document the degree of risk/potential for harm to self." "5. Provide group therapy for expression of feelings." "7. Teach problem solving techniques" "8. Provide medications."

Intervention statements 1 and 8 were actually generic and routine nursing functions that would be provided these patients regardless of their presenting symptoms. Intervention 5 was a broad and generic statement that failed to include the focus of group therapy based on each patient's needs and presenting clinical history. This group was assigned to the RN and LPN [Licensed Practical Nurse]; however Group Therapy was on the unit schedule to be provided by the social worker. Intervention 7 failed to include a method of delivery (group or individual sessions) and what aspects of problem solving were pertinent to each patient's need.

5. Patient G7: Problem - "Violence directed at others as evidenced by: Patient became upset at [his/her] mom, patient threw things at [his/her] mom...Patient was threatening to kill [his/her] mom if [s/he] went back to sleep."

RN Interventions: "1. Assess and document the degree of risk/potential for harm to others." "3. Daily provide a safe environment, removing all dangerous objects from the patient's environment." "9. Provide medications."

Intervention statements 1, 3, and 9 were actually generic and routine nursing functions that would be provided these patients regardless of their presenting symptoms.

6. Patient G8: Problem - "Violence directed at self as evidenced by: Suicidal ideation."

RN Interventions: "1. Assess and document the degree of risk/potential for harm to self." "2. Implement assaultive precaution/close observation per facility policy, documenting the need for and frequency of intervention needed." "3. Daily provide a safe environment, removing all dangerous objects from the patient's environment." "5. Provide group therapy for expression of feelings." "7. Teach problem solving techniques."

Intervention statements 1, 2, and 3 were actually generic and routine nursing functions that would be provided these patients regardless of their presenting symptoms. Intervention 5 was a broad and generic statement that failed to include the focus of group therapy based on each patient's needs and presenting clinical history. Group Therapy was on the unit schedule to be provided by the social worker not the registered nurse or licensed practical nurse. Intervention 7 failed to include a method of delivery (group or individual sessions) and what aspects of problem solving were pertinent to each patient's need.

B. Staff Interview

In an interview on 11/13/14 at 2:35 p.m. with the Director of Nursing (DON) and Assistant DON, the MTPs for Patients G5 and G6 were reviewed. They acknowledged that medical interventions were not included on the MTPs. They agreed that nursing interventions were nursing tasks rather than specific interventions to assist patients themselves to improve or reduce presenting symptoms and accomplish treatment outcomes.

Based on record review and interviews, it was determined that the Director of Social Services failed to monitor and evaluate the quality and appropriateness of social services and therapeutic activities provided to patients at the facility. Specifically the Director of Social Services failed to assure that the social service assessments included individualized recommendations for social work services from the data gathered for six (6) of eight (8) active sample patients (R2, R3, G5, G6, G7, and G8) and also failed to provide structured evening activities during weekdays and on weekends for six (6) of eight (8) active sample patients (R2, R3, G5, G6, G7, and G8). (Refer to B108 and B157)

Based on report and interview, the facility failed to provide and implement a structured therapeutic program for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, G5, G6, G7, and G8). Specifically, there were no structured evening activities available during weekdays and on weekends. The lack of structured activities results patients without sufficient activities to assist in their recovery.

Findings include:

A. Document Review
1. A review of the schedules for each unit showed that there were no groups provided by activity therapy on the evening shift. On 11/14/14 the following activity therapy groups were scheduled. These unit schedules were representative of the schedule of activity therapy seven days a week.

1. Patient R1 and R2 assigned to Adult One South: "Expressive Therapy (AT)" from 9:15 - 10:15 a.m. and "Expressive Therapy (AT)" from 1:00 - 2:00 p.m. [Patients were separated in two groups - Group A and Group B]

2. Patient R3 assigned to Adult Four South: "Art Therapy (AT)" from 2:00 - 3:00 p.m.

3. Patient R4 assigned to South Restorations: "Art Therapy (AT)" from 10:15 - 11:15 a.m.

4. Patient G5 and G6 assigned to South Generations (Geriatric Unit): "Recreational Therapy (AT)" from 10:30 - 11:30 a.m.

5. Patient G7 assigned to Inspiration (Dual Diagnosis): "Music Therapy (AT)" from 9:30 - 10:30 a.m.

6. Patient G8 assigned to Foundation (Adolescent Unit): "Expressive Therapy (AT)" from 12:30 - 1:30 p.m.

C. Staff Interview

1. In an interview on 11/13/14 at approximately 11:40 a.m., with the Director of Activity Therapy (also Director of Social Work), the MTPs for Patients G5 and G6 were reviewed. The Director of Active therapy confirmed that patients received one hour of activity therapy per week and that there were no groups offered by activity therapy on the evening shift.